Evidence-based guidelines for the prevention, diagnosis and treatment of congenital cytomegalovirus (cCMV) were recently released by two independent expert groups. Of particular emphasis was the relationship between cCMV and sensorineural hearing loss (SNHL), a major component of the virus’ overall disease burden. In this study, a literature review was performed to estimate the proportion of cCMV-related SNHL cases, which might be identified through selective cCMV testing following failed newborn hearing screening. Furthermore, it was of interest to estimate the potential benefit of emerging antiviral therapies. Currently, at most 10% of cCMV-related SNHL is likely to be identified clinically. Through use of a selective cCMV testing protocol, however, a significant improvement in the identification rate can be achieved. Recent expert group statements strongly recommend antiviral therapy in cases of moderate-to-severe disease, especially in the presence of central nervous system involvement. Though differences exist between recommendations in instances of isolated SNHL or SNHL in combination with only mild symptoms, the majority of experts in both groups offered at least a weak recommendation for antiviral treatment. Available results suggest antiviral treatment could therefore benefit a meaningful proportion of newborns referred for cCMV testing following failed newborn hearing screening. Congenital cytomegalovirus (cCMV) is the leading non-genetic cause of sensorineural hearing loss (SNHL) worldwide and a significant contributor to neurodevelopmental delay ,2,3,4. WEarly identification of cCMV infection has the potential to significantly impact the treatment of permanent childhood hearing loss (PCHL), which has for several decades been shaped predominantly by an early intervention focus . Indeed, the worldwide spread of universal newborn hearing screening (UNHS) programs has been driven in large part by the success the programs have had in mitigating many of the negative effects of PCHL on children’s speech, language and literacy development ,9,10,11.Two informal expert groups, one comprised of North American, Australian, and British specialists in the area of CMV  assays, with both sensitivities and specificities amenable to mass screening , are effIt was the objective of this article to review the epidemiology of congenital cytomegalovirus infection and its effects in relation to hearing loss, present the potential benefits and drawbacks of targeted cCMV testing, as well as assess the efficacy of selective testing and the potential benefit of additional antiviral therapy according to recently published recommendations.Results from universal CMV screening programs in developed countries suggest the mean prevalence of congenital cytomegalovirus infection to be approximately 0.58% (95% CI: 0.41–0.79), though prevalence has been shown to vary meaningfully across populations according to numerous factors . For exaFor the purposes of this study, the 0.6% cCMV prevalence estimate of Cannon et al. , which wThe clinical spectrum of cCMV infection ranges from the fully asymptomatic (ca. 85–90%) all the way to life-threatening illness ,19. For Accepted definitions of symptomatic, congenital CMV infection therefore frequently include symptoms that generally do not prompt the physician to order a CMV test. In the presence of known CMV-related signs or symptoms, current clinical guidelines ,17 recomThe proportion of symptomatic children which might be diagnosed clinically was recently estimated  by compaAccording to a meta-analysis of studies investigating universal CMV-screened children , sensoriIn an effort to estimate the disease burden of cCMV-associated hearing loss, epidemiological data ,37 obtaiIndependent of the absolute prevalence of cCMV, however, it remains that hearing loss will largely be missed unless the infection is identified during pregnancy, by chance or by more or less systematic screening see . Only 1 The benefit that might result from different implementations of CMV testing or screening may be estimated from the data in The selective testing approach was first described in a large-scale, retrospective study in the Southwestern United States . Over a The proportion of newborns which did not pass NHS and which might be identified with cCMV-related congenital SNHL was recently evaluated in a multicenter diagnostic study . In thatFrom that, selective CMV testing of newborns who do not pass NHS could be used to identify the majority of CMV-related SNHL at birth see , i.e., aComprehensive studies have evaluated which methods are most appropriate for laboratory diagnosis of cCMV-infection in the context of a mass screening . Since dried blood spots (DBS) are often routinely collected for metabolic screening, there has been interest in PCR–based methods for CMV screening. A multicenter study, however, that compared single-primer PCR and 2-primer real-time PCR analysis of DBS to saliva rapid culture, demonstrated low sensitivity for use in mass screening for cCMV in 20,448 infants . Only 17Both urine and saliva from infected newborns contain high CMV viral loads and are amenable to rapid testing by PCR with high sensitivity . HoweverIn a large, prospective, multicenter screening study of newborns, real-time PCR assays of liquid-saliva and dried-saliva specimens were compared with rapid culture of saliva specimens obtained at birth . Of 17,6Both recent expert group statements concurred in strongly recommending that diagnosis of cCMV infection in neonates include real-time PCR of saliva, urine, or both . Furthermore, saliva was identified as the preferred sample, with a recommendation of urine to be used for confirmation of a positive result ,15.The benefit of selective CMV testing with respect to hearing loss arises primarily from the positive effects of antiviral therapy on auditory thresholds and the associated improvements in performance in both aided and unaided conditions. Additional benefits come in the form of early intervention services and increased awareness on the part of caregivers and educators. However, the potential benefits of antiviral therapy must be viewed in relation to the potential risks, namely toxicities. Side effects and associated risks of ganciclovir (GCV) and valganciclovir (VGCV), such as neutropenia, are well-known ,13,54, a(p < 0.01). At 1 year and beyond , 5 of 24 (21%) GCV recipients had worsened hearing versus 13 of 19 (68%) control patients. It was concluded that GCV prevents hearing deterioration at 6 months and may prevent hearing deterioration at more than 1 year.Despite many case reports and cohort studies, data from only 2 RCTs on antiviral treatment for cCMV have been published ,67,68,69More recently, a second randomized trial conducted by the CASG compared antiviral efficacy and safety of a 6-week versus 6-month treatment with oral VGCV , thus deClinical trials provide solid evidence upon which to base treatment decisions for only a portion of the infants presenting to clinicians. Based on the above-mentioned studies, which were rated as level 1 evidence according to the Oxford Centre for Evidence Based Medicine (CEBM), the International Congenital Cytomegalovirus Recommendations Group (ICCRG ) recommeUsing the GRADE rating system, the ESPID expert group recommended  that babIn babies with one or two mild, transient, or clinically insignificant manifestations of cCMV infection , the ICCRG recommended against the routine use of antiviral therapy . For theIf it is assumed that cases of moderate-to-severe, symptomatic disease can be clinically diagnosed, recommendations for antiviral therapy will apply to about 10% (53/503) of cCMV-related SNHL cases at birth see  and may In cases of asymptomatic, congenital cytomegalovirus infection with isolated sensorineural hearing loss, the ICCRG recommended against routine treatment with VGCV due to a lack of quality evidence (level 3 evidence). However, as only one infant with isolated sensorineural hearing loss had been enrolled in a RCT , it was clinicaltrials.gov NCT02005822). Though no consensus could be reached due to the large range of hearing losses encountered, a majority of the ESPID experts concluded that babies with isolated, confirmed SNHL should indeed be categorized within the “severe” CNS group. As the main treatment benefit was a preservation, rather than improvement, of hearing thresholds, a majority of the experts also recommended inclusion of SNHL at birth within their indications for a 6-week to 6-month antiviral treatment regimen. The relatively low quality of evidence supporting this recommendation should be considered when contemplating clinical implementation of this specific recommendation .A similar argument was made by the ESPID expert group . In esseWhereas the ICCRG recommended that decisions about the treatment of isolated sensorineural hearing loss be made on a case-by-case basis, a majority the ESPID expert group members recommended the addition of SNHL at birth to the indications for treatment. If SNHL was included in the indications for antiviral treatment irrespective of severity of additional clinical symptoms, recommendations of antiviral treatment would apply to all cases of cCMV-related congenital hearing loss—constituting about half of the disease burden of hearing loss. The potential benefit of selective testing, which may allow detection of up to 57% of cases with congenital SNHL, would therefore increase considerably.Almost half of the hearing loss-related disease burden accrued within the first 6 years of life exists not from birth, but rather occurs with delayed onset   efforts The above considerations apply not only to both unilateral and bilateral cases of congenital SNHL, which to a great extent will be identified through selective CMV testing, but also to the other major part of cCMV-related SNHL. Specifically, it applies for newborns with delayed-onset SNHL with mostly asymptomatic, or at least not clinically diagnosable, CMV-infection who constitute about 46% (382 + 65/971) of the total disease burden see . In asymSelective cCMV testing in newborns who fail newborn hearing screening allows for the identification of patients with congenital CMV that might otherwise be missed due to the lack of specific symptoms. However, PCR testing of urine or saliva needs to be performed within 3 weeks of age to allow for differentiation between congenital and postnatal CMV. Selective CMV testing can be estimated to identify at least 57% of congenital cCMV-related SNHL, but will nonetheless miss upwards of 43% of cases. This will most frequently occur in instances of mild hearing loss, though progressive and late-onset hearing loss have also proven difficult to identify consistently.Two expert groups, the ICCRG  and the The addition of isolated SNHL as an indication for antiviral treatment, irrespective of the presence or severity of additional clinical symptoms, results in a recommendation encompassing all cases of cCMV-related congenital SNHL. The potential benefit through antiviral therapy might thus extend to the 57% of cases with congenital SNHL detectable via selective testing. The remaining 43%, however, might only be detected via universal CMV screening. Though initial costs will necessarily rise due to the addition of the selective testing procedures, it remains that a dramatic improvement in the identification rate of asymptomatic newborns is possible, which not only results in reduced overall, long-term disease burden due to timely antiviral therapy as well as access to early intervention services, but also could do so at a financial cost far below that of a universal CMV screening program.


This paper reviews and re-analyses data from published studies on the effects of noise exposure on the progression of hearing loss once noise exposure has ceased, focusing particularly on noise exposure during military service. The data are consistent with the idea that such exposure accelerates the progression of hearing loss at frequencies where the hearing loss is absent or mild at the end of military service (hearing threshold levels (HTLs) up to approximately 50 dB HL), but has no effect on or slows the progression of hearing loss at frequencies where the hearing loss exceeds approximately 50 dB. Acceleration appears to occur over a wide frequency range, including 1 kHz. However, each of the studies reviewed has limitations. There is a need for further longitudinal studies of changes in HTLs over a wide range of frequencies and including individuals with a range of HTLs and ages at the end of military service. Longitudinal studies are also needed to establish whether the progression of hearing loss following the end of exposure to high-level sounds depends on the type of noise exposure (steady broadband factory noises versus impulsive sounds). Two common causes of hearing loss are exposure to high-level sound  and incrMild to moderate hearing loss as revealed in the audiogram is probably primarily a consequence of loss of function of the outer hair cells (OHCs) in the cochlea. Hearing loss up to approximately 55 dB may be caused exclusively by loss of OHC function ,8. GreatIf hearing loss approaching 55 dB is present at some frequencies at the end of noise exposure, this could be due to near-complete loss of function of OHCs. In this case, acceleration of the subsequent progression of hearing loss due to further OHC damage is not expected. However, damage to IHCs and/or synapses might contribute to the hearing loss, in which case there could be scope for accelerated progression. If the hearing loss at the end of noise exposure is slight or mild at some frequencies, then there is scope for acceleration of the subsequent progression of hearing loss at those frequencies due to further damage to OHCs, IHCs and/or synapses.Direct evidence for acceleration of the progression of hearing loss following exposure to high-level noise has come from two studies using mice. Kujawa and Liberman  comparedIn a second study using mice , cochleaMice are known to be more sensitive to damage from noise exposure than humans. It has been estimated that noise levels would have to be 14 dB higher in humans to cause the same temporary threshold shift as in mice . It seemThere are only a few studies that have directly examined whether and how noise exposure affects the progression of hearing loss in humans after the exposure has ceased. These studies are summarised in Gates, Schmid, Kujawa, Nam and D’Agostino  examinedRosenhall  presenteLee, Matthews, Dubno and Mills  studied Hederstierna and Rosenhall  studied Macrae  comparedMacrae analysed the audiograms of 240 individuals who had hearing loss at 4 kHz at the end of military service. Selection criteria were: (1) no conductive component to the hearing loss; (2) at the end of military service, an HTL at 4 kHz 20 dB or more greater than predicted for their age, based on the data of Glorig and Nixon ; (3) as Macrae divided the individuals into age groups and tabulated the changes in HTL at 1 and 4 kHz from the initial measurement to the time of the second measurement for each group. The relevant time interval varied across groups and the groups themselves varied somewhat depending on the frequency of interest and age. To make it easier to compare across groups, the changes in HTL tabulated by Macrae have been converted to rates of change of HTL in dB/year. The results for the left ear at 1 kHz are shown in The results in Macrae  also groOverall, the results of Macrae are consistent with the idea that for frequencies for which the hearing loss at the end of noise exposure is up to 50 dB, the progression of hearing loss following the end of the exposure is greater than would be expected from age alone. However, for frequencies for which the hearing loss at the end of noise exposure is 55 dB or more, the progression is similar to or less than expected from age alone. The accelerated progression produced by noise exposure, when it occurs, appears to be related more to the HTL at the end of the noise exposure than to age. This conclusion is supported by the observation that at 1 kHz acceleration occurred over the whole age range studied. It is noteworthy that acceleration occurred at 1 kHz, since it is often assumed that noise exposure has little effect at this frequency ,35. HoweXiong, Yang, Lai and Wang  performep < 0.01) higher HTLs at 4, 6, and 8 kHz than the non-exposed group, consistent with the idea that the noise exposure during military service accelerated the subsequent progression of hearing loss.Mean HTLs for the two groups, and differences across groups, are shown in Some limitations of this study should be noted. Firstly, the authors did not present the audiograms obtained for Group I at the end of military service, and the audiograms for Group II were not measured when they were 23–25 years old, so it is not clear how well the two groups were matched in HTL at 4, 6, and 8 kHz at the time when Group I were discharged from military service. Secondly, because Group I were selected to have HTLs within the “normal” range at the end of military service, while many of the military personnel who fought in the same war had hearing loss at the end of military service , Group IKim, Lim, Kim and Park  studied Overall, the results of the three studies that focused on the effects of noise exposure during military service support the idea that such noise exposure can accelerate the subsequent progression of hearing loss at frequencies where the hearing loss at the end of military service is up to approximately 50 dB. For greater hearing losses, the prior exposure seems to have little effect or even slows the progression of hearing loss, consistent with the idea, described in Each of the studies on the effects of noise exposure during military service had limitations. Two of the studies ,29 had cIt is of interest that in the study of Macrae , there wIt is unclear whether the progression of hearing loss following the end of exposure to high-level sounds differs depending on the type of noise exposure. One might expect this to be the case, since the characteristics of NIHL produced by steady noises of the type encountered in factories are different from the the characteristics of NIHL produced by the impulsive types of sounds encountered in military service, which is denoted hereafter M-NIHL. Specifically: 1) steady broadband noises lead to a characteristic dip or notch in the audiogram, typically centered at 4 kHz and with little hearing loss at 1 kHz and below or at 8 kHz  steady b, whereasThe population studies reviewed in It should be emphasized that all of the studies reviewed here focused on average or median changes in HTL over time. In all studies, substantial individual variability was noted. It is likely to be the case that some individuals with M-NIHL will show little or no acceleration of the progression of hearing loss following the end of military service, while others will show very marked acceleration. Such individual differences might reflect differences in the underlying physiological damage to the auditory system, genetic makeup, cardiovascular health, lifestyle, and diet ,44.The evidence reviewed here is consistent with the idea that exposure to the high-level sounds that are encountered during military service accelerates the progression of hearing loss after the exposure has ceased for frequencies where the hearing loss is absent or mild (HTLs up to approximately 50 dB HL), but has no effect on or slows the progression of hearing loss for frequencies where the hearing loss exceeds 50 dB. However, each of the studies reviewed has its limitations. Further longitudinal studies are needed of changes in HTLs over a wide range of frequencies and including individuals with a range of HTLs and ages at the end of military service. Further longitudinal studies are also needed to establish whether the progression of hearing loss following the end of exposure to high-level sounds differs depending on the type of noise exposure.


Most hospitals recommend performing neonatal hearing screening. Transient evoked otoacoustic emission (TEOAE) tests represent an ideal technique for conducting this process. Previous studies have related the influence of ABO blood group and Rhesus antigens (Rh) on the susceptibility to various pathologies. However, available data about the potential relationship between ABO blood groups, Rh, and TEOAE pass rates are sparse. Recently, several authors concluded that O blood group and Rh+ are possible influential factors of TEOAE pass rates. Significantly different TEOAE amplitude response between the four main ABO blood groups were observed among normal-hearing individuals. Moreover, ABO blood groups were discussed as a possible influential factor for the development of noise-induced hearing loss later in life. The aim of this study was to investigate the relationship between ABO blood groups, Rh, and the first TEOAE pass rates in healthy newborns. Data were retrospectively collected from healthy newborns at the maternity ward of F. Borja hospital in Gandia (Spain). Rh and ABO were compared with the results of TEOAE performed within the first 48 h of life. Results: the study group included 2765 newborns. No significant correlation between ABO blood group or Rh and TEOAE pass rates was observed in comparative tables. Conclusion: ABO blood group and Rhesus antigens do not appear to have a significant impact on the pass rate of TEOAE screening in healthy newborns. ABO blood group system antigens are complex carbohydrate molecules located on the extracellular surface of red blood cell membranes. However, along with their expression on red blood cells, ABO antigens are also pervasively present on a variety of human cells and tissues, including the epithelium, sensory neurons, platelets, and the vascular endothelium surfaces. The clinical significance of the ABO blood group system extends beyond transfusion medicine; several reports suggest an important involvement in cardiovascular, oncological, and other diseases .In 1985, Mollicone et al.  describeOtoacoustic emissions (OAEs) are low-level acoustic signals generated in the cochlea and passed through the middle ear into the external ear canal. OAEs are an objective indication of normal cochlear function. OAEs occur in nearly all ears with normal hearing and middle ear function, with larger amplitude found in females and in right ears. Additionally, OAEs can be classified into spontaneous OAE (SOAEs) and evoked OAEs. SOAEs arise in normal-hearing ears independently without external acoustic stimulation; SOAEs exist in 50–70% of ears with normal hearing. Detecting SOAEs alone is not clinically useful, but, on average, ears with the presence of SOAEs exhibit larger amplitude evoked OAEs than do ears without SOAEs. Evoked type OAEs include transient-evoked otoacoustic emissions (TEOAEs) and distortion-product otoacoustic emissions (DPOAEs). Both are clinically useful and often selected for monitoring cochlear function. TEOAEs and DPOAEs have been shown to have good sensitivity and good specificity for hearing screening. TEOAEs are measured after a broadband click is presented to the ear. TEOAEs are evoked across a broad frequency range when stimulated by temporally short clicks, which have broad spectral bandwidths, and multiple cochlear locations may contribute to TEOAEs measured at any specific frequency. DPOAEs are sounds generated in the cochlea in response to two primary tones simultaneously presented to the ear canal of the same ear. DPOAE testing can record evoked OAEs of higher frequencies than TEOAE testing. Like TEOAEs, DPOAEs are measurable in almost all normal-hearing ears without middle ear pathology, remaining relatively stable over time. Researchers have compared the sensitivity of evoked OAE testing with pure-tone audiometry and concluded that OAE testing is more sensitive in detecting the early onset of cochlear pathologies before a change in hearing thresholds [Newborn hearing screening is both crucial and routinely performed. Only 50% of babies born with hearing loss have a hearing loss risk factor. Early detection leads to timely treatment of the affected neonates, resulting in a better final prognosis ,9,10.Several techniques are used in newborn hearing screening. Transient evoked otoacoustic emission (TEOAE) testing is one of the most frequently used techniques because of its accuracy, simplicity, speed, and low cost. Additionally, as previously stated, TEOAE testing offers high sensitivity and specificity, especially regarding cochlear status in hearing loss ,12.A major drawback of TEOAE testing as a screening technique for newborns relates to the middle ear status, which can severely affect its pass rate. Also, the presence of debris and vernix in the external meatus of the newborn can result in false positive screenings. Both factors lead to a failure rate greater than the actual hearing loss, thus a two-step newborn hearing screening protocol has been introduced to allow for clearance of the middle and external ear.There are well-known hearing loss risk factors defined by the Joint Committee on Infant Hearing and The Commission for Early Detection of Hearing Loss (CODEPEH) based in Spain . HoweverAdditionally, another crucial factor is the newborn’s age at the time of testing, which can be related to the mother’s length of hospital stay depending on the type of birth  . Data stRecent studies ,17 have The findings contrast with other authors who concluded that blood group O (and possibly AB) plays a preventive role, while blood group A or B are burdensome for otitis media with effusion (OME) which can affect positively amplitude of TEOAE due to normal middle ear status allowing better OAE detection. No relationship was found when examining Rh factor as a predictor for OME .Until now, these human studies related to risk of hearing loss and blood group type or Rh are mainly in adults, whilst no study provides an exploration of blood groups or Rh in relation to congenital hearing status. That is the reason why, in order to minimize the potential for data bias or unclear results, this research study focused on analyzing information exclusively on healthy newborns vaginally delivered without any hearing risk factors.Significant differences in TEOAE amplitudes between groups can alter the pass rate of screening tests; therefore, the aim of this study was to analyze ABO blood group and Rh influences on the pass rate of the TEOAE test as a method for universal newborn hearing screening during the first 48 h of life.Data were collected between 2016–2018 from all healthy newborns without known hearing loss risk factors in the maternity ward of the Francesc de Borja Hospital in Gandia (Spain). The study was approved by the ethical committee of this Hospital on 31 January 2018 with code e2/2018.The focus of the study was limited to healthy newborns. Neonates who were admitted to the neonatal center exhibiting symptoms of any disease were not included in the research. Additionally, newborns with Apgar lower than 7 at 5 min were excluded, as were newborns delivered by caesarean section based on the practice of performing otoacoustic emissions after 72 h of birth. As previously stated, it is widely known that time has a positive influence on the initial test response.The bilateral TEOAE screening was performed as close to 48 h of life as possible. All nurses performed the screening, on every shift, every day of the week, depending on availability and work load. The screening was performed in a newborn room with as little background noise as possible after parental verbal consent was obtained. Testing usually took place after feeding time to ensure the newborn was calm. No sedation was administered.® based on the ILO88  system and connected to the ILO ECP® neonatal probe. The system utilizes a click-type non-linear stimulus of 1 ms duration, the intensity of which is 84 ± 3 dB sound pressure level (SPL) and 80 c/s frequency. A normal result (pass) requires a signal/noise level response above 6 dB with a frequency range from 0–6 kHz. A newborn with normal bilateral response was accepted as a pass; otherwise it was deemed a referral [The TEOAEs were recorded with an ECHOCHECK OAE Screenerreferral .®, Barcelona, Spain).Determination of blood group and Rh was completed using neonatal cord blood with anticoagulant etilendiaminotetraacetic acid (EDTA) by means of DG Gel Newborn card .The independent variables are ABO blood group (group O/Other) and Rh (+/−) of newborn.Following frequency analysis of the variables, a univariate analysis was completed between the TEOAE result and the study variables with the Chi-squared test and risk estimate with odds ratio.Statistical analyses were only conducted for patients that had data available for either of the study variables (blood group O/other vs. TEOAE pass/refer or Rh +/− vs. TEOAE pass/refer). In order to minimize the risk of inaccurate data analysis, the relationships between gender and breastfeeding (well known factors influencing the TEOAE pass rate) versus blood groups and Rh groups were analyzed.p < 0.05. The data were analyzed using Excel® 2016 and SPSS® version 20.The significance level was established at Data concerning ABO blood groups were available for 2765 newborns, of which the majority showed A and O blood group . Based oThe relationship between blood group and TEOAE pass rate was not significant, as shown in There were no statistical differences with respect to gender or lactancy between blood groups .Rh was registered in 2765 newborns (386 Rh− vs. 2379 Rh+). Distribution is shown in Relationship between Rh and TEOAE pass rate was not significant .There were no Rh statistical differences between groups in gender or in lactancy .Recent studies have concluded that there are some differences in TEOAE response in adults depending on blood groups or Rh; studies to determine if these differences are present in newborns that have not suffered ear injuries and are supposed to have intact hearing capacity  are absent. The results of the present study suggest there is not any influence between O blood group or Rh+ and results (pass rate) in the first TEOAE registered in healthy newborns vaginally delivered at 48 h of life; however there are some observations worth discussing.A recent study from Chow  stated t® uses a nonlinear stimulus and thus increases the validity of our results, instead of being a limitation.In a similar study from Chen  with 60 Similar findings were reported by Prabhu . This stThere may be a number of possible explanations for this observed occurrence. These studies were completed in adults; therefore, age or other factors may have influenced the hearing response. Additionally, perhaps individuals with blood group O might be genetically predisposed to factors that affect OAE parameters related to outer hair cell function.Furthermore, noise-induced hearing loss was found to occur less in Turkish individuals with a non-O blood group  than those with blood group O , while aSusceptibility to noise-related hearing loss and the progression of damaging outcomes are highly variable among exposed individuals , and theThe low number of patients analyzed is a limitation of these studies, as is age , thus opening the possibility of other epidemiological factors influencing the OAE response.The data stemming from a robust number of newborns in this study strongly suggest that there are not any differences in the pass rate of TEOAE tests at birth ; it can The findings also suggest that the blood group perhaps only expresses a risk factor for the development of hearing loss, increasing the susceptibility to common life injuries such as noise. It is also not a congenital hearing handicap in newborns and a less important factor to obtain a refer result in the TEOAE test.Widely accepted data-altering factors, such as gender or breastfeeding, were not significantly different between groups , thus heThe Rh system is one of the clinically important blood groups. Human blood group antigens are transiently expressed in developing cochlear hair cells. The temporal antigen expression seems to correspond to the main events of inner ear differentiation , relating inner ear characteristics to Rh.Bener et al.  providedMore recently, Aycicek  conducteAs the Rh-associated glycoproteins play an important role in the ammonium transport in the kidneys, they might also have a similar role in the inner ear, which is anatomically and ultra-structurally similar.This research study did not find any evidence on the difference in the pass rate of the TEOAE test related to Rh . PerhapsIn summary, neither blood group nor Rh were important factors at birth to modify pass rate of TEOAE tests, an important question for newborn hearing screening programs. Differences stemming from adult studies must be further researched and confirmed given the lack of evidence to suggest congenital origin of the deficiency. It is thus necessary to study other factors that can influence the TEOAE response in adult life.The Echocheck Screener results do not provide actual TEOAE response amplitude values. As stated by other authors, it is possible that blood group O or Rh-positive newborns may have reduced amplitude OAE responses compared with the other blood groups. Although the responses may be significantly lower, those could still be adequate for newborns to pass the screening test. The TEOAE test without normal results indicates a hearing loss greater than 30 dB HL; therefore, given that there were no differences between groups, it can be stated that blood group does not make a significant difference in screening results. However, this study cannot conclude that there is not a difference in OAE response amplitudes across blood groups. Additional studies using actual response amplitude data are needed to consider the latter point.The nonlinear protocol utilized in the current study is the most common method to record TEOAEs ,27. ThisThe Echocheck Screener explores a frequency range from 0 to 6 kHz; previously cited studies showed some effect in 2 kHz in the range of Ecocheck. However, further studies are required to determine if there is any effect in some of the frequencies out of this range, such as differences in higher frequencies that cannot be detected with this device.Given that healthy newborns were examined for this study, it remains unknown if blood group or Rh increases the susceptibility to other neonatal hearing loss factors such as hypoxia or ototoxic drugs adding risk and lowering TEOAE response in the newborns. The same limitation applies to newborns delivered by cesarean section that were excluded based on the TEOAE tests being registered after 48 h, when pass rate results are increasingly reliable.Additionally, perhaps there are perinatal factors stronger than blood group or Rh that can mask their effect if the influence is mild in nature. This research study analyzed and accounted for well-known factors such as gender and breastfeeding, however, there may be other unknown elements that could influence results.Failing the TEOAE test reflects hearing loss; however, there are other factors that can alter the results, including the high frequency of the etiology not being in the inner ear but in the middle ear or in the external meatus. The findings make it cumbersome to pair the test result to actual cochlear response, however, given the large sample size, and the fact that all the newborns in the study were healthy, it can be assumed that in order to pass the test, the influence of middle ear status was similar for all.ABO blood group and Rhesus antigens (Rh) appear to not be significant factors in the pass rate of TEOAE screening in healthy newborns, however, additional studies are needed to determine if there is any mild effect in the response amplitude that is not significant enough to make a “test refer”, or if it affects frequencies not explored by the Echocheck screener.


We employed a hospital-based Internet of Things (IoT) platform to validate the role of real-time activities of daily living (ADL) measurement as a digital biomarker for cognitive impairment in a hospital setting. Observational study. 12 patients with dementia, 11 patients with mild cognitive impairment (MCI), and 15 cognitively normal older adults. The results of 13 experimental ADL tasks were categorized into success or fail. The total number of successful task and the average success proportion of each group was calculated. Time to complete the total tasks was also measured. Patients with dementia, patients with MCI, and cognitively normal older adults performed 13 experimental ADL tasks in a hospital setting. Significant differences in the average success rate of 13 tasks were found among groups. Dementia group showed the lowest success proportion (49.3%) compared with MCI group (78.3%) and normal group (97.4%). Correlation between classical ADL scales and the number of completed ADL tasks was statistically significant. In particular, instrumental ADL (I-ADL) had stronger relationship with the number of completed ADL tasks than Barthel’s ADL (B-ADL). Dementia group required more time to accomplish the tasks when compared to MCI and normal groups. This study demonstrated that there is a clear relationship between the performance of experimental ADL tasks and the severity of cognitive impairment. The evaluation of ADLs involving the IoTs platform in an ecological setting allows accurate assessment and quantification of the patient’s functional level. Activities of daily living (ADL) are utilized routinely as predictors of health and function among community-dwelling older adults to detect the early onset of disability to enable appropriate care management. Currently, the approaches for assessment are inadequate, lacking reliability, sensitivity, and validity. It is, therefore, critical to have instruments that would be more sensitive in detecting preclinical stages of functional decline.1. Among these abilities, impairment in cognitive function hinders overall performance of ADLs of older adults, which could interrupt with their independent living2. Therefore, evaluating the decline in ADLs is crucial for cognitively impaired patients to enable assessment of their actual functional status and decide whether a patient would need assistance with daily tasks. Besides, the accurate assessment of ADLs contributes to the diagnosis of cognitive disorders, including dementia and mild cognitive impairment (MCI). Longitudinally, changes in ADL performance could be monitored through the course of the cognitive disorders to investigate the progression or improvement with medications.Accomplishing routine ADLs requires several fundamental abilities: cognitive, motor, and perceptual abilities3. Furthermore, previous research has proven a disagreement between indirect ADL ratings from caregivers and the actual functional statuses of patients5. Caregivers tend to overestimate their ADL assistance and report lower levels of the functional status of patients, compared with patients’ direct assessment; thus, indicating that the indirect measurement using questionnaires has unequivocal limitations in that the subjective evaluation of ADLs is susceptible to bias and errors.Classical ADL assessment relies on patient-reported outcomes in which the patients provide responses regarding their statuses themselves or indirect ratings from informants such as caregivers. However, considering patients’ old age and cognitive dysfunction, the accuracy and reliability of self-rated questionnaires are doubtable9. The use of sensor-based technology for the recognition and classification of ADLs at home environment has been proposed in many studies11. Some of them used body-mounted systems that allow data quantitation, along with disease risk and early detection, while others utilized non-intrusive ambient sensor systems that enable capturing of environmental data for cumulative measurements. These evaluations have proven that those with body-mounted sensors, as well as non-intrusive ambient sensors could distinguish and classify different ADLs successfully by detecting and quantifying patients’ behaviors. Furthermore, it has been shown that differences in ADL pattern-performance between dementia patients and healthy controls are detectible with the use of unobtrusive in-home sensors12. On the other hand, there have been attempts to measure ADLs by direct observation and performance quantification of ADL tasks in a laboratory environment6. Assigning identical tasks to every participant in a controlled setting provides more objective and reliable data regarding the performance of ADLs.Several studies have attempted direct measurement of ADLs in a home or experimental settingsIn light of a need for direct measurement of ADLs, it is highly desirable to assess ADLs with real-time observations. On top of that, it is essential to control different variables which can exist in the living space by implementing an experimental space where ADLs can be evaluated. And unlike previous studies that focused on observing and categorizing various ADL performances, we made it possible to compare cognitive functions in a more objective way by having all participants perform the same type of ADLs.17. While video- or microphone-based platforms are remarkable in detecting human activities technically, concerns over maintaining privacy have been raised. Installing videos and microphones in the most private space and transmitting the information on daily lives to an external server are likely to fail approval by the general population, despite their technological advantages.We employed a hospital-based Internet of Things (IoT) platform to validate the role of digital real-time ADL measurement for cognitive impairment, as the next steps in the progress of the development of the IoT devices. In the course of the advancement of this IoT instrument, there have been many studies on various platforms for the recognition of daily activities in the living environment and/or monitoring the deterioration of cognitive abilitiesOur IoT instruments platform was constructed with deliberation on the optimal balance between privacy and technical feasibility. A series of processes, including distinguishing a person’s identity, deciding whether a person’s behavior is in the normal range or not without videos or microphones, and transmitting the information to caregivers or a designated community care center requires highly sophisticated technologies.We hypothesize that there would be considerable differences in the performance of the experimental tasks depending on the degree of cognitive impairment of the study participants. At the same time, we explored the potential of the hospital-based IoT platform in assessing ADLs for clinical decision-making. With the results from this platform, we analyze the discriminant power of the experimental tasks to determine if the real-time measurement of ADLs would have clinical significance in distinguishing the cognitively impaired patients.controls] = 87.56%–107.31, CIMCI = 66.79%–89.85%, CIdementia = 38.32%–60.40%; P < 0.001). Among the three groups, the dementia patients showed the lowest average success proportion. Overall, among the 13 different tasks that were subjected to completion, the type of task that involved using a microwave oven (task 12) demonstrated the lowest success proportion while entering the test room (task 1) demonstrated the highest success. In the analysis of task completion time, there were significant differences among the three groups regarding the time it took to complete the tasks . On average, the dementia group required more time to complete the tasks, compared with the MCI group  and normal control group . Among the tasks, moving to the kitchen (task 9) required the longest amount of time, while entering the test room took the least amount of time (task 1). In summary, dementia patients needed more time to finish the tasks and yet showed the least successful performance, whereas the normal group performed most of the tasks successfully with the least time.Figure Figure χ2 = 101.84, P < 0.001, Model 2; χ2 = 36.58, P < 0.001, Model 3; χ2 = 68.39, P < 0.001). Model 1 showed the highest discriminant power , as this model comprised the individual variables which had been used to discriminate against the experimental groups in the first place. Model 2, which was constructed with B-ADL and I-ADL, excluded the cognition assessment scales  in order to compare with Model 3, which showed the lowest discriminant power among the classifying groups . The misclassification rate of Model 2 was highest among the three models (31.5%). Although Model 3 revealed lower discrimination hit ratio, compared with Model 1, it showed a higher discriminant hit ratio (89.5%) than Model 2 (67.6%).Table Figure rho =  − 0.75; rho =  − 0.64, P < 0.05, respectively), followed by the result of ambulating . On the other hand, B-ADL scores were significantly related to only four of the tasks .An association between the scores obtained on the clinical ADL scales (B-ADL and I-ADL) and the results of 13 experimental tasks was identified. Figure The goal of this study was to evaluate the ADL of normal older adults and cognitively impaired patients using IoT devices and network technologies and to verify their effectiveness in the hospital setting. ADL performance of three cognitive groups of dementia patients, MCI patients, and normal participants was evaluated using 13 experimental tasks. We used an IoT-based platform to measure participants’ task success proportion and task completion time and statistically confirmed how effectively these results could classify the groups. Accordingly, the ADL experimental tasks among patients with dementia had the lowest success proportion and the longest completion time of task time. When it came to the distribution pattern of the results, the greater the severity of the group’s cognitive decline, the more heterogeneous the distribution pattern of the individual patient was. Additionally, the classifier composed of the ADL experiment tasks showed greater discriminant power to distinguish three cognitive groups than the classifier composed of B-ADL and I-ADL scores.Through this experiment, it was evident that there are systemic statistically significant differences in the performance of ADL tasks relative to the different cognitive levels of the three groups. The dementia group showed the worst performance among the three groups, while the MCI patients showed better performance than the dementia patients but not as good as the normal participants. Thus, the results of performing the experimental tasks, which are derived from ADLs in real life, are likely to reflect the deterioration of patients with cognitive impairment in their living environment.Our analysis(LDA) that looked at how well the experiments in this study could distinguish the groups which had already been separated by clinical scales. It was proved that the classifier created using the results of the experimental task distinguished the clinical groups to a precise degree, although the task of evaluating the cognitive function itself was not included in the experiment. These results are consistent with the purpose of this study, set to quickly and accurately measure the ability to perform ADLs in a clinical scene by recognizing the success or failure of the task using IoT devices. Moreover, the results of this study not only show the technical feasibility and clinical usefulness of the IoT technology but also suggest the potential of the IoT devices to advance in their development into a useful platform that could evaluate ADLs accurately, while satisfying the conditions to protect the privacy of patients. The advantage of such privacy protection can lead to the use of the IoT devices as a method to measure ADLs in the daily life of patient.21. The experimental tasks in this study included both types of ADL tasks; those involving ambulating and maintaining hygiene represent B-ADL, and those involving utilization of different instruments  represent I-ADL. The fact that the performance results of the tasks have a stronger correlation with I-ADL than the B-ADL suggests that the tasks in this study could better detect the deterioration of early cognitive function in a like manner as I-ADL.Among the different types of ADL, it has been demonstrated that the decline in I-ADL is more sensitive to MCI or early dementia than B-ADL because I-ADL deteriorates when higher cognitive function is impaired22, this was a point-in-time assessment and possibly not fully demonstrate the participants’ daily living skills in their homes or a facility.The major limitation of this study trace to the experimental procedures because participants with hearing impairment or gait disturbance were excluded who might have difficulties in performing the tasks successfully despite normal cognitive function. Meanwhile, since the tasks of evaluating ADLs are limited to a few, it could not fully represent activities in daily life consisting of hundreds of older adults. In the same vein, evaluations of social activities, outings, and financial management have not yet been incorporated into the tasks due to constraints in the laboratory setting. Also, unlike previous studies in which ADL was assessed over a period of timeRegarding the IoT platform, despite its several advantages, which include the short duration of measurement time, high-level of patients’ privacy, and autonomous network system among the devices, the platform exhibited a relatively high frequency of errors during the experiment (12.15%), and thus, needs to be improved in future studies.In conclusion, the evaluation of ADLs using the IoT platform demonstrated a clear correlation between cognitive function and ADL performance. The results of ADL performance showed a substantial determinant power in regard to classify the participants into three cognitive groups. The significant association between I-ADL score and ADL performance also suggests that the direct ADL measurement can prove its value in detecting early stage of cognitive decline. Furthermore, the measurement of ADLs in a hospital setting showed the potential to provide clinicians with evidence to understand the cognitive level of patients and tools to follow up on changes in cognitive function in the course of the patient’ disease.23.We conducted an observational study with an enrollment of a total of 38 participants, 12 dementia patients, 11 MCI patients, and 15 normal controls, recruited via the clinic in the Department of Neurology at Kyungpook National University Chilgok Hospital, Daegu, South Korea. We excluded patients with following conditions. (1) Patients with major psychiatric illnesses according to the criteria of DSM-IV, (2) patients who has been treated with chronic kidney disease, chronic respiratory disease, malignant tumor, and uncontrolled diabetes or hypertension. (3) Patients with systemic conditions that are known to cause dementia , (4) Patients with substance-induced conditions, (5) patients with profound hearing loss, blindness, or gait disorder which makes it difficult to be testedThis study was approved by the Institutional Review Board of Kyungpook National University . All procedures about this study were explained to the participants and a written informed consent was obtained prior to participation. Patients with dementia and mild cognitive impairment provided their own written informed consent. Also informed consent was obtained from legally authorized representatives of the dementia and with mild cognitive impairment participants. The study was conducted following the principles established in the Helsinki Declaration update of 2008.24, which included K-MMSE, CDR, GDS, B-ADL, and I-ADL).Demographic data, including age, sex, and educational level of the participants, were gathered, as displayed in Table Three different devices were designed to measure and assess ADL in this experiment Fig. . The resThe mobile identification device (MID), wore by each participant, was developed in the form of Smart Band or Smart Tag. The MID communicated with the RD so that it could recognize a participant performing a specific task. The RD and MID used two different communication methods, low frequency (LF) and Bluetooth low energy (BLE). When a participant performed an experimental task, the LF signal was generated from the RD to wake up the nearby MID, and the BLE enabled the RD to gather the information regarding the participant’s identity and the distance from the MID. Furthermore, this combination of LF and BLE allowed the RD in every entrance to detect a participant’s access to the MID. In this study, we used this method to capture data on the movement of the participants tagged with the MID.The location anchor hub (LAH) was placed in every unit space (10 × 10 cm) to collect data from the RD and MID in the same area and perform self-analysis of the data, whereby, it distinguishes the results of the tasks and decide whether it would repeat the recorded prompt or allow the participant to proceed to the next task. The LAH also gathered the received signal strength indicator of BLE, advertising from the MID so that it could broadcast a task-specific prompting, according to the presumed location of the MID. The LAH experiments automatically measure the ADL and analyze the results, including the task performance and task completion time based on the recorded data.Thirteen experimental tasks were developed for the measurement of the ADL see Fig. . The perA number was assigned to each task according to the sequence of the task performance. The procedure started from entering the test room (Task 1), followed by entering the toilet in the test room (Task 2). Then the participants were instructed to use the toilet (Task 3) and navigate to the sink (Task 4). After washing hands at the sink (Task 5) and wiping hands by a paper towel (Task 6), participants measured their own blood pressures with a sphygmomanometer (Task 7) in the test room. Subsequently, they were asked to use the Smart Pill Reminder, which provided pills automatically (Task 8). Next, participants were directed to the kitchen outside the test room (Task 9) and operate the gas stove (Task 10), followed by using the coffee machine (Task 11) and the microwave (Task 12) in the kitchen. Finally, they were asked to go back to the test room, where they initiated the experiment (Task 13). All the tasks except Task 5 were measured by the SRD. The ESD detected participants’ hands washing at the sink (Task 5). When a participant equipped with a MID initiated a sequence of the tasks, the measuring devices autonomously communicated with each other, and restored data, based on the participants’ location, the results of task performance, and task completion time in a memory device.rho). Statistical Package for Social Sciences  was used for LDA, a repeated-measured analysis of variance (ANOVA), and descriptive statistics. One-way ANOVA was used for participants’ demographics. The success proportion and task completion time were analyzed using repeated-measures ANOVA. Wilks’ lambda, Eigenvalues, and Discriminant hit ratio of three LDA models were calculated with SPSS. P-values for a two-tailed test were selected and P < 0.05, P < 0.01, and P < 0.001 were considered significant when comparing demographics, LDA, correlation, and ANOVA.Data preprocessing, data visualization, correlation analysis, and Linear Discriminant Analysis (LDA) was conducted by R software . We verified the relationship between the clinical ADL parameters  and thirteen ADL tasks using Spearman’s correlation coefficient (


Globally, access to hearing health care is a growing concern with 900 million people estimated to suffer from disabling hearing loss by 2050. Hearing loss is one of the most common chronic health conditions, yet access to hearing health care is limited. Incorporating Web-based  service delivery into current treatment pathways could improve access and allow for better scalability of services. Current electronic health studies in audiology have focused on technical feasibility, sensitivity, and specificity of diagnostic hearing testing and not on patient satisfaction, experiences, and sustainable models along the entire patient journey.This study aimed to investigate a hybrid (Web-based and face-to-face) hearing health service in terms of uptake, experience, and satisfaction in adult patients with hearing loss.A nonprofit hearing research clinic using online and face-to-face services was implemented in Durban, South Africa, using online recruitment from the clinic’s Facebook page and Google AdWords, which directed persons to an online Web-based hearing screening test. Web-based and face-to-face care pathways included assessment, treatment, and rehabilitation. To evaluate the service, an online survey comprising (1) a validated satisfaction measurement tool (Short Assessment of Patient Satisfaction), (2) a process evaluation of all the 5 steps completed, and (3) personal preferences of communication methods used vs methods preferred was conducted, which was sent to 46 patients who used clinic services.P=.007) was found between age and the number of appointments per patient. Around 61% (19/31) of patients previously completed diagnostic testing at other practices, with 95% (18/19) rating the services at the hybrid clinic as better. The net promoter score was 87, indicating that patients were highly likely to recommend the hybrid clinic to friends and family.Of the patients invited, 67% (31/46) completed the survey with mean age 66 years, (SD 16). Almost all patients, 92% (30/31) reported that the online screening test assisted them in seeking hearing health care. Approximately 60% (18/31) of the patients accessed the online hearing screening test from an Android device. Patients stayed in contact with the audiologist mostly through WhatsApp instant messaging , and most patients  preferred to use this method of communication. The patients continuing with hearing health care were significantly older and had significantly poorer speech recognition abilities compared with the patients who discontinued seeking hearing health care. A statistically significant positive result (This study applied Web-based and face-to-face components into a hybrid clinic and measured an overall positive experience with high patient satisfaction through a process evaluation. The findings support the potential of a hybrid clinic with synchronous and asynchronous modes of communication to be a scalable hearing health care model, addressing the needs of adults with hearing loss globally. Globally, access to hearing health care (HHC) is a significant challenge affecting 466 million people, and this number is expected to rise to 900 million people by 2050, who are estimated to have disabling hearing loss . The limTraditional HHC service delivery models focus on face-to-face, clinic-based testing, hearing aid or device fittings, counseling, and rehabilitation requiring several patient visits. HHC can be made more accessible through scalable models of care that capitalize on global trends in connectivity and technology . For exaThe use of these telecommunication and information technologies in medicine is called telemedicine or telehealth; in the field of ear and hearing health, the terms tele-otology and tele-audiology are also used . Owing tThere is a growing body of evidence on the use of telehealth in HHC, including screening ,17 diagnA dearth of evidence on patient satisfaction when using telehealth HHC services is apparent , as onlyOffering hearing services completely online along the entire patient journey is challenging. Online components were selected based on validated and evidence-based tools, which would not compromise the quality of patient care . These components  were included in face-to-face appointments as online alternatives were not yet available at the conception of this study. The model is described further in the following section and in the study by Ratanjee-Vanmali et al .In a previous study, we reported on the behaviors of participants who failed the online hearing screening test. Approximately 25% (13/51) of participants proceed from motivational engagement to diagnostic testing and the remainder 75% (38/51) do not transition for the following reasons: unanswered phone call, 45% (17/38), further investigation , incorrect contact details, 8%(3/38), doctor did not advocate for further treatment, 8%(3/38), limited finances, 8% (3/38), and beyond the test geolocation, 3% (1/38) . TherefoThis study aimed to describe a process evaluation of HHC through a hybrid clinic combining online and face-to-face services , with a The institutional review board approved the research (GW20170409HS).This research project established a nonprofit hearing research clinic  in DurbaUpon completion, patients could opt to provide their contact details to be contacted by the clinic. If patients contacted the clinic without taking the online hearing screening test, they received a link encouraging them to complete the online test. At the beginning of every face-to-face appointment, the clinic audiologist verified the completion of the online hearing screening test. Asynchronous and synchronous online communication, as well as face-to-face communication supporting screening, diagnostics, hearing aid fitting, rehabilitation, and continuous monitoring and coaching, were offered. In total, 5 steps were included in the patient journey . The firThe online hearing screening test is an adaptive triple digit–in–noise test developed and validated for South African English that determines a speech reception threshold ,31. The When beginning the online hearing screening test, each participant was required to provide their date of birth. For each participant completing the online hearing screening test, the signal-to-noise ratio (SNR) where 50% of digits are recognized correctly, was recorded. The geolocation was also provided, which helped verify whether participants were within the geolocation of the test, ie, the greater Durban area. The pass or fail threshold of the online hearing screening test was based on optimal sensitivity and specificity to a 4-frequency pure tone average at 0.5, 1, 2, and 4 kHz ≤25 dB HL in the better ear.On completion of the screening test, individuals were informed of their result in terms of pass or fail. Individuals could share their contact details if they wanted the clinic audiologist to contact them. The online hearing screening test results were stored in mHealth Studio Cloud; even if individuals did not share their contact details, the result was stored with an accurate geolocation which ensured that only data from the target location was used in the analysis . Only thThis step consisted of a phone call or WhatsApp message thread where the clinic audiologist assessed the readiness to book a face-to-face diagnostic hearing evaluation and provided motivational engagement.Individuals who shared their contact details received an email with the clinic audiologist’s contact details, motivational engagement questions, and suitable times and dates for a phone call.Readiness measurement and motivational engagement consisted of 2 validated tools: the line and staging algorithm that were used with the participant over the phone. The line is a single-item measure to assess readiness for hearing help-seeking in one question: “How important is it for you to improve your hearing right now?” Responses are recorded on a Likert scale from 0 to 10, where 0 indicates not at all and 10 indicates very much ,34. The This step consisted of a face-to-face appointment where the clinic audiologist completed a battery of assessments including an in-depth case history, video-otoscopy, acoustic reflexes, pure tone audiometry (air and bone conduction), and speech audiometry. If no red flag  suggesting a medical referral was raised, a hearing aid trial was recommended.A successful hearing aid trial entailed that the patient acquired hearing aids fit according to their personalized gain setting, signal processing, noise management system, automatic systems, style, and color. During the hearing aid trial, a receiver in the ear with domes chosen to meet acoustic requirements was fit to meet the patient’s audiological profile. Patients were then offered a choice to opt for the style of hearing aids they preferred once counselled on the acoustic performance, physical characteristics of the available hearing aids, and personal needs (from in-the-ear custom options to behind-the-ear hearing aids). Trial hearing aids were then fit and customized to the audiometric profile of the patient using real-ear measurements to take individual ear canal properties into account.All patients who acquired hearing aids were offered an online audiological rehabilitation program  and the The online audiological rehabilitation program consisted of 5 modules  that are a combination of videos, tasks, testimonials, and reading assignments. The completion of a module would unlock the next module. The 5 modules were completed all at once or weekly as per the patient’s availability. Through prerecorded videos, a coach guided the participants through the different modules and components. More information regarding the hybrid clinic has been reported elsewhere .An online questionnaire was used to determine the experience and satisfaction of patients seeking and receiving HHC using the hybrid clinic, incorporating online and face-to-face services. The online questionnaire was hosted and administered by Qualtrics  . The resThe questionnaire  consisteThe online questionnaire included a process evaluation, recorded on a 5-point Likert scale, which evaluated all the 5 steps . The metSAPS  assessesThe net promoter score (NPS) is a single question about willingness to recommend a product or service that companies commonly use : “On a sThe online questionnaire was sent via email to 46 patients who completed the diagnostic hearing evaluation (steps 1-3). Data for each patient gathered from their files were linked by their email address and then hidden to ensure anonymity and were issued patient numbers during data analysis. Data were collected over 3 months (December 2018-February 2019); patients had sought help from the clinic during a period of 19 months (June 2017-January 2019). All patients who completed the survey were in contact with the clinic within 6 months of completing the online questionnaire.The initial email invitation was sent on December 4, 2018, and a WhatsApp message was sent prompting patients to check their email mailboxes for the questionnaire. Up to seven reminder messages (email and WhatsApp) were sent to nonresponses over 12 weeks.Patient data were stored in two locations: (1) a cloud-based system for appointment times and notes and (2) a server-based system for diagnostic results. Both systems were password protected and only accessible by the clinic audiologist.Purposive sampling was used to collect patients’ experiences and satisfaction of the hybrid clinic services. Patients who failed the online hearing screening provided consent to be contacted by the clinic audiologist before submitting their details. Written consent to partake in the study was provided during the face-to-face diagnostic hearing evaluation (step 3).P<.05. The Shapiro-Wilk test (nonparametric test) was used to test normality, which confirmed that the data were not normally distributed. Cronbach alpha was used to test the internal validity of the entire process evaluation questionnaire.Data were analyzed using SPSS Inc, version 25  . StatistThe reporting of questionnaire results is in accordance, as far as possible, with the Checklist for Reporting Results of Internet E-Surveys .A total of 665 participants completed the online hearing screening test and submitted their details for further HHC services during this evaluation period. A total of 629 participants were contacted by telephone or WhatsApp for motivational engagement; a few were unreachable owing to incorrect details submitted. Out of the 629 participants contacted, 46 (7%) became patients of the clinic and sought HHC services . Of the Patients (N=31) accessed the online hearing screening from Android , iOS , and Windows PC  devices. The majority of patients agreed or strongly agreed that the online hearing screening was simple to complete , was quick and informative , was easy to use  and assisted them to continue HHC , quick , provided useful  and relevant  information, assisted in taking the next step , and assisted in booking the diagnostic hearing evaluation ; Patients communicated with the clinic using WhatsApp messaging , emails , voice calls , text messages , and Facebook Messenger . The majority of patients preferred the following methods of communication with the clinic audiologist: WhatsApp messaging , email , or voice calls .Patients attending face-to-face diagnostic appointments agreed and strongly agreed that the test was comprehensive , provided the information needed , was easy to complete , and was trustworthy  with sufficient time spent taking it  had previously completed a diagnostic hearing evaluation (step 3) at other practices. In comparison with previous experiences, one person rated the hybrid clinic as the same while the other 18 patients rated their experiences as better.From the open-ended responses, two main themes emerged for the differences between prior experiences and the hybrid clinic: clinician engagement and technology. Clinician engagement included aspects of personal attention, patience, dedication, thorough explanations, professional behavior, exceeding expectations, friendliness, and trust. Technology included aspects of the latest technology and equipment and offering trial hearing aids.Patients agreed and strongly agreed that a hearing aid trial helped to experience the difference that hearing aids can make in their life . All patients who acquired their hearing aids (steps 4-5) agreed and strongly agreed that the hearing aid trial and its usage was beneficial .Of those patients who were fitted with hearing aids (steps 4-5), the majority  complimented the service received, were satisfied with the care offered, and did not have suggestions for service improvements. Reasons for patients not continuing with HHC  included cost as a prohibitive factor , concerns regarding the stigma of wearing hearing aids , and belief that the hearing loss was not severe enough to warrant the use of hearing aids . One person suggested a financing option to make hearing aids more affordable.Except for 1 person, all patients agreed and strongly agreed that the online audiological rehabilitation was helpful . In addition to the program, support was offered to patients as required both online and by face-to-face methods.The mean SAPS score of the 31 patients reported was 26 SD 3; . There wThe NPS score was 87, which indicates that patients are highly likely to recommend the clinic to friends and family. The majority of patients  provided reasons for their rating including competence, result-driven exceptional service , tailored service , and reliable and efficient service .The three most important reasons for continuing with HHC services with the hybrid clinic were as follows: personalized care and understanding audiologist, who is patient and accommodating ; confidence in the audiologist, kind, caring, helpful, caring, efficient ; and technical knowledge of the product and equipment .r=0.367; P=.007) and a positive but not significant correlation  was reported between age and the number of support instances.A significant positive correlation was found between age and the number of appointments  in terms of wait time when loading the widget on mobile devices or computers, proficiency with the digital device, or the actual test duration. Hearing screening tests are typically offered in isolation, and longitudinal studies show that a significant percentage of people do not follow-up with diagnostic measures and rehabilitation -49. ApprWhatsApp messaging was rated highly, and patients were satisfied with this mode of communication. Patients used and preferred WhatsApp messaging as the primary communication method with the clinic where a dedicated mobile phone with WhatsApp, phone calls, and email was set up for this hybrid clinic. In other health professions, physicians have successfully incorporated WhatsApp into clinical practice with no need for further training or technical competency building .The advantages and disadvantages of using WhatsApp in clinical practice are well documented within health care . HoweverThe diagnostic hearing evaluation (step 3) was an integral step to establish a therapeutic relationship in this hybrid model. A strength of this model was that the therapeutic relationship already commenced before the face-to-face appointment (step 3) and was continued through the patient’s HHC journey with the same clinic audiologist either online or in-person. The benefit of clinician continuity is mixed; in a physician environment, seeing a known provider is found to be beneficial in terms of a cost-benefit factor , whereasPrevious tele-audiology studies have taken steps toward investigating patient satisfaction within remote hearing aid fittings , serviceThe online audiological rehabilitation offering was reported as a positive addition to this hybrid clinic’s services. eHealth might be a viable option to offer tele-audiology services to both adult patients and their significant other as they already use internet-connected technologies to access health care, and this could promote patient-centered care from a biopsychosocial context . TeleheaPatient satisfaction in this study, which used 5 steps in a hybrid HHC service delivery model, was found to be higher than previously published SAPS data. In this study, the SAPS mean score was 26 (SD 3) as compared with findings from an incontinence clinic   and a psThe audiologist’s clinical engagement and professional services were identified as essential components in the positive patient experiences in this study. Previous research also indicates that patients prefer patient-centered interactions with a health professional, and this is associated with high satisfaction . OfferinEven though 61% (19/31) of patients experienced previous HHC services from other audiologists or clinics, 95% (18/19) rated the services offered in this hybrid clinic more favorably. Patient experience and satisfaction were equally high and positive in both online and face-to-face service offerings in this hybrid clinic. However, there is still a paucity of evidence regarding the uptake of eHealth HHC, its effectiveness, and the satisfaction of patients using such service delivery models. As technology evolves, so will the continuum of direct-to-consumer and traditional face-to-face models. This study applied online and face-to-face components into a hybrid clinic and measured high patient satisfaction through a process evaluation. This model still required the need for 1 or 2 face-to-face appointments with the audiologist compared with more traditional clinical pathways. The fact that older patients needed more appointments may indicate that more audiological support is needed in the initial stages of adapting to hearing aids where additional support could be offered using asynchronous methods. This study provides initial evidence that can support audiologists who are limited in numbers but are required to provide services to a large area. This model may also provide patients with an alternative service delivery model, who could benefit from a combination of online and face-to-face appointments. Individual audiologists can customize this hybrid model to meet the needs of their patient demographic and for those patients willing to seek HHC differently.This study offered individuals searching for HHC within the target location with an online hearing screening test as the first action to initiate care. Combining online and face-to-face communication methods also allowed patients to stay in touch with the audiologist when needed. Patients paid for their HHC services, removing volunteer biases and highlighting the potential of this model to translate into a scalable clinical practice. However, patients who pay for their hearing aids could introduce another bias or view services as more favorable, and this could be considered a limitation. Another limitation of the study is the lack of a comparator to establish whether this hybrid model was better or worse as compared with more traditional HHC delivery models where satisfaction could be measured as being similar in face-to-face only with no online services employed. The fact that the same person served as the clinician and as the researcher collecting the online questionnaires and that patients could have been influenced to provide favorable ratings  could also be considered limitations in this study. The completion of the questionnaire is also vulnerable to both nonresponse bias  and recall bias. It is not possible to separate the influence of the audiologist’s skills versus the hybrid model when analyzing the patients’ satisfaction with the care received. This study also had a relatively small sample within a defined area of South Africa that required patients to have internet access and the necessary digital skills to complete an online hearing screening test, which limits generalizability. Future studies in modifications to the service delivery models would benefit from a comparator group designed into research studies and to test mobile and computer proficiency and the effects of age on the uptake of HHC in such a hybrid model. Another future consideration would be to document the long-term effects in terms of economic viability and scalability of such a model. This hybrid model is the first concept to be tested, and we foresee modifications to this service delivery model made possible in the future when technology advances to facilitate more audiological services remotely to meet the needs of the patient and the audiologist.In conclusion, the positive patient experience and satisfaction demonstrates the potential of hybrid online and face-to-face HHC to meet patient needs. Sustainable and scalable service delivery models that incorporate eHealth are required to meet the challenges of untreated hearing loss globally.


Ototoxicity associated with platinum-based chemotherapy is highly prevalent and can cause detrimental consequences among cancer survivors.In this article, we highlight important aspects of the evaluation of ototoxicity with the aim to increase awareness of Oncologists in this regard. Standard pure tone audiometry alone is inadequate for this context. Comprehensive and consistent hearing tests should be implemented in a monitoring and surveillance program. High-frequency audiometry (10–16 kHz) is a sensitive tool in the detection of ototoxic hearing loss at onset. In addition to threshold audiometry, measures of speech comprehension (both in quiet and in noise) can add useful information in the evaluation of hearing in real-life situations. Not only hearing loss, but also tinnitus and imbalance are common in patients who receive platinum-based chemotherapy, and can cause debilitating effects upon quality of life in this population. Moreover, self-report measures associated with cochlear and vestibular handicaps can provide valuable information regarding the impact of ototoxicity.It is vital to build awareness about the variety and impact of the symptoms of ototoxicity. Comprehensive evaluation of hearing status along with self-reported impact of the cochlear and vestibular handicap should be implemented in a monitoring and surveillance program for appropriate investigation and management. Platinum-based chemotherapies, such as cisplatin and carboplatin, are highly effective chemotherapeutic agents used for the treatment of a variety of life-threatening common cancers including testicular, gynaecologic, bladder, head and neck, and non-small cell lung cancer . DespiteOtotoxicity refers to drug-related damage affecting the inner ear structures, specifically to the cochlea and the vestibular labyrinth, and their associated neural structures , 7. OtotAlthough hearing loss is not a fatal condition, it can have significant negative impacts on communication and health-related quality of life , and hasEarly identification of ototoxicity might provide oncologists with an opportunity to adjust the chemotherapy regimen, either lowering the dosage or change to alternative drug, to reduce or prevent further hearing deterioration . The priWhilst there are many studies that report ototoxicity associated with platinum-based chemotherapy, the literature is characterized by small sample sizes, inadequate baseline measures, and non-standard reporting of audiometric measures. The prevalence of platinum-based ototoxicity in adults reported in the literature is approximately 50–80% , 20 and In this review, we argue that the prevalence of hearing loss associated with platinum-based chemotherapy can only be robustly determined by the consistent and appropriate use of measures of hearing in a strict pre, post, and long-term framework. Furthermore, we contend that the standard audiogram, a measure of the threshold of pure tone detection in quiet, is not a sufficient measure of real-world hearing. The use of extended high-frequency audiogram (HFA) (10–16 kHz) facilitates early detection of ototoxic hearing loss at onset. Measures of speech comprehension, both in quiet and in noise, should also be utilized. Additionally, we discuss that treating ototoxicity as a synonym for hearing loss excludes the prevalent issues of tinnitus and/or imbalance found in this population. Finally, whilst self-report measures of auditory or vestibular handicap are imperfect tools, they should be brought to bear in studies of platinum-induced ototoxicity to determine the impact of ototoxicity.Hearing loss caused by ototoxic medication has a relatively predictable pattern as it initially preferentially damages outer hair cells in the basal turn of the cochlea and then progresses to the apical turn . TherefoConventional pure tone audiometry (PTA) remains the mainstay for the identification and categorisation hearing impairment in many ototoxicity grading systems . A PTA mClinically, ototoxicity is diagnosed by comparing functional status before and after the administration of ototoxic drugs; hence, baseline evaluation is essential. This prevents inaccurate diagnosis of iatrogenic ototoxic hearing loss actually caused by previous hearing impairment prior to chemotherapy treatment such as presbycusis or noise-induced hearing loss. This is particularly important in adult population as those conditions share similar audiometric results to those caused by ototoxic medications. Obtaining pre- and post-treatment hearing assessments also support basic and clinical research on drugs or interventions that can neutralize ototoxicity while not interfering with the efficacy of the anti-neoplastic capabilities of chemotherapy. Pre-existing hearing status in combination with cisplatin cumulative dose can be useful in the prediction of the degree of ototoxic hearing loss . A tool Drug-induced hearing loss is generally irreversible and occurs in a dose-related and cumulative fashion , 36. ConThe use of different criteria and grading systems for ototoxicity has made the analysis of published data challenging to interpret and has partly contributed to the variability in reporting the prevalence of drug-induced hearing loss throughout the literature . Hence, All of the available information emphasizes the importance of coherent and proper hearing measurement before, during, and after chemotherapy to determine the incidence and prevalence of hearing impairment associated with platinum-based chemotherapy. However, such monitoring programs are not routinely implemented  despite A complaint expressed by people with hearing impairment is of hearing difficulties in noisy environments , though,Speech discrimination abilities may be affected as well as detection of hearing thresholds after receiving platinum-based chemotherapy . HearingTinnitus is a subjective perception of sound, for example, hissing, whistling or buzzing, without an external source , and whiVestibular effects associated with platinum-based chemotherapy are less frequently described in the literature compared to auditory symptoms, but can be debilitating . VestibuOtotoxic medications are generally administered systemically and, therefore, affect both ears simultaneously. Bilateral symmetrical gradual vestibular loss usually results in insidious disequilibrium, postural imbalance, or oscillopsia . A compeAlthough testing can detect hearing loss at an early stage, the impact upon daily activities and quality of life as assessed by self-report is also important. One common limitation of the available cochleotoxicity grading systems is a lack of indication of significant clinical change of hearing linked to reduced communication function and quality of life . SimilarSelf-report measures of communication difficulty should complement audiometric examinations in monitoring protocol to guide treatment plans and hearing rehabilitation as well as to gain a better understanding of the incidence and burden of ototoxicity. An example of patient-reported tools is the Scale of Chemotherapy-Induced Neurotoxicity (SCIN) . PatientOtotoxicity associated with platinum-based chemotherapy is a salient issue. It should be a priority to build awareness among patients and healthcare providers about the significance and variety of symptoms of ototoxicity such as reduced hearing, tinnitus, and imbalance. Comprehensive and robust baseline hearing tests within a monitoring and surveillance program should be scheduled to assess prevalence of hearing loss associated with platinum-based chemotherapy. Measures of speech-in-noise complement speech discrimination testing in quiet conditions and can add helpful information in the evaluation of real-life hearing abilities. Furthermore, the potential impact of cochlear and vestibular handicap caused by ototoxicity should be assessed by self-report measures.


Both hearing and vision impairments are some of the most common deficits experienced by older adults. We examined the impact of self-reported vision and hearing impairments on disability-free life expectancy (DFLE). We used harmonized data from the Gateway to Global Aging Data from the US Health and Retirement Study (HRS) and the English Longitudinal Study of Ageing (ELSA). We used discrete-time multistate life table models to estimate disability-free life expectancy by sex, age and country. In both countries and at all ages either vision or hearing impairment was associated with shorter DFLE compared to those who reported no impairments. Reporting both vision and hearing impairments reduced DFLE. For example, at the age of 50, men and women with both vision and hearing impairments could expect to live up to 12 fewer years free from disability compared with men and women with no impairments, similar results were found in both countries.