Hearing aids are important assistive devices for hearing rehabilitation. However, the cost of commonly available commercial hearing aids is often higher than the average monthly income of individuals in some developing countries. Therefore, there is a great need to locally produce cheaper, but still effective, hearing aids. The Thai-produced P02 hearing aid was designed to meet this requirement.To compare the effectiveness of the P02 hearing aid with two common commercially available digital hearing aids (Clip-II™ and Concerto Basic®).A prospective, randomized controlled trial with a cross-over design was conducted from October 2012 to September 2014 in a rural Thai community. There were 73 participants (mean age of 73.7 ± 7.3 years) included in this study with moderate to severe hearing loss who were assessed for hearing aid performance, including probe microphone real-ear measurement, functional gain, speech discrimination, and participant satisfaction with the overall quality of perceived sound and the design of the device.p-value > 0.05). Real-ear measurements of the three hearing aids met the target curve in 93% of the participants. The best real-ear measurement of the hearing aid following the target curve was significantly lower than that of Clip-II™ and Concerto Basic®  at high frequency. However, participants rated the overall quality of sound higher for the P02 hearing aid than that of Clip-II™ but lower than that of Concerto Basic® . Participants revealed that the P02 hearing aid provided the highest satisfaction ratings for design and user-friendliness with statistical significance .There were no statistically significant differences in functional gain or speech discrimination among the three hearing aids evaluated (The P02 hearing aid was an effective device for older Thai adults with hearing disabilities. Additionally, its modern design, simplicity of use, and ease of maintenance were attractive to this group of individuals. These benefits support the rehabilitation potential of this hearing aid model and its positive impact on the quality of life of older adults in developing countries.Clinicaltrial.govNCT01902914. Date of registration: July 18, 2013.This study was registered under  Hearing impairment is a global problem that affects communication and individuals’ quality of life. In 2019, the World Health Organization (WHO) estimated that 1.57 billion people globally presented with hearing loss. Of all people with hearing impairment, 62.1% were older than 50 years. With an ageing society, the number of people with hearing loss will increase to an estimate of 2.45 billion people by 2050 . The exaHearing aids play an important role in aural rehabilitation; however, the cost of hearing aids is higher than the average monthly income of some individuals in Thailand . The WHOThe National Electronics and Computer Technology Center (NECTEC), a Thai governmental organization, developed body-worn aid, digital, programmable hearing aids and has been producing them since 2006. The first model, PDN-01B, also called P01, met the electro-acoustical test standards set by the International Electrotechnical Commission (IEC 60118–7) . Clinica®  and Clip-II™ . These three hearing aids have a similar level of amplification. Their specifications are provided in Table This study was designed to compare the effectiveness of a locally produced Thai body-worn hearing aid (P02) versus two common commercially available digital trimmer hearing aids, Concerto BasicA prospective, randomized controlled trial with a cross-over design was conducted from October 2012 to September 2014 in rural Thai districts, including Phuwieng; Wiengkao; and Nongnakum, Khon Kaen Province. Inclusion criteria were participants who were ≥ 60 years old, were new hearing aid candidates, had bilateral sensorineural hearing loss with an average pure-tone air-conduction threshold between 500 and 2000 Hz in their better-hearing ear within a range of 41–75 dB, had no otorrhea for at least 3 months, had no pathology of the external ear canal by otoscopy examination, and had no suggestive middle ear effusion or mass by tympanometry. Participants were excluded if they had speech discrimination with a Thai monosyllable word list of less than 40% in both ears or suggestive retro-cochlear pathology. Written informed consent was obtained from all participants.® and Clip-II™ devices considered as the controls. The testing order of the three hearing aids was produced by computer-generated randomization for each participant. The audiologists were blinded to the generated order sequence since each participant’s order was placed in an envelope before the hearing aid testing began. All participants’ hearing levels were tested with a standard audiogram before the hearing test day and on the same day as the experiment; hearing aid testing was performed on the better hearing ear. Hearing aid performance was evaluated by probe microphone real-ear measurement and was adjusted for each participant, and each hearing aid met the best target curve by an audiologist in a quiet room. The hearing aid was then placed in a bag for masking from the second audiologist and participants. In a standard soundproof room, participants’ functional gain and speech discrimination before and after using each hearing aid were evaluated by a second audiologist to avoid bias. Participants and the second audiologist were blinded to the brand of hearing aid and the hearing aid performance results.Participants tested all three hearing aids with the P02 device considered the intervention and Concerto BasicAfter each participant used the three hearing aids, the participant was asked to choose the top two ranks of hearing aids in order of preference according to their overall satisfaction with the quality of perceived sound. However, the participant was able to choose more than one brand of hearing aid in the same ranking.The participant was still blinded to the hearing aid identity during this choice task. In addition, participants were asked if they were satisfied with the hearing aid design by another researcher who was blinded to the hearing aid data. The ranking of satisfaction in the hearing aid design was evaluated in the same fashion as the satisfaction of quality sound perception.t-tests using 95% confidential intervals were used to compare the mean differences. The chi-square test was used to test ordinal variables. A value of p < 0.05 was considered statistically significant. This study was registered under Clinicaltrial.gov (NCT01902914), and the protocol was reviewed and approved by the Human Ethics Committee of Khon Kaen University (HE551268).The primary hearing aid performance outcome was the functional gain in speech frequency, analysed by subtracting the unaided and aided air-conduction threshold and pure-tone average threshold at 500–2000 Hz in the free field. Real-ear measurement, speech discrimination score, quality of sound, and design satisfaction were considered secondary outcomes. Paired One hundred eligible people initially consented to participate in the study. However, 16 withdrew from the study before visiting the audiology clinic on the day of the proposed hearing aid evaluation. Thus, 84 participants underwent a repeat examination by otologists and audiology testing to confirm that they met the eligibility criteria; 11 participants  were then excluded. Thus, 73 participants eventually completed the full study protocol presented in the CONSORT diagram Fig. .Fig. 2TAll participants self-reported hearing loss, with 63% reporting tinnitus and aural pressure and 34% reporting vertiginous symptoms. The demographic data is shown in Table ® at 1000 Hz ; conversely, the Clip-II™ and the Concerto Basic® performance at 4000 Hz was better than that of the P02 .We found that the P02 mean air-conduction pure-tone aided and unaided thresholds were significantly better than those of the Clip-II™ and the Concerto Basic® at a frequency of more than 2000 Hz; the best closest objective real-ear measurement to the target curve of P02 was lower than those of the Clip-II™ and the Concerto Basic® . However, participants’ subjective assessment of overall sound quality showed a preference for the P02 device over the Clip-II™ but was lower than that of the Concerto Basic® . Participants’ satisfaction with the hearing aid design was the highest for the P02  .In objective real-ear measurement testing, the three hearing aids met the target curve in 93% of the participants for each hearing aid. Subgroup analysis showed that the P02 real ear measurement was farther from the target curve than that of the Clip-II™ and that of the Concerto Basic05) Fig. .Fig. 4CMany factors affect hearing aid selection, including the degree of hearing loss, problems experienced by the person, patient motives and expectations, personality traits, auditory counselling, and economic issues . FurtherThe price of a hearing aid is one of the barriers against patient use; therefore, locally produced hearing aids with low cost would minimize this obstacle while maximizing its coverage in low- and middle-income countries. Recently, several designs of hearing aids suitable for this purpose have been made available. The body-worn hearing aid is the largest one that may be more convenient  as they are easier to see and manipulate . Many ol™ and Concerto Basic®. However, Concerto Basic® and Clip-II™ provided a significantly better functional gain than the P02 device at 4000 Hz, whereas the functional gain of the P02 device was significantly better than that of Concerto Basic® and Clip-II™ at 1000 Hz. Although these differences reached statistical significance, differences less than 10 dB may have a minor impact on hearing in clinical practice. Regarding objective real-ear test performance, Concerto Basic® and Clip-II™ were better than the P02 model at high frequencies. Notably, participants’ subjective satisfaction ratings of overall sound quality were higher for the P02 device than for both alternatives. These results may be due to the different techniques utilized to limit excessive amplifier sound across hearing aids. Clip-II™ and Concerto Basic® use linear peak clipping, whereas the P02 model uses a wide dynamic range compressor. Both limiters produce some sound distortion and loss of sound detail; thus, the result of the real-ear test showed that the curves of the three hearing aids were different from the target curve, with the P02 curve being furthest apart at the highest frequency. Noffsinger et al. [®.In our study, functional gain and speech discrimination with the P02 device were found to be similar to those obtained with Clip-IIr et al.  have preThe P02 design, similar to a modern music media player rather than appearing as a disability aid, reduces stigma for the wearer. Undoubtedly, this positive attitudinal feature contributed to its higher satisfaction rating compared with the other two aids. The P02 is a lighter-weight hearing aid with a built-in rechargeable battery, holds a 3-day charge, and is easily charged by a main electricity supply. Using rechargeable batteries is more convenient than having to regularly replace disposable batteries and reduces electronic waste. The P02 hearing aid is still in the prototype phase, but the cost is estimated to be 100 USD, which is cheaper than currently available commercial aids; thus, it is more affordable for older adults in a rural community in developing countries.®, the commonly available commercial hearing aids, although participants gave the P02 model higher subjective ratings for quality of sound. A P02 limitation is the detail distortion that individuals experienced in high frequencies, as shown in the real-ear result. Any adjustments to obtain more gain in the high-frequency range should maintain the same comfortable sound. A limitation of this study is the short time that individuals spent using hearing aids to acclimatize to them; therefore, a longer duration of use of the hearing aids would be useful to assess satisfaction with the device.In summary, the P02 device seemed as effective as Clip-II™ and Concerto BasicThe P02 model, a Thai-produced digital programmable body-worn hearing aid, seemed as effective as two other comparable common commercial hearing aids for use with older Thai adults with hearing disabilities. Furthermore, the P02 device has the benefits of a modern design, simplicity of use, potential cost savings, and maintenance convenience via the use of a built-in rechargeable battery.


The global sound quality and music perception were also improved, as judged by ratings on questionnaires and scales. Finally, most patients chose to keep the new fitting definitively. Conclusions: By modifying the default fMAPs, the EA improved the speech discrimination in noise and the sound quality in bimodal binaural conditions.Optimizing hearing in patients with a unilateral cochlear implant (CI) and contralateral acoustic hearing is a challenge. Evolutionary algorithms (EA) can explore a large set of potential solutions in a stochastic manner to approach the optimum of a minimization problem. The objective of this study was to develop and evaluate an EA-based protocol to modify the default frequency settings of a MAP (fMAP) of the CI in patients with bimodal hearing. Methods: This monocentric prospective study included 27 adult CI users . A fitting program based on EA was developed to approach the best fMAP. Generated fMAPs were tested by speech recognition  in noise and free-field-like conditions. By combining these first fMAPs and adding some random changes, a total of 13 fMAPs over 3 generations were produced. Participants were evaluated before and 45 to 60 days after the fitting by WRS in noise and questionnaires on global sound quality and music perception in bimodal binaural conditions. Results: WRS in noise improved with the EA-based fitting in comparison to the default fMAP (41.67 ± 9.70% versus 64.63 ± 16.34%, respectively,  Stereophony is based on combining information in the brain from the two ears. The brain makes use of many different cues to determine the 3D characteristics of an auditory landscape . Their cAdvantages of binaural stimulation, as opposed to monaural hearing, are (1) redundancy (summation effect) which enhances the signal detection; (2) localization of the sound-source  based on inter-aural time differences (ITD) and level differences (ILD); and (3) improved speech discrimination in noise when signal and noise are spatially separated (squelch effect).Moreover, with binaural hearing, the head-shadow increases the signal-to-noise ratio at the farthest ear from the noise (as the head attenuates the noise), while this ratio decreases at the nearest ear to the noise source.Bimodal binaural hearing refers to the use of a cochlear implant (CI) in one ear in combination with a functional acoustic hearing with or without a hearing aid (HA) on the contralateral side. This association provides adults and children with improved speech perception in quiet and in noise, better music perception, auditory comfort, higher sound quality, enhanced sound localization, and as a result, a better quality of life in comparison to unilateral CI ,3,4,5. THowever, there is great variability in the integration process; while some bimodal users show substantial benefit, others receive little or no advantage.This variability could be due to the characteristics of the individual listeners , to different processing times between CI and contralateral HA or NH ear , to freqSome patients experience even bimodal interference and report better hearing with one of the ears ,13,14,15Alternatively, binaural interactions could be improved through frequency band adjustments without electrode deactivation , or throThe facility to obtain the bimodal integration appears to influence the auditory outcome . Apart fBased on these findings, an improvement of the spatial CI coding, which relies on the cochlear tonotopy, could theoretically improve the binaural integration. The Greenwood map offers a relatively precise function describing the physiological place-frequency relation in the human cochlea . With CIIn a standard CI fitting, the default frequency allocations to active electrodes are not modified and only the sensation of loudness is adjusted ,23. ModiWe hypothesized that reallocating the frequency bands in the CI would lead to a better fusion of the central binaural information, an improved hearing in noise, and a higher sound quality in bimodal binaural conditions. Binaural redundancy is one of the binaural advantages that could be addressed with bimodal rehabilitation. Binaural redundancy could increase loudness via binaural summation but could also improve the detection threshold and frequency differences, and as a result, the speech recognition in noise . Adults Moreover, inter-aural mismatch has also been shown to limit speech understanding in noise when signal and noise are spatially separated ,30. ThisA place-matched frequency mapping based on electrode location could be hampered by the difficulty to determine the amount of neural survival or local electric stimulation interactions in the cochlea for an individual ,33. ITD In the bimodal context, patients wear a HA on the contralateral ear with various signal processing programs . Since the number of fitting combinations is very high, artificial intelligence can be employed to search this vast domain for the best solution.Evolutionary algorithms (EA) are a family of algorithms inspired by Darwin’s theory of evolution ,35. InitThe objective of the present study was to develop and evaluate a fitting protocol based on the CI frequency reallocation for bimodal binaural CI users with different CI brands using an interactive EA method. Twenty-seven adults  volunteered to participate in this monocentric and prospective study. All participants were unilateral CI users for a minimum of 6 months with functional contralateral hearing . Their mean age was 58 ± 16.7 years . The average duration of the deafness before CI was 23.5 ± 15.8 years . In the implanted ear, patients wore various brands of CIs and coding strategies. In the contralateral ear, 23 participants wore a behind-the-ear HA which was fitted with a NAL-NL1 protocol and checked by their audiologist within the 3-month period before inclusion. Three participants had contralateral normal hearing .At inclusion, the clinical and audiometric data were obtained, and each CI was fitted with an fMAP based on the EA. Other fMAPs already available on the processor were left unmodified. Participants were asked to use the EA-based fMAP as much as possible, but they were free to switch to their usual fMAPs ad lib. The second session was conducted 45 to 60 days later. Patients were again evaluated with a pure-tone, speech recognition test in quiet and noise in free-field-like conditions and questionnaires. The main criterion of the study was the improvement of the word recognition score (WRS) in noise with EA-based fMAP.®, Interacoustics, Middelfart, Denmark). The signal was delivered by a loudspeaker  placed at the level of the head 1 m in front of the participant. All evaluations were performed in the bimodal binaural condition in an audiometry booth with a calibrated audiometer  were delivered by the same loudspeaker;In a preliminary trial with different lists of 20 words, the signal-to-noise ratio (SNR) was individually adapted  to obtain a percentage of WRS between 3/10 and 7/10. Every patient kept its individually adapted SNR at the same level through the follow-up. Two series of words were also administered for the initial and the final evaluations.At the initial and the final evaluation, the audiometry tests included:During the EA-based fitting, each generated fMAP was tested with a different series of 10 words to obtain a WRS in noise out of ten at the same level of SNR used for the evaluations. No feedback was provided during speech recognition tests.The improvement of the WRS in noise on 20 words at the initial and at the final evaluation was the main judgment criterion of the study.We also asked the participants to complete a quality-of-hearing questionnaire, APHAB (Abbreviated Profile of Hearing Aid Benefit) in its French version related to their handicap before and after the new CI fitting . The queEvolutionary algorithms are calculation methods based on biological evolution. Among this family of algorithms, the most popular are genetic algorithms ,51,52,53The general idea is to bring changes to a set of solutions in the optics of improving them by gradual changes and the assessment of the effects of these changes. During this process, the initial values can be changed randomly in a predefined range, especially to generate the initial set of solutions (parents). Later, limited random changes are also introduced in the process to create new solutions (crossover and mutations). This characteristic classes the evolutionary algorithms as stochastic . This alLOW) to 1.2 times the upper limit (1.2 × fHIGH);Input default settings to define the boundaries of the exploration space: exploration domain for each band was set at the lower limit of the same band ;Evaluation of P1 to P4 by speech recognition in noise. Each fMAP obtains a score: SP1, SP2, SP3, SP4;Input SP1 to 4;Generation of children ;Selection of 2 individuals among the previous generation by tournament: Two individuals of the previous generation are randomly selected; the one with the highest probability is chosen. The previous process is repeated. In this way, two individuals are finally selected;Crossover: combining electrode settings from 2 parent fMAPs to obtain a child;LOW and fHIGH with a probability Pm in the predefined range;Gaussian mutation: mutations can be applied to fEvaluation of the 3 children by WRS yielding scores SCn ;Input SCn;Selection of 4 individuals with the highest WRS among all generated individuals .Evolutionary loop, until stop-criteria (number of generations = 3 in our study):Output: The best fMAP (highest WRS) obtained during the evolutionary process.The general procedure was as follows :Input deHIGH) was determined by the EA in an exploration domain ranging from the lower limit of the same band (fLOW) to 1.2 × fHIGH  as described before . In this × fHIGH .LOW of each frequency band was set equal to the fHIGH of the previous band. Larger values of overlapping and mutation probability would have created a total disruption of the original fMAP, requiring longer adaptation periods, a larger exploration domain with more generations, and longer tests. With these constraints, the default fMAP generated a random initial population of 4 parent fMAPs  and the result was fed to the algorithm. Two parent MAPs were randomly selected using a tournament selection. The best fMAP (based on WRS) became the first parent and the repetition of the same procedure produced the second parent. These two parents generated a child fMAP by combining their frequency bands (crossover) and applying mutations. During the combination, a variable proportion of the available frequency bands from one parent were combined with those from the second parent to form a new set of frequency bands for the offspring. The combination process did not modify the upper and lower frequency band limits. For the generation of child-fMAPs mutation was applied. LOW, 1.2 × fHIGH]. The mutation probability for a frequency band in each generated fMAP was set at 0.2, with a standard deviation of 0.1 × frequency band width (Gaussian mutation). The tournament selection was repeated 2 more times to generate 2 other couples of parent MAPs. For these selections, a sampling with replacement strategy was employed. Crossbreeding of each couple produced a child fMAP. Hence, the first generation of 3 child-fMAPs was created and tested by WRS in noise. To create the second generation, 4 parents were selected from 7 already generated fMAPs (4 parents and 3 children). The selection and crossbreeding generated 3 children for the second generation. Finally, for the third generation, 4 parents were selected from 10 generated fMAPs (4 parents and 6 children), and 3 children were obtained. The process was stopped after 3 generations. In total, 13 fMAPs including 4 parents and 9 children over 3 generations, were produced. In the end, the fMAP with the highest WRS was selected. In the case of 2 fMAPs with the same score, the one preferred by the patient based on sound quality was selected. This algorithm differed from the general scheme by the fact that the optimization cycle was halted after 3 generations, and not when an optimization criterion was reached. This specificity was imposed by the length of the procedure and the necessity of multiple speech audiometries, which could not be increased indefinitely.During a mutation, the upper-frequency band limit was modified in a stochastic manner. This modification was limited to the exploration domain [fBEPS+ research software  was used for frequency allocation in Advanced Bionics CIs. For all other CIs, routine clinical software was used. The minimal frequency fitting step was 1 Hz for MED-EL and Cochlear CIs, 62 Hz for Advanced Bionics CIs, and 131 Hz for the Oticon Medical CI. For Advanced Bionics and Oticon CIs, the closest frequency increments to the provided fMAP were selected. The minimum frequency band width was 62 Hz for Advanced Bionics and Cochlear CIs, 1 Hz for MED-EL CIs, and 131 Hz for the Oticon Medical CI. These values are obligatory and inherent to the fitting software, the coding strategy, or both.The postoperative CT scans were analyzed with Osirix . The length of the cochlea from the round window (RW) to the apex and the position of each electrode from the apex were measured in millimeters . A tridiPower calculations were carried out by G*Power . Based p-value < 0.05 was considered significant.Statistical tests were conducted on Prism, version 8, GraphPad Software, San Diego, CA, USA, 2018. Paired comparisons of continuous variables with non-normal distributions were analyzed by Wilcoxon signed-rank test, and the results were expressed as mean ± standard error of mean, median, and range. ANOVA or mixed-model analysis were employed to compare center frequencies deduced from EA to those obtained from the Greenwood MAPs and the manufacturer’s default settings. Their normal distribution was verified by D’Agostino and Pearson’s test. The results were expressed as mean ± standard error of mean. A All 27 participants performed the first and the second evaluation sessions and fully completed all evaluation steps. The average duration of the fitting session was 135 ± 30 min. Subjects 2 and 4  did not The algorithm suggested a different frequency allocation per electrode than the default setting. The EA yielded an enlargement of the bands in the low frequencies . The center frequencies deduced from the Greenwood map were compared to those from the EA and the default fMAPs . Both EAn = 7), the second (n = 6), or the third (n = 8) generations. In 9 patients, several fMAPs yielded the same optimal WRS . In these cases, the patient chose the fMAP among those with the highest WRS based on subjective quality of sound.The best fMAP was not always obtained at the last generation . In 6 pan = 27, p = 0.0001, Wilcoxon sign-ranked test). The duration of hearing deprivation was not correlated to the initial or the final WRS . At the final evaluation, the WRS in quiet remained unchanged . Similarly, the EA-based fitting did not alter the pure-tone average in the free-field-like condition .At the final evaluation, WRS in noise was significantly improved with EA . The quality of hearing was also significantly improved in EC, RV, and BN APHAB subdomains .The quality of hearing, as assessed by HISQUI, was significantly improved , the contribution of the CI to auditory performances is significant ,59. CI dThe idea behind the change in the frequency bands was to optimize the correspondence between the ears and the binaural hearing. Testing these patients in a monaural condition would have probably provided additional interesting data. By reducing channel interactions or by a better correspondence between frequency allocations and functional channels, the EA-based fMAP could also improve monaural hearing.In a theoretical approach, many have attempted to address the issue of binaural optimization by restoring the pitch-place function of the implanted cochlea according to the original cochlear tonotopy ,63. But Several explanations can be advanced for this failure. The electrode array covers, at best, partially the cochlear apex coding for the low frequencies. Consequently, adjusting the fMAP to the Greenwood function means neglecting a significant part of the spectrum in low and mid frequencies . In the In contrast to the theoretical approaches based on the Greenwood map, frequency band adjustments have been also tackled through a purely empirical approach ,68,69. BIn line with studies that suggest that low-frequency resolution is determinant in speech discrimination, pitch-matching studies showed that perceived pitches with CI were lower than what was estimated by the place-pitch function in unilateral CI users with a normal contralateral hearing ,71,72. SIn quiet, the maximum speech discrimination was not influenced by the EA-based fitting. This can be explained by the ceiling effect . The best fMAP was not always obtained at the last generation . In six Although EA-based fitting procedure is long and can only be applied to motivated patients, conventional protocols of binaural pitch-matching are even more time-consuming, and more difficult ,77. IndeRecently, inter-aural place mismatch was evaluated in bilateral CI and SSD patients with unilateral CI  using ITThe relationship between loudness and pitch can also add complexity to the modifications of frequency band allocations: pitch and loudness are both affected by the rate of stimulation ,81,82. MIn the future, the algorithm could be integrated into the fitting software to accelerate the procedure and improve its acceptability by the patients. Evaluation procedures other than the WRS, such as musical sound categorization tasks, could be evaluated to improve the process.By modifying the default fMAP, the evolutionary algorithm increased the word recognition score in noise and improved APHAB and HISQUI scores. Most of the patients (23 out of 27) preferred the modified fMAP and kept it at the end of the study. These improvements were observed despite the heterogeneity of the CI brands and the contralateral ear condition. These results open insights on integrating this type of approach in standard CI fitting.


TM electrode array. Methods: Fifteen adults presenting indications of electro-acoustic stimulation (pure-tone audiometry (PTA) thresholds ≤70 dB below 750 Hz) were implanted with the EVO™ electrode array. Hearing thresholds were collected at five time-points from CI activation to twelve months (12M) after activation. Hearing thresholds and hearing preservation profiles (HEARRING group classification) were assessed. Results: All subjects had measurable hearing thresholds at follow-up. No case of complete loss of hearing or minimal hearing preservation was reported at any time point. At activation (Nact = 15), five participants had complete hearing preservation, and ten participants had partial hearing preservation. At the 12M time point (N12m = 6), three participants had complete hearing preservation, and three participants had partial hearing preservation. Mean hearing loss at activation was 11 dB for full range PTA and 25 dB for PTAs low-frequency (125–500 Hz). Conclusions: This study provides the first longitudinal follow-up on associated hearing profiles to the EVO™ electrode array, which are comparable to the literature. However, other studies on larger populations should be performed.Background: A prospective longitudinal multicentre study was conducted to assess the one-year postsurgical hearing preservation profile of the EVO The cochlear implant (CI) can constitute a dilemma for subjects with severe high-frequency hearing loss (HL). On the one hand, this population mostly does not benefit from conventional hearing aids. On the other hand, a traumatic CI insertion could damage their low-frequency residual hearing. Preservation of the cochlear structure is key to the success of cochlear implantation for this population. When these subjects are CI candidates (averaged hearing thresholds <80 dB HL according to recommendations of CI manufacturers), they may be offered electro-acoustic stimulation (EAS). However, EAS is only possible if the candidate has sufficient functional residual hearing after surgery. With the increasing understanding of the mechanisms underlying intracochlear trauma and the establishment of predictive factors associated with low-frequency hearing preservation (HP), recent decades have witnessed an evolution towards atraumatic surgery ,2, accomTM electrode array has been designed to preserve hearing. This 24 mm long electrode array carries 20 electrodes. Its narrow diameter and flexibility, as well as its soft surface and round tip, were designed for lower-trauma insertion %). Similarly, at the 1M time point (N1m = 15), five participants (33.3%) had complete HP (range = (79:125)%), and ten participants (66.7%) had partial HP (range = (31:70)%). At the 3M time point (N3m = 14), five participants (35.7%) had complete HP (range = (75:118)%), and nine participants (64.3%) had partial HP (range = (84:02)%).Over the early follow-up period, no participant showed a total loss of hearing or a minimal HP according the HEARRING classification. At activation (N6m = 13), all participants had measurable hearing thresholds. p < 0.001) and were as well not all similar with at least one change in the five testing frequencies as statistically significantly different from others  = 257.1, p < 0.001) with a significant interaction effect between frequency and visit  = 2.3, p = 0.001). Post hoc pairwise multi-comparisons indicated that changes at activation visit, at 1M, at 3M and at 6M time points, were significantly higher from hearing thresholds measured at the preoperative visit between 125 Hz and 1000 Hz. No significant differences were found at both 2000 Hz and 4000 Hz along the follow-up. No significant difference was found between post-operative hearing thresholds. At the 6M time point (N6m = 13), five participants (38.5%) had complete HP (range = (75:118)%), and eight participants (61.5%) had partial HP (range = (27:61)%). No participant had total loss of hearing or minimal HP according the HEARRING classification.At 6M time point , HL at 1M vs. 6M time points (p = 0.33) and HL at 3M vs. 6M time points (p = 0.18)). Similarly, within the same period, mean HL in the low frequency region (125–500 Hz) was found to be stable , HL at 1M vs. 6M time points (p = 0.44) and HL at 3M vs. 6M time points (p = 0.45)). Average HL in regards to the preceding time point within the period of activation visit and the 6M visit was stable , as there stable  with no 12m = 6), all remaining participants had measurable hearing thresholds, as illustrated in At the 12M time point ) and 76.9% participants at the 6M time point ). A total of 83.3% of participants had low frequency PTAs ≤ 80 dB (HL) at the 12M time point . For all subjects with functional hearing, standard HP evaluations showed that at activation (Nact = 10), around 60% of subjects had at least partial HP (0–30 dB) and approximatively 40% minimal HP (>30 dB). At the 1M time point (N1m = 11), around 55% of subjects had at least partial HP and 45% minimal HP. At the 3M time point (N3m = 11), 64% of subjects had at least partial HP and 36% minimal HP. At the 6M time point (N6m = 10), around 70% of subjects had at least partial HP and 30% minimal HP. At the 12M time point (N12m = 5), around 80% of subjects had at least partial HP and 20% minimal HP.TM electrode array was originally designed for less traumatic insertions [To the best of our knowledge, this is the first study that investigated HP in unilateral adult CI recipients with only the EVO™ electrode array up to 12-months follow-up. The EVOsertions  and satisertions . Combinisertions ,22,23, asertions .With full range PTAs, none of the study participants had complete loss of hearing or minimal HP at any time point during follow-up with an overall 100% HP  detection following the HEARRING group classification. Despite the different number of tested participants, the distribution of HP scores along the different time points was reasonably equivalent. Although the current sample size is quite limited, these data are mostly aligned with the evidence reported in the literature on comparable electrode lengths and CI procedures ,26,27. n = 17), reported 41% of complete low-frequency HP at 43 days (range 3–93) and at 582 days (range 229–1041) after implantation. Using different classification techniques, other studies reported comparable complete HP rates ranging from 25 to 77% [Complete low-frequency HP was obtained in (33–40%) range at the early follow-up, in 38.5% at 6M and 66.7% at 12M. Higher rates of complete low-frequency HP at 1 month (68%) have been reported in a retrospective study but with different inclusion criteria (PTA 125–750 Hz) and several types of electrode arrays . Another range 3–3 and at 5 to 77% ,29.At activation, the HL shift in this study was 11 dB for full range PTA and 25 dB for PTAs of low-frequency (125–500 Hz). These shifts remained stable up to 6M after activation with no significant deterioration. This highlights the fact that the major hearing deterioration could occur in the early months after surgery. Interestingly, the subjects who chose to remain with the EAS up to 12M after activation presented less hearing deterioration with lower shifts for both full range PTA (mean: 7.4 dB) and PTAs of low-frequency (125–500 Hz) (mean: 16.7 dB). Other studies presented comparable HL values ,28,30.It is noteworthy to point to the difference of PTA criteria on inclusion across studies and its impact on establishing HP profiles of similar electrode arrays on a larger scale. Differences in the choice of assessment of full range PTA or low-frequency PTA at inclusion, and which frequency range, constitute a major obstacle to perform meta-analysis and draw a larger picture.One of the limits of the HEARRING classification is that it does not indicate functional hearing. For instance, Subject 14 had partial HP from activation to the 6M time point and yet presented no functional hearing with PTAs of low-frequency 125–500 Hz) ≥80 dB HL. This could explain why this participant chose not to carry on with the EAS, as we could assume there was no amplification benefit. The main challenge remains on how to define functional hearing. There are several recent recommendations in the literature on choosing one definition over the other: median in low frequency hearing at 250 and 500 Hz of 70 dB or better , or pure–500 Hz ≥All subjects with functional hearing presented at least partial HP or minimal HP and no case of loss of residual hearing. Although the sample size is comparatively smaller in the current study, these outcomes are relatively aligned with recent studies reporting on hearing preservation and using the same method ,21,28,30p = 0.03). Iso-Mustajärvi et al. [When investigating correlations between potential predictive factors on hearing outcomes, only one significant correlation was found between age at inclusion and PTAs of low-frequency (125–500 Hz) at activation . At the 6M time point, 92.9% (13/14) of participants decided to keep the EAS when given the choice, out of which 46.2% kept it at 12M. Spitzer et al.  reportedTM electrode array is designed for hearing preservation surgeries, and the present data show that all participants had measurable hearing levels with complete and partial preservation profiles. Thresholds remained stable over the follow-up period, with a steady hearing threshold shift suggesting that hearing loss was stable along the follow-up period. Participants who chose to remain with EAS had better hearing preservation profiles and lower hearing threshold shift. This study confirms the atraumatic profile of the EVOTM electrode array, but other studies on larger populations should be performed.The EVO


To analyze the prevalence & characteristics of sudden sensorineural hearing loss.st July 2019 to 31st October 2019. Study was conducted at Audiology section of ENT department, Lahore General Hospital, Pakistan. Sample included both genders, aged 17-70 years. Cases suffering from inflammatory or obstructive conditions of the external or middle ear and those who could not undergo pure tone audiometry were excluded from the study. Following consent for inclusion in study, data was collected using basic demographic and medical history sheet followed by Audiometric evaluation. Statistical Software for Social Sciences Version 20.0 was used for data analysis.This cross sectional study including n=377 cases of sensorineural hearing impairment, using non-probability convenience sampling, who fulfilled the selection criteria was conducted from 1The prevalence rate of sudden sensorineural hearing loss of 14(3.7%) being significantly more common in males 11(78%) than females 3(22%) (p=0.05) & age group 15-35 years (p=0.001). It is commonly of severe or profound degree with downward sloping audiogram (p<0.05), however it is not associated with vertigo (p=0.32), tinnitus (p=0.08) with no side predilection (p=0.27).We conclude that the prevalence of SSNHL is 3.7% being significantly more prevalent in males and those aged15-25 years. It is mostly characterized by severe to profound degree of hearing loss with downward sloping audiogram with no associated vertigo, tinnitus and side predilection. Sudden sensorineural hearing loss (SSNHL) is considered a medical emergency3The exact incidence of Sudden SNHL is not known. Estimate of incidence show a wide range of 11-77 per 100,000 people per year,7SSNHL is a subjective symptom perceived by the patient and hence to determine prevalence of hearing loss (HL), its type and threshold of hearing, a pure-tone audiogram is required.Acknowledging the available literature, the exact prevalence of SSNHL is not known with highly variable incidence reported in studies,th June, 2019 and informed consent of the sample. A basic demographic sheet, medical history sheet and PTA were used to collect data.This is a cross sectional study which recruited n= 377 patients with SNHL, who attended Audiology section of ENT Department of Lahore General Hospital, Pakistan using non probability convenience sampling technique over a period of four months extending from 1st July 2019 to 31st October 2019. Sample included both genders, aged 17-70 years. Cases with inflammatory and obstructive pathologies of external and middle ear, those who could not undergo audiological testing or were found to have conductive element were excluded. Study was conducted after obtaining approval of IRB of Isra Institute of Rehabilitation Sciences, Isra University vide Registration No 1609-M.Phil HS-007 dated 24History was noted in a confidential setting including duration of HL, associated complications like tinnitus, vertigo, exposure to ototoxic agents, occupational or leisure noise and treatment history. This was followed by physical examination including otoscopy to rule out any obstructive and inflammatory pathology and pure tone audiometry was done in cases suspected of having sensory neural hearing loss. Computer based Pure Tone Audiometer Labat, made in Italy was used and testing performed in sound proof room which met American National Standards Institute (ANSI) S 3.1-1991 standards. Both ears will be tested for air and bone conduction using the method of ascending pure tones at frequencies of 0.5, 1, 2, 4, 6 and 8 kHz before descending to 1 and 0.5 kHz. Bone conduction was checked at frequencies of 0.5 to 4 kHzData collected was analyzed using SPSS - Version 20.0. Descriptive statistics was used. Variables specially studied included degree and type of HL, ears affected, associated symptoms and age and gender. Pearson’s Chi-square test was used to determine association of type of HL with demographic and clinical variables. Independent sample t-test was used to see any significant difference in mean thresholds between the two ears. P-value of 0.05 was taken as significant.Sample of 377 cases, revealed 203 (53.8%) males and 174(46.2%) females with a ratio of 1.67:1 and mean age of 42.04±1.73 years . Of the Majority (n=12) cases of age group 15-35 years suffered SSNHL, while remaining (n=2) belonged to 36-55 years age group indicating significant (p=0.001) age association with SSNHL. Similarly gender association was noted (p=0.05) with 11 males and 3 females having SSNHL.No significant association (p=0.32) of vertigo was noted with no case of vertigo among cases of SSHL. Similarly no significant association (P=0.081) of tinnitus was noted with eight out of 14 cases of SSNHL having tinnitus and 125 out of 363 cases of chronic hearing loss with tinnitus.There was significant association (p=0.032) of severity of hearing loss in the right ear with maximum (n=8) cases having profound and n=4 having severe hearing loss among cases with SSNHL. On the other hand in the Left ear majority (n=6) had severe HL while n=5 had normal hearing in the group with SSNHL. While in the chronic HL cases majority (n=111) had profound HL. The difference was significant (p<0.001)No significant difference (p-0.27) was noted as regards side affected in SSNHL and chronic HL groups. As regards threshold of hearing in cases with SSNHL study revealed a continuous rise from a Mean threshold of 54.28±28.22 at 250 Hz to 72.89±31.04 at 8 KHz in the Right Ear and from 54.88±28.62 at 250 Hz to 75.46+30.78 at 8 KHz in the Left Ear. However, t-test statistics did not reveal any significant difference at all the frequencies form 250- to 8 kHz .Sudden sensorineural hearing loss, recovers spontaneously in majority, hence exact incidence is not known with a wide range of 11 to 77 per 100,000 people affected per year.9In the current study of the 89 cases with unilateral HL, 5 had SSNHL, while of the 288 cases with bilateral HL 9 had SSNHL, however the difference was not statistically significant (p-0.27). In contrast to our study in which majority had bilateral HL, in a study by Atay G et al. in 45.9% cases right ear was affected and in 54.1% left ear was affected.10Present research revealed that SSNHL is more prevalent in males as compared to females. With a total population of 203 (53.8%) males and 174(46.2%) females, 11 males and three females had SSNHL and difference was significant (p=0.05). Similarly, in study by Atay G et al. males were predominantly affected.In the present study, SSNHL was significantly (p=0.001) more common in age group 15-35 years with 12 cases, while remaining two cases belonged to 36-55 years age group. In contrast Alexander and Harris, reported a higher incidence of 77/ 100000 cases at age 65 and above compared to 11/100000 below 18 years of age.As regards etiology, different studies have reported widely varying prevalence of different etiological causes. According to Lloyd SKW et al. in 30% cases of SSNHL cause is identified including infection (44%), otologic disease (17%), neurologic and vascular 12%), malignancies (7%) and miscellaneous (4%), while the remaining 70% cases are idiopathic.%, malignIn the present study there was significant association (p=0.032) of severity of hearing loss with type of HL with majority (eight cases) having profound SSNHL followed by (4 cases) with severe SSNHL in the right ear. On the other hand in the Left ear majority (6 cases) had severe SSNHL while (five cases) had normal hearing in the group with SSNHL. In this study the mean threshold of hearing in cases with SSNHL showed a continuous rise (Downward sloping audiogram) from a Mean threshold of 54.28±28.22 at 250 Hz to 72.89±31.04 at 8 KHz in the Right Ear and from 54.88±28.62 at 250 Hz to 75.46±30.78 at 8 KHz in the Left Ear. However, t-test statistics did not reveal any significant difference at all frequencies form 250- to 8kHz. In contrast in a study by Atay G et al. reported that majority (29.8%) had flat audiogram configuration, followed by downward sloping audiogram in 26% and upward sloping audiogram configuration in 22.7%. However profound degree of HL was noted in 21.5% cases of SSNHL.10Common associated symptoms include aural fullness, vertigo and tinnitus.17According to Atay G et al. early initiation of treatment within five days (p<.05) and flat audiogram in mid frequencies (p<0.05) show better prognosis 20We conclude that the prevalence of SSNHL is 3.7% being significantly more prevalent in males and those aged 15-25 years. It is mostly characterized by severe to profound degree of hearing loss with downward sloping audiogram with no associated vertigo, tinnitus and side predilection.EN: Data Analysis & Interpretation, Literature Review & responsible for integrity of the researchGS: Conceptualization of work, designing of research & Manuscript Writing.NM: Critical revision of article.MNB: Literature search and Review.


Mucormycosis is a devastating fungal infection seen in patients who are immunosuppressed or in severe inflammatory states. Mucormycosis has been increasingly seen in the setting of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. We describe a 68-year-old male with a past medical history of uncontrolled diabetes mellitus who presented with acute vision loss and was found to have concomitant diabetic ketoacidosis (DKA) and coronavirus disease 2019 (COVID-19) infection on presentation. Rhinocerebral mucormycosis was suspected given the patient's presentation and was confirmed with an ethmoidal sinus biopsy. Our case was further complicated by the presence of cavernous sinus thrombosis, cerebral infarcts, and, later, the development of a left orbital hematoma following therapeutic anticoagulation. This case report aims to address the rare but now increasing incidence of rhinocerebral mucormycosis in the setting of COVID-19, further complicated by DKA, cerebral thrombosis, and intraorbital hematoma. Rhizopus, Mucor, Rhizomucor, etc., in the fungi order Mucorales [Mucorales as it allows for its viability in acidic environments [Mucormycosis is an angioinvasive fungal infection classically seen in immunosuppressed and suboptimally controlled diabetic patients. Mucormycosis is typically caused by ucorales . As the ucorales . Rhinoceucorales . Mucormyucorales . An enzyronments .We present a case of rhinocerebral mucormycosis in a patient that was synergistically compounded by DKA and COVID-19, further complicated by the development of cavernous sinus thrombosis, embolic brain infarcts, and an intraorbital hematoma. To our knowledge, this is the first documented case of intraorbital hematoma post exenteration in the setting of rhinocerebral mucormycosis.This case was presented as an abstract at the ACP Texas Chapter Resident Abstract Competition on 11/06/2021.A 68-year-old male with a past medical history of type 2 diabetes mellitus and a recent COVID-19 infection  presented to our institution with a four-day history of left eye pain, left eyelid swelling, progressive vision loss, and headache. These symptoms were preceded by a headache that radiated to the left eye. He was diagnosed with COVID-19 pneumonia at a different hospital approximately 10 days before presentation and was discharged with supportive care instructions as the patient only had mild symptoms and did not require supplemental oxygen. His symptoms at the time included loss of taste, shortness of breath, and a dry cough. His left eye pain and shortness of breath continued to worsen. On the day of presentation, just before arriving at our institution, he had visited a separate medical institution for left eye pain and shortness of breath, where, upon evaluation, he was noted to have an increased left eye intraocular pressure (IOP) elevated at 51 mmHg  and he subsequently underwent canthotomy. He tested positive for COVID-19 and was placed on supplemental oxygen (without further treatment). From that medical facility, he was transferred to our hospital. He denied smoking, alcohol consumption, or use of illicit drugs. His home medications for diabetes mellitus included glipizide and metformin.On physical examination, he was requiring 15 liters of oxygen through a high-flow nasal cannula and was saturating above 94%. His blood pressure was 125/70 mmHg with a heart rate of 95 beats per minute. Grossly, his left eyelid was swollen with chemosis and proptosis. His IOP bilaterally was normal at 14 mmHg, and his left eye showed lateral canthotomy without cantholysis. Pupils were equal and reactive to light in his right eye, but his left eye revealed a 5 mm fixed pupil to light with complete ophthalmoplegia. He had a loss of V1 sensation with a dull V2 sensation on the left side and no sensory deficit noted on the right side. Cranial nerve examination was otherwise unremarkable. Motor strength was 5/5 in all four extremities, with intact sensation in the rest of his dermatomes. Chest auscultation revealed bilateral crackles. Cardiac examination was unremarkable without any appreciable murmurs auscultated.9/L). Complete metabolic profile was significant for elevated creatinine of 1.4 mg/dL (baseline was 0.90 mg/dL), an elevated anion gap metabolic acidosis (23) with a bicarbonate level of 18 mEq/L , and hyperglycemia of 379 mg/dL. Beta-hydroxybutyrate was noted to be elevated at 5 mg/dL. Urinalysis was positive for ketonuria. Hemoglobin A1c was elevated at 11% and C-reactive protein (CRP) was greater than 18 mg/dL. Arterial blood gas (ABG) showed a pH of 7.36 with a partial pressure of oxygen (pO2) of 66 mmHg, bicarbonate of 18 mEq/L, and appropriate respiratory compensation with a partial pressure of carbon dioxide (pCO2) of 33 mmHg.Complete blood count revealed reactive thrombocytosis with a platelet level of 562 (562 x 10Computed tomography (CT) of the orbit was obtained and demonstrated left orbital cellulitis with mucosal thickening in the left maxillary sinus with a 1.7 x 1.4 cm soft tissue lesion  confirmed a proptotic left globe along with a left cavernous sinus thrombosis (CST).The patient was admitted into the ICU and started on a heparin drip for the CST and an insulin drip for his DKA. At this point, ophthalmology, neurology, ENT, and infectious disease (ID) were all involved in his care. Given high suspicion for mucormycosis on initial CT, the patient was started on broad-spectrum antimicrobial coverage with intravenous vancomycin, metronidazole, cefepime, and amphotericin B. As for his acute hypoxic respiratory failure secondary to COVID-19 pneumonia, he was started on dexamethasone and remdesivir. Three days into his hospitalization, his hypoxic respiratory failure acutely decompensated along with worsening facial swelling, necessitating intubation for airway protection.Candida on H&E stain  stain Figure  and Grocn Figure .Despite the combined endoscopic treatment along with IV amphotericin, there was minimal improvement noted. He was started on a 10-day trial of posaconazole, and he later underwent left orbital exenteration. Despite the orbital exenteration, he continued to deteriorate, requiring three additional nasal endoscopies with debridement involving the inferior turbinates. Approximately one week later, he had involvement of the contralateral orbit. Ten days after the exenteration, he developed a left orbital hematoma confirmed by a CT orbit, measuring 67 x 57 mm  tube placed. After stabilization, ID was reconsulted, and the patient was discharged on a two-week course of posaconazole and discharged to a long-term care facility.Rhizopus is the most frequent culprit in diabetic patients diagnosed with mucormycosis [Mucormycosis is a deadly angioinvasive fungal infection that has been seen with increased incidence since the COVID-19 pandemic began and is classically associated with DKA and other inflammatory/immunosuppressed states . The presentation of mucormycosis is variable depending on the infection location  . Rhizopurmycosis .The prevalence of mucormycosis is estimated to be approximately 0.12-0.16 per 10,000 discharges, of which 23% resulted in inpatient mortality. Of note, readmission rates were 37% at the three months mark. This signifies the high morbidity and mortality resulting from mucormycosis [Rhizopus spores. Acidosis can be triggered by multiple mechanisms including the lactic acidosis seen with tissue hypoperfusion and sepsis in addition to the respiratory acidosis due to respiratory failure. These synergistic acidic mediums and systemic inflammation in turn cause hyperferritinemia, which provides a source of iron for the further dissemination of mucormycosis [In the COVID-19 era, there are only 101 cases of mucormycosis in patients diagnosed with COVID-19 documented in the world with 80% of those cases noted to be in India and far fewer (nine cases) in the United States . Of notermycosis . In hypermycosis ,7.Mucorales utilizes a receptor known as glucose-regulated protein 78 (GRP78) as a means of invasion into tissues and endothelial cells [It appears that COVID-19 and mucormycosis also share collaborative mechanisms of cellular uptake via endocytosis. al cells ,8,9. GivMucorales [Mucorales spore germination, which can lead to fatal mucormycosis [Thus, this severe combination of DKA and COVID-19 not only causes a significant upregulation in these receptors but also allows for increased cellular invasion of COVID-19 and ucorales ,8. All ormycosis .The presentation of mucormycosis is variable with a unified general mechanism of vascular invasion leading to necrosis and infarction. Most commonly, mucormycosis presents in the form of rhino-orbital-cerebral mucormycosis, involving the sinuses with a high likelihood of orbital and cerebral invasion. Presenting symptoms generally include fever, purulent discharge, and congestion, and later evolve to eschar formation ,10. A clMoreover, pulmonary involvement can occur with inhalation of the spores and can cause fever with hemoptysis secondary to pulmonary infarcts. In such presentations, patients are at risk of cardiac and mediastinal involvement due to contiguous spread . GastroiPrompt diagnostic workup should be done owing to the high morbidity and mortality caused by the disease. High clinical suspicion should be maintained and invasive testing should be included in the initial workup . CultureImmediate medical treatment with amphotericin B and surgical debridement are the two mainstays of treating mucormycosis. A delay in treatment of one week nearly doubles the 30-day mortality rate to 66% . AmphoteWith regards to our case presentation, there are many unique conclusions that can be inferred. Our patient was found to have substantial left-sided nasal necrotic debris that was confirmed to be mucormycosis, only 10 days after his COVID-19 diagnosis. In our case, the patient likely developed CST, four to five days prior to presentation when he began to have symptoms of vision loss, eyelid swelling, and headache. As mucormycosis was the likely triggering factor for his CST, he likely developed the exponential growth of mucormycosis within the first five days of his COVID 19 infection and acute DKA. This highlights that there is a short window (of days) in which complications from mucormycosis can occur. Of note, he was not on any immunosuppressants (dexamethasone) prior to the development of his mucormycosis, but rather, his underlying uncontrolled diabetes alongside COVID-19 pneumonia was the medium through which his mucormycosis developed.In addition, his hospitalization was such that he was treated with intravenous antifungals with multiple nasal endoscopic debridements. The necrosis of the left side of his sinuses involved the contralateral right side despite treatment with antifungals and debridement. This emphasizes the aggressive and rapidly progressive nature of the disease along with the cascade of multi-factorial triggers.Mucormycosis remains a deadly fungal infection that occurs more often in patients with immunocompromised and/or acute inflammatory states. The complex collaborative interplay of DKA and the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus has caused an uprise in mucormycosis cases globally. These inflammatory states, as seen in this report, can contribute to the severity and prognosis of mucormycosis. Prompt recognition and diagnosis of mucormycosis and its associated complications by physicians are of paramount significance. Expeditious administration of antifungal therapeutics along with surgical intervention is crucial due to the high mortality of this pathogen. It should be noted that even in cases where diagnosis and treatment are promptly initiated, morbidity and mortality remain high. Further research targeting diagnostic modalities, anti-microbial development, and surgical approaches is needed to improve patient outcomes.


Against this gap, complexity dynamic system theory (CDST) has recently been applied to explore processes and changes that a construct may undergo. To shed more light, the present study examined the current research methods used in this research domain and presented the contributions and different conceptualizations that can be made through CDST. In the end, some implications and future directions are suggested for passionate scholars.Language learning is a dynamic and complex process in which different factors and variables are constantly interacting. However, many studies done on constructs related to teacher-learner psychology have used one-shot quantitative research designs, while it is impossible to capture the complexity and dynamism of such variables  To capture the dynamism of many variables in second language acquisition (SLA) and language learning psychology (LLP),scholars are recommended to use Complexity Dynamic System Theory (CDST) which grew out of Larsen-Freeman's , agency, self-efficacy, demotivation, and enjoyment . Emergence proposes that the overall state of a system is something greater than the sum of its interacting components. Self-organization posits that systems do not follow a pre-specified plan but are intrinsically predisposed to organize themselves and show coherent patterns. Soft assembly suggests that the underlying components of a system can be re-configured into clear patterns as systems self-organize. Another feature of CDST is fractalization which refers to the ability of a system to exhibit and predict self-similar patterns/behaviors across various levels and timescales. Non-linearity suggests that the relationship between two factors in language learning is not always linear and straightforward. Finally, sensitive dependence on initial conditions or the butterfly effect argues that small features of the initial system can influence its subsequent evolution and functionality. Hence, small variations between two L2 students may entirely affect their language learning outcomes.As put by Mercer , for a sresearch questions which are emergent and dynamically re-phraseable, process-oriented approach to understand an event considering one's cognition, emotion, social context, culture, and interactions, focus on individual-experiences rather than generalizable patterns of behavior, different analytical tools, and favoring dense, longitudinal, and individual data instead of large samples. Moreover, CDST research highlights ongoing and retrospective data collection techniques in place of self-report data in interviews, journals, and narratives to capture the dynamics of behavior. Likewise, CDST takes a holistic perspective which is against the reduction and fragmentation of factors and processes. It should be noted that referring to CDST as a conceptual framework to explain the data is not enough and it must be followed in the research design, data collection procedure, and data analysis phases.Research in CDST perspective differs from simple quantitative and qualitative studies common in exploring teacher-learner psychology. The unique research properties of this meta-theory include; its substantially different Over the last decades, numerous studies have been conducted on different variables related to teacher-learner psychology mainly using one-shot and quantitative research designs constructed in a learner. Hence, the use of traditional quantitative-qualitative research designs falls short of scientific standards in this scholarly domain. That is why, when the same variables are examined by CDST, contradictory results may be obtained when the researcher scrutinizes the nature of a variable and its interacting sub-systems.It is evident that many of these constructs related to emotions and interpersonal communication skills  are unlikely to be measured Despite its existing logistic challenges and the generalizability of findings, CDST has different applications to research in SLA and LLP. As a case in point, researchers can investigate constructs related to teacher-learner psychology focusing on different timescales to see if the observed patterns of behavior occur at other levels. Similarly, CDST provides fresh insights for running idiodynamic studies to explore the nature of dynamic, stable, and variable changes in a construct (Boudreau et al., via one-shot research instruments. To capture its complexity and dynamism, CDST approach was introduced to SLA and LLP research to detect the developmental process of many social, cognitive, and psychological teacher-learner variables. Although this theory seems technical, complicated, and with logistic problems, its application to L2 education is advantageous in that it can increase the awareness of L2 teachers, students, materials developers, and researchers. Teachers can use the findings to improve students' language learning by using teaching methods and classroom activities that are in tune with the principles of CDST. Similarly, students would find this study of value in that they can realize that language learning is the result of an interplay of numerous interacting components and takes a logical time to develop. Materials developers can develop textbooks and activities which reflect the dynamism and non-linearity of language competence. Finally, researchers can use the ideas of this study to run comparable studies in other fields and contexts as CDST is context-specific. Moreover, running cross-cultural studies is a fresh topic for research to see the applicability of CDST in different cultures. Additionally, future studies can be conducted on teacher-related and interpersonal communication variables from the perspective of CDST. Likewise, emotions in language education can be explored longitudinally through the lens of CDST. Finally, CDST research designs can be employed by future scholars to drive the field forward regarding the dynamics of SLA.In this study, it was concluded that language learning psychology is a complicated phenomenon that is not measurable JY independently drafted the first manuscript and revised meticulously before it was submitted to this special issue for Frontiers in Psychology.The author declares 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.


The sense of hearing enables us to enjoy sounds and music and engage with other people. The sense of hearing is, however, vulnerable to environmental challenges, such as exposure to noise. Indeed, more than 1.5 billion people experience some decline in hearing ability during their lifetime, of whom at least 430 million will be affected by disabling hearing loss. If not identified and addressed in a timely way, hearing loss can severely reduce the quality of life at various stages, for example by delaying language development, reducing social engagement, compromising economic independence and educational opportunities [Some causes of hearing loss can be prevented, for example from occupational or leisure noise. The World Health Organization  estimates that more than 1 billion young people put themselves at risk of permanent hearing loss by listening to loud music over long periods of time. Mitigating such risks through public health action is essential to addressing hearing loss in the community .Hearing impairment often results from loss of the sensory hair cells and primary auditory neurons due to disease or trauma to the cochlea of the inner ear. The etiology of sensorineural hearing loss (SNHL) is complex and multifactorial, arising from congenital and acquired causes. Congenital hearing loss commonly manifests as hearing deficits at birth or during early development, while acquired hearing loss is usually sustained in later life from infection, exposure to excessive noise, ototoxic drugs, or the ageing process.Substantial progress has been made in recent years towards understanding the underlying mechanisms of SNHL and the discovery of novel therapeutic targets to prevent and mitigate the hearing loss. In addition, the link between hearing loss and dementia has been established, with the view that hearing loss prevention may also protect cognitive function.The aim of this special issue was to advance our understanding of the causes and mechanisms of hearing loss and propose novel strategies to protect and restore hearing. We invited investigators to contribute original research articles and state-of-the-art reviews to address the mechanisms of SNHL caused by cochlear injury or gene mutations, propose new strategies to promote hearing rescue after cochlear injury, and identify novel biomarkers of hearing loss. The collection includes seven original research papers and two reviews from the international groups investigating different aspects of SNHL.d-galactose injections. Hypoxia had the greatest effect on hearing loss induction, whilst HFD and d-galactose injections induced metabolic changes that promote cell ageing and apoptosis without significant changes in auditory thresholds. When two or more oxidative stress stimuli were combined, hearing loss occurred over a shorter period. The incidence of hearing loss was the highest in triple-exposure conditions than in any single factor model. The authors suggest that this novel animal model can aid in the development of preventative and treatment strategies for ARHL.Two articles focused on age-related hearing loss (ARHL). ARHL is the most common sensory disorder among the elderly, characterized by a decline in hearing sensitivity and speech discrimination, delayed central processing of acoustic information, and impaired localization of sound sources . MultiplEven though approximately one in three people over the age of 65 years suffer from hearing loss, pharmacological therapies for ARHL are still lacking. Previous animal studies have shown that some antioxidants, apoptosis inhibitors, and neuroprotective compounds can delay the onset of ARHL, but none of these compounds successfully completed clinical trials. Szepesy and co-workers [Noise-induced hearing loss (NIHL) has become a leading occupational health risk in developed countries. NIHL may also result from unsafe recreational, social, and residential noise exposures. People with excessive exposure to noise are frequently the population with a lifestyle of irregular circadian rhythms, which may affect auditory function. The study by Yang and co-workers  providesMicroRNAs are small non-coding single-stranded RNAs that regulate posttranscriptional gene expression. Acute exposure to traumatic noise induces microRNA expression changes not only in the cochlea, but also in central auditory pathways. Park and collaborators  demonstr1 adenosine receptors, which confer considerable otoprotection against acoustic trauma and other forms of SNHL such as from cisplatin and aminoglycoside antibiotics. Intratympanic administration of a small molecule RGS4 inhibitor 48 h after exposure to traumatic noise attenuated noise-induced PTS in rats by up to 19 dB, whilst the earlier drug administration (24 h) led to even better preservation of auditory thresholds (up to 32 dB). This was linked to improved survival of sensorineural tissues and afferent synapses in the cochlea. This study demonstrates that intratympanic administration of an RGS4 inhibitor can rescue cochlear injury and hearing loss induced by acoustic overexposure. The authors postulate that the study presents a novel paradigm for the treatment of various forms of SNHL based on regulation of A1 receptor signaling. There is a significant need for the development of effective therapies to prevent permanent cochlear damage and hearing loss after acoustic overexposure. Fok and colleagues  identifiOn a different note, the paper by Eitelmann and co-workers  reportedAn interesting contribution by Germana and colleagues  focused The voltage-gated potassium channel KCNQ4 has an essential role in regulating auditory function in the inner ear, by contributing to potassium recycling and maintenance of cochlear homeostasis. Reduced activity of the KCNQ4 channel has been associated with a genetic form of hearing loss, noise-induced hearing loss, and age-related hearing loss . Rim andSudden sensorineural hearing loss (SSHL), also known as sudden deafness, is an unexplained, rapid loss of hearing which often affects only one ear and is considered a medical emergency . SSHL caIn conclusion, this Special Issue highlights the diverse range of approaches to SNHL, from designing new animal models of ARHL, to the use of microRNAs as biomarkers of cochlear injury and drug repurposing for the therapy of age-related and noise-induced hearing loss. Further investigation into the underlying molecular mechanisms of SNHL and the integration of the novel drug, cell, and gene therapy strategies into controlled clinical studies will permit significant advances in a field where there are currently many unmet needs.


Gastrointestinal Mucormycosis (GIM) is a rare life-threatening angio-invasive infection. The classic risk factors include immunosuppression and metabolic derangement. Usually, there are classical risk factors in patients affected by Ileocecal mucormycosis. Few case reports have shown the absence of salient clinical presentation of mucormycosis in prolonged hospitalisation. The presence of association of mucormycosis in patients of typhoid infection is rare. Here, we present a case of invasive ileal mucormycosis occurring as a sequel to typhoid infection which lacked the typical risk factors for mucormycosis. Gastrointestinal (GI) mucormycosis is an uncommon, usually opportunistic, life-threatening angio-invasive infection, and accounts for 4 to 7 % of all cases of mucormycosis ,2. TradiSalmonella typhimurium.A 29-year-old male patient with no comorbidities presented with abdominal pain, fever, and yellow discoloration of the eyes for 10 days. On admission, the patient was malnourished with icterus, abdominal distension, and shifting dullness. On examination, BP was 70/40 mm Hg and pulse rate 100/min. Ultrasound abdomen showed hepatosplenomegaly with ascites. He was not on any previous treatment and his covid RT-PCR was negative. Blood culture showed growth of The patient was treated with antifungals, ciprofloxacin, and amikacin for typhoid. He developed melaena two weeks later and was not responding to conservative management. Hence, exploratory laparotomy with ileocolic resection and anastomosis was done. Post-op blood culture showed no growth. Gross examination of the right hemicolectomy specimen showed a necrotic polypoid mass protruding into the lumen of the thinned-out terminal ileum with extensive mucosal congestion and ulceration.Mucorales (Figure Microscopy exhibited transmural necrosis of the ileal wall with acute inflammatory exudate. The intestinal wall, Peyer's patches, and mesenteric lymph nodes showed necrosis Figure . Many ass Figure . Thrombos Figure .The patient was discharged in satisfactory condition on posaconazole and antibiotics.Mucormycosis is a fatal infection caused by fungi belonging to the subphylum Mucoromycotina and order Mucorales . GIM (GaTypical risk factors of mucormycosis are diabetes, defects in host phagocytes resulting in the immunocompromised state, corticosteroid use, immunosuppression for organ or stem cell transplantation, and increased levels of serum iron as a result of acidosis or administration of deferoxamine ,3,7. GIMS. typhimurium enteritis facilitates hyphal invasion into the intestinal wall and impaired phagocytic function of macrophages in typhoid infection further facilitates the growth of fungi [GI mucormycosis with concurrent typhoid fever has been very rarely reported in the literature . Pathophof fungi . Angioinof fungi .Diagnosis of GIM can often be delayed because of non-specific presentation. The most common symptoms are non-specific abdominal pain and distention associated with nausea and vomiting. Fever and haematochezia can be present. The diagnosis is usually during surgery or endoscopy by biopsy of the suspected area . SuccessSalmonella infections are very common. The exact mechanism of their association is not well understood but can be attributed to disturbed host immunity in typhoid infections or due to prolonged hospital admission in immunocompetent persons.Association of GI mucormycosis with enteric fever is very rare. It assumes importance in developing countries where Patients not improving on conservative management of typhoid and presenting with melaena warrant exploration. It is important to have a high index of suspicion in these patients so that early identification of such a life-threatening infection can be made.


Nearly half of all adults over the age of 60 years have hearing loss. Recent research suggests adults with hearing loss experience increased health care expenditures and hospitalization. However, little is known about whether these are preventable hospitalizations which may indicate poorer healthcare system engagement. In this cross-sectional analysis, we examined data from combined 2016-2018 Medicare Current Beneficiary Survey (MCBS) datasets. Participants are asked to describe their self-perceived trouble hearing. Preventable hospitalizations were defined and generated from administrative claims files based on the Agency for Healthcare Research and Quality identified conditions that should be manageable in ambulatory care settings. Multivariate regression models adjusted for demographic/socioeconomic characteristics and general health determinants were used to explore the association between trouble hearing and outcomes. The combined 2016-2018 MCBS administrative claims files included 18,814 participant-years, 49.8% reported no trouble hearing, 43.4% reported a little trouble and 6.8% a lot of trouble hearing, respectively. A higher proportion of those with a lot of trouble hearing (6.8%) experienced at least one preventable hospitalization compared to those with a little trouble hearing (3.4%) and no trouble hearing (2.5%). In a fully adjusted logistic regression model, hearing loss was associated with 1.35 times the odds of experiencing at least one preventable hospitalization per year . Medicare beneficiaries with hearing loss experience higher rates of preventable hospitalizations. This may be due to avoidance of care due to communication barriers. Further work is needed to understand underlying reasons and whether addressing hearing loss modifies the observed association.