The Norwegian regulations for nursing homes consider access to meaningful activities to be an indicator for the quality of nursing homes. Activities of daily living (ADL) provide important basic self-care skills for nursing home residents. Due to the physical changes caused by ageing and comorbidities, nursing home residents may experience functional decline over time, which may affect their ability to perform meaningful ADL, such as outdoor activity, which is considered a valuable and meaningful activity in Norwegian culture. This study aimed to investigate the association between ADL status, institution-dwelling and outdoor activity among nursing home residents.This cross-sectional study included 784 residents aged >67 years living in 21 nursing homes in 15 Norwegian municipalities between November 2016 and May 2018. The Barthel Index was used to assess the nursing home residents’ ADL status. Other variables collected were age, gender, body weight and height, visits per month, institution, ward, and participation in weekly outdoor activities. Descriptive statistics were used to provide an overview of the residents’ characteristics. A Poisson regression model was used to test the association between the outdoor activity level as the dependent variable and ADL score, institution, and other control variables as independent variables.More than half (57%) of the nursing home residents in this sample did not go outdoors. More than 50% of the residents had an ADL score <10, which indicates low performance status. Further, we found that residents’ ADL status, institution, ward, and number of visits had an impact on how often the residents went outdoors.The nursing home residents in this study rarely went outdoors, which is interesting because Norwegians appreciate this activity. Differences in the number of visits might explain why some residents went outdoors more often than other residents did. Our findings also highlight that the institutions impact the outdoor activity. How the institutions are organized and how important this activity is considered to be in the institutions determine how often the activity is performed.The low frequency of the outdoor activities might be explained by a low ADL score. More than 50% of the residents had an ADL score <10, which indicates low performance status. Despite regulations for nursing home quality in Norway, this result suggests that organizational differences matter, which is an important implication for further research, health policy and practice. Norway is an example of the Nordic welfare model and its welfare state is characterized by public funding and service provision . NorwegiThe availability of activities for nursing home residents may contribute to their well-being and dignity . By contThe outdoor lifestyle traditionally holds a prominent position in Norwegian culture  and is cDespite the new regulations, changing nursing home practices is difficult . AccordiPhysical activity, rehabilitation or exercise may improve independence and prevent the decline in ADL in elderly residents in long-term care facilities . It is uSeveral factors might influence nursing home residents’ ADL status. Previous research has investigated the importance of ADL related to different aspects, such as loneliness, less participation in activities and depression. Few studies have focused on the relationships between ADL status and participation in different activities among nursing home residents. One study investigated physical and social aspects of residents’ mobility level and reported that nursing home residents dependent on a wheelchair or elevator during care were less involved in physical and social activities compared with more-mobile residents . This stDespite Norwegian regulations , the freTo what extent are nursing home residents’ ADL status and the institution they live in associated with outdoor activity?The aim of this study was to investigate the association between nursing home residents ADL status, institution-dwelling and outdoor activity. The following research question was formulated: A cross-sectional design was used.The data were collected by first-year nursing students during their placement in nursing homes between November 2016 and May 2018. The placement was either during the autumn semester, i.e., 8 weeks from the middle of October until the middle of December, or 8 weeks during the spring semester, from the middle of April until the middle of June. The data were collected during the daytime by means of a study manual, which the students had been presented in lectures at the university. For standardized instruments and questionnaires, we used the connected manual, procedure or protocol. The process of data collection was supervised by the university teacher and the nurses working at the different nursing homes. Each patient was registered once.Our responses were collected from 21 different nursing homes. These institutions differ because they have different combinations of ward types and may have different attitudes towards outdoor activity. All nursing homes in this study except for one are financed and operated by the municipality. The single private nursing home is not run by a commercial actor, but by the parish associated with the Bergen Cathedral in Bergen, the second largest city and municipality in Norway. Nursing homes all share the same national financing system.The study included 784 residents aged >67 years living in 21 nursing homes in 15 Norwegian municipalities. The inclusion criteria were all residents aged >67 years living in the selected nursing homes, while the exclusion criteria were residents receiving palliative care, related to ethical considerations, to protect them from harm related to the completion of questionnaires in their presence. In addition, residents in the palliative phase may be unable to take part in the outdoor activities described in this paper. Five of the nursing homes were located in rural areas, while others were located in small villages. The nursing homes were not selected completely at random because the selection was partially determined by what nursing homes the nursing students attended during their practice period.ADL score because ADL is a measurement of physical capability (higher scores mean better capabilities). We observed the residents by using the method described in the Barthel Index for measuring performance in ADL, as translated and revised by We expected increasing levels of outdoor activities, e.g., making trips outside the nursing home, with increasing Outdoor activity is the dependent variable in our analysis. In this study, the residents either walked on their own or with assistance from staff or visitors. Some residents went outdoors with a walker or in a wheelchair. Some of the residents had an electric wheelchair and went outside on their own. However, the purpose was still the same: outdoor activity. The level of this activity was measured and documented as the number of times the activity was performed during a week. Further, we introduce nursing homes as random effects to allow for the fact that not all types of nursing homes are included. These effects will tell us whether activity levels vary between institutions. We included a dummy variable for residing in a short-term/rehabilitation ward and one for residing in a dementia ward. Long-term ward residents are expected to be older, frailer and in need of more care; thus, we expected these residents to have the lowest levels of making trips outside the nursing home.number of visits (per week) is interpreted as a proxy for less social isolation . We expected that low BMI would be associated with fewer trips outside the nursing home.All variables were registered in a form and documented in Excel version 16.16.19 .There are some limitations in using this approach. The sample is not completely randomized since the nursing homes were not selected at random, neither were the residents in the nursing homes. The students may also understand the concept differently or they did not apply it consistently. However, a detailed protocol was provided to the students so that their observations were made consistently. For instance, what date format should be used, and age and length of stay should be integer numbers. We could not eliminate ambivalence in the data collection completely.Descriptive statistics were used to give an overview of the demographic and clinical characteristics of the participants, including age, gender, BMI, ADL status, institution and the prevalence of residents’ outdoor activities. We sorted the informants into different groups according to the quartiles from the distribution of ADL scores. We then analysed the levels of the outdoor activities between these groups. To further examine the association between ADL score and outdoor activity, we included age, BMI, gender, visits per month, type of ward and ADL score as well as institutions in a multivariate Poisson regression model. The data were analysed using the SAS GLIMMIX procedure with a Poisson log-link function. The two-sided significance level was set to 0.05.We designed a model with outdoor activity as the dependent variable and ADL status as an explanatory variable affecting the level of this activity. In addition, we controlled for several other explanatory variables that may have an influence on both activity level and ADL scores, thereby eliminating possible spurious factors. We also included institutions as an independent variable, assuming they are random effects, which allows the coefficients to vary between institutions.We assume that institutions (nursing homes) represent several unmeasured characteristics that vary between them. These characteristics may be different service quality, different organizations, different informal routines established among staff, different efficiency in using resources, or different resident characteristics. These characteristics are not measured and probably cannot be measured. Institutions are clusters therefore we include them as random effects in the regression model to account for these variations. On the other hand, the impacts of different ward types are fixed effects since ward types have the same definition for all nursing homes and therefore do not measure any latent characteristics. The model is estimated as random intercept model, each institution has an individual- specific random effect in addition to the fixed effects of all other independent variables . A mixedThe model allowed us to control for other regressors when assessing the effect of ADL score or institutions on outdoor activity. Thus, we could compare activity level between residents in the same ward and with the same age, gender, number of visits per month and BMI, but with different ADL scores in different institutions.Clustering occurs when entities are distributed on several levels. When this is the case, error terms within a cluster will not be independently distributed of error terms in another cluster . In our χ2/df has a value <2. Therefore, we assumed no overdispersion in the model.The Further, we computed the intraclass correlation (ICC1) from the estimated model. This was performed by using a function in R, since SAS does not provide this statistic . The corExcept for the ICC1, all statistical analyses were performed using SAS software .The Regional Medical Ethics Committee (REK West), University of Bergen  and the Norwegian Social Science Data Services (46303) approved the study, which was endorsed by all nursing homes. Voluntary, written informed consent was obtained from all participants. In situations where the resident was not able to give consent related to e.g., dementia or cognitive impairment, either the resident’s relatives or the department manager gave consent.n = 784), included more women (69%) than men (31%), , which is consistent with the population distribution in this age group . Both women live in institution number 1. Resident A had an ADL score of 10, while resident B had an ADL score of 15. From our model, we expected resident A to take 0.43 trips outside the nursing home in the preceding week and resident B to take 0.56 trips. Accordingly, we expected that 16 days would be needed for resident A to take one trip outdoors and 13 days would be needed for resident B. Had the two residents lived in institution number 7, the expected number of trips would have been 1.3 and 1.7 trips outdoors, assuming values for age, number of visits, BMI and gender stay the same and ADL score is 10 and 15, respectively, as above. In other words, both residents A and B would have three times more outdoor activities if they had been living in institution 7 instead of 1. This result shows that institutions have an impact on activity level. This is confirmed by estimation of institutional random effects  of the participants in this study did not go outdoors during the preceding week. Their ADL status might explain this pattern because more than 50% of the residents had an ADL score <10, which indicates low performance status. The institutions that the residents live in have an impact on outdoor activity, which suggests that organizational differences matter. This is an important implication for further research, health policy and practice. Planning for nursing home residents’ activities requires staff competence in assessing the capacity and needs of all residents. Those residents with few family members or friends might benefit from visits from volunteers taking on an important function in collaboration with the nursing staff in managing different kind of activities, such as outdoor activities. Our findings show that residents rarely engage in outdoor activities, even though the need for activities and engagement for nursing home residents is well known. Therefore, a greater focus on activities for elderly nursing home residents should be increased and customized in line with each resident’s individual needs and wishes.10.7717/peerj.10202/supp-1Supplemental Information 1Click here for additional data file.


Objective: Segmental demyelination is the pathological hallmark of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), but other elementary lesions are frequently observed, configuring a series of different pathological pictures. In this article, we review the pathological findings of a large series of sural nerve biopsies from our cohort of CIDP patients. Patients and Methods: Patients with CIDP who underwent nerve biopsy were retrospectively selected from those referred to the Institute of Neurology of the “Università Cattolica del Sacro Cuore” in Rome, Italy, from 1982 to February 2020. Sural nerve biopsy was performed according to standard protocols. Results: Sural nerve biopsy was performed in 43/130 CIDP patients. Demyelinating abnormalities and axonal loss were found in 67.4% and 83.7% of biopsies, respectively. Conversely, onion bulbs and inflammatory infiltrates were rare . In three cases, we observed normal pathological findings. Conclusions: A pathognomonic pathological finding of CIDP cannot be established, but we confirm the utility of nerve biopsy in this setting to confirm the diagnosis  and to elucidate pathogenic mechanisms. Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a clinically heterogeneous, roughly symmetric, sensory and motor neuropathy of likely immune origin ,2,3. ItsIn its classic presentation, CIDP appears as a mainly motor neuropathy, affecting both distal and proximal muscles of the four limbs, along with sensory involvement and generalized areflexia, evolving as a monophasic, relapsing, or progressive disorder in more than two months. However, there is a remarkable heterogeneity in clinical presentation, and several variants of CIDP have thus far been described, all characterized by electrophysiological and/or histopathological features of segmental demyelination . Demyelinating lesions are distributed in a multifocal pattern in the peripheral nervous system. The examination of sensory nerve biopsy represents a privileged instrument both for diagnostic purposes and for understanding possible pathogenic mechanisms ,15,16,17Segmental demyelination is typically considered as the pathological hallmark of CIDP, but other elementary lesions are frequently observed, including axonal degeneration, proliferation of Schwann cells leading to the formation of “onion bulbs”, and inflammatory infiltrates. In a minority of cases, endoneural and intramyelinic edema, and axonal shrinking have been described too ,16,17,18For many years now, macrophage-mediated demyelination has been described in CIDP. The first description by Prineas demonstrated, using electron microscopic examination of nerve samples from patients with recurrent idiopathic polyneuropathy, that myelin breakdown is initiated by macrophages penetrating Schwann cells, and in the following years, this mechanism was confirmed in other studies ,16,17,18Recently, autoantibodies against nodes of Ranvier and paranodes have been identified, and their association with distinct subgroups of CIDP patients has been described .All the described alterations can combine in many ways, configuring a series of different pathological pictures.In this article, we review the pathological findings of a large series of sural nerve biopsies from our cohort of CIDP patients in order to underline the most frequent pathological alterations and to make a correlation with clinical findings.Patients were retrospectively selected from those referred to the Institute of Neurology of the “Università Cattolica del Sacro Cuore” in Rome, Italy, from 1982 to February 2020.Diagnosis was defined according to the European Federation of Neurological Societies and the Peripheral Nerve Society (EFNS/PNS) diagnostic criteria for CIDP , includiAs regards the phenotype, based on clinical and electrophysiological features, patients were further divided into two classes: “typical” and “atypical” CIDP .Patients with an approximately symmetrical sensory-motor neuropathy, with motor involvement grossly more prominent than the sensory one, were labeled as having a “typical CIDP”. In contrast, in the second group, we included all the patients with any of the atypical variants of CIDP so far described: distal acquired demyelinating symmetric neuropathy (DADS neuropathy); multifocal acquired demyelinating sensory and motor neuropathy (MADSAM neuropathy or Lewis–Sumner syndrome); pure motor CIDP; sensory CIDP; and focal CIDP .Furthermore, according to the disease course after the initial phase, three different types of disease course were recognized: monophasic course, relapsing-remitting course, chronic progressive course .Sural nerve biopsy was performed, after obtaining informed consent, as previously described . Light aStatistical analysis of data was performed by SPSS  version 24.0 to assess any differences between the group of patients who underwent nerve biopsy and the group of patients for which nerve biopsy was not performed (biopsy performed vs. biopsy not performed). Moreover, considering only patients who underwent nerve biopsy, statistical analysis was carried out to assess any differences based on the clinical phenotype . Mann–Whitney U test and Fisher’s two-tailed exact test were used to compare numerical and nominal dichotomous variables, respectively. In case of categorical polytomous variables, a Chi-squared test was performed. Significance was set at 0.05.The study was approved by the “Fondazione Policlinico Universitario A. Gemelli IRCCS—Università Cattolica del Sacro Cuore” Ethics Committee, Rome (Prot. 23255/16 ID 1229). The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki , as reflected in a priori approval by the institution‘s Human Research Committee.A total of 130 patients  were diagnosed with CIDP in the period examined. Male-to-female ratio was 1.8. Mean age at onset was 48.7 years . Mean follow-up was 97.0 months . A typical presentation was observed in 84/130 (64.6%) patients; conversely, an atypical phenotype was observed in 46/130 (35.4%) patients .Demographic and clinical characteristics of the entire CIDP cohort are summarized in A total of 43 out of 130 (33.1%) patients  underwent a nerve biopsy. Male-to-female ratio was 1.9. Mean age at onset was 46.7 years . Mean follow-up was 139.5 months . Mean age at biopsy was 51.8 years . Mean time from disease onset to nerve biopsy was 68.8 months .According to diagnostic criteria, 38/43 had a definite CIDP, 2/43 had a probable CIDP, 0/43 had a possible CIDP, and 3/43 did not fulfil EFNS/PNS diagnostic criteria .A typical presentation was observed in 30/43 (69.8%) patients . Mean agAn atypical phenotype was observed in 13/43 (30.2%) patients . Mean agDemographic and clinical characteristics of CIDP patients who underwent nerve biopsy and their comparison with the remaining cohort are summarized Obvious demyelinating abnormalities in both semithin sections and teased fiber analysis were found in 16 biopsies (37.2%). Conversely, demyelination was detected only in semithin sections (fibers with very thin or absent myelin sheath) in seven cases (16.3%) a, and onElectron microscopy confirmed the alterations seen on light microscopy and in some cases showed macrophages loaded with myelin debris invading the basal lamina of myelinated fibers a–d. In three patients, evidence of demyelination and/or remyelination was not evaluable because of the severe axonal loss. In the remaining 11 patients (25.6%), there was not any feature suggestive of either demyelination or remyelination.Onion bulbs and inflammatory infiltrates, considered as other typical features of the disease, were present only in eight (18.6%) and two (4.7%) patients, respectively a–d.Subperineural edema was detected in four patients (9.3%), and endoneural edema in another patient (2.3%). Marked myelin swelling due to intramyelinic edema was observed in three other cases (7.0%) a–e.In the great majority of nerve specimens , we detected a variable degree of axonal loss , sometimes with focal distribution a. WallerDetailed pathological findings are summarized in In our cohort, a similar percentage of biopsies was performed in patients with typical and atypical phenotypes, and no specific pathological alteration was predominant in one group than in the other. Comparisons between pathological findings among the patients who underwent nerve biopsy based on the clinical phenotype are reported in Our series confirms that segmental demyelination is the pathological hallmark of CIDP, together with other elementary lesions, as widely reported in the literature on nerve biopsies and in rare autopsy studies  22]. Im. Im22]. Several factors contribute to such variability. Firstly, the observed picture on nerve biopsy represents only a snapshot of the cascade of events occurring over time. Therefore, the type of lesions observed is strictly dependent on the disease phase in which the sampling is performed. Secondly, CIDP is a multifocal disorder where the spatial distribution of the lesions follows the laws of variability and unpredictability typical of stochastic phenomena, including inflammatory processes . The nerSegmental demyelination is characterized by the destruction of the myelin sheath which generally involves short (less than one internode long) segments, while the axonal structures remain intact. In our series, demyelination was found in 67% of patients  4,6,7,8,15,16,17Demyelinating phenomena can be observed in light microscopy and/or electron microscopy, but teased fiber examination allows a more accurate identification and quantification of these phenomena a,b 4]. . 4]. The American Academy of Neurology (AAN) commission suggested quantitative criteria to establish “unequivocal evidence of demyelination and/or remyelination” in nerve biopsies of patients with CIDP: at least 12% of 50 dissociated fibers, minimum of four internodes each, must have these alterations, or by electron microscopy, a minimum of five fibers must show demyelination .Although demyelination represents the prevalent and probably primary event of CIDP, pathological examination shows that, in most patients, this lesion is associated with a significant loss of fibers a. In ourAxonal involvement can represent an “innocent by-stander” effect, a non-specific consequence of an inflammatory process that primarily affects myelin. However, it should be borne in mind that the distinction between axonal and demyelinating pathologies, while retaining an undoubted value in the diagnosis and classification of neuropathies, is an artificial simplification since neuritis and Schwann cells form a morpho-functional unit in which the two components are strictly interdependent .A “pure” demyelinating disease, in which the nerve biopsy showed only myelin destruction without the involvement of the axons, was observed in only 5% in our cohort (two patients) ,15,16,17It is important to underline that, in about 25% of our cohort, the nerve biopsy does not show clear demyelinating phenomena but only a loss of fibers, associated or not with axonal degeneration in the active phase. This finding may be a consequence of the multifocality of the disease. Fiber loss will be the only alteration when active inflammation, responsible for demyelination and destruction of the axons, occurs in the segments proximal to the site of the biopsy sample. Confirming this data, in all patients with pathological evidence of “axonal” neuropathy from our cohort, neurophysiological investigations  show signs of demyelination. However, rare cases have been reported in which both the pathological examination of the nerve and nerve conduction studies showed an exclusively axonal involvement . One posThe hypothesis of an inflammatory nature for CIDP is related to the observation that inflammatory cells, namely macrophages and T cells, actively participate in the pathogenesis of the disease . HoweverIn one patient in our cohort, we detected antibodies against Contactin-1 : the patIn a variable percentage , the morIn our cohort, 7% of biopsies were completely normal, a percentage similar to that reported in the literature, ranging from 10% to 20% of cases. This can be explained once again by the multifocal nature of CIDP, in which the nerve sample may not show any alterations because it is spared from the inflammatory process by chance. Furthermore, normal aspects of nerve biopsy, when associated with the absence of clinical and electrophysiological sensory involvement, occur in pure motor CIDP, which has been suggested to represent a distinct nosological entity ,34,35. FIn some patients , the nerIn conclusion, we confirm that nerve biopsy may be helpful in the diagnosis of CIDP and may probably contribute to improve our understanding of pathogenetic mechanisms and to identify proper treatments.


Older adults with mild or no hearing loss make more errors and expend more effort listening to speech. Cochlear implants (CI) restore hearing to deaf patients but with limited fidelity. We hypothesized that patient-reported hearing and health-related quality of life in CI patients may similarly vary according to age. Speech Spatial Qualities (SSQ) of hearing scale and Health Utilities Index Mark III (HUI) questionnaires were administered to 543 unilaterally implanted adults across Europe, South Africa, and South America. Data were acquired before surgery and at 1, 2, and 3 years post-surgery. Data were analyzed using linear mixed models with visit, age group , and side of implant as main factors and adjusted for other covariates. Tinnitus and dizziness prevalence did not vary with age, but older groups had more preoperative hearing. Preoperatively and postoperatively, SSQ scores were significantly higher (Δ0.75–0.82) for those aged <45 compared with those 55+. However, gains in SSQ scores were equivalent across age groups, although postoperative SSQ scores were higher in right-ear implanted subjects. All age groups benefited equally in terms of HUI gain (0.18), with no decrease in scores with age. Overall, younger adults appeared to cope better with a degraded hearing before and after CI, leading to better subjective hearing performance. Cochlear implants (CI) are the treatment of choice to restore the reception of sound when hearing aids no longer provide an adequate level of speech understanding for the listener to function in everyday situations. A CI bypasses the peripheral system, replacing acoustic input with electrical signals and thus reestablishing the means to receive sensory information and activate neural transmission, albeit with considerably reduced fidelity compared with normal hearing ; at the level of transmission, all forms of retrocochlear pathology , which is a pervasive, progressive disorder commonly referred to as presbycusis  were extracted from the Implant Recipient Observational Study (IROS) database  described by Lenarz et al.  for frequencies 500, 1,000, 2,000, and 4,000 Hz. These values were categorized into standard degrees of hearing loss (HL) which represent ranges of four-frequency pure-tone average (PTA) thresholds as mild 26–40 dB HL, moderate 41–55 dB HL, moderately severe 56–70 dB HL, severe 71–90 dB and profound >90 dB HL.The Speech, Spatial, and Qualities of Hearing Scale (SSQ) is a validated, disease-specific, self-report questionnaire specifically designed for hearing-impaired individuals  is one of the most widely applied self-report rating scales in studies describing the health-related quality of life in hearing-impaired adults. As a multi-attribute health scale, it covers vision, hearing, speech, ambulation, dexterity, emotion, cognition, and pain. Study participants were directed to complete the HUI questionnaire, consisting of 17 questions on their own. HUI Mark 3 scores range from zero (dead) to one , but can also be less than zero in the case of depression combined with other low scores (worse than dead).Demographics, comorbidities, and limited hearing history, and audiometric data were also collected. Here, we considered the ear of implant; the degree of HL; presence or absence of tinnitus and dizziness; hearing aid and telephone use; and duration of HL.Kruskal–Wallis one-way analysis of variance (ANOVA) and chi-squared tests were used to determine whether the continuous and categorical predictors, respectively, differed between age groups.Linear mixed-effects models were developed to determine the effects of age group and side of implant  on SSQ and HUI scores. An interaction between age group and visit or implant side and visit were included in the model to determine whether change over time was different for specific age groups or implant sides. In the linear mixed-effects models, a random intercept for each person was used to account for the correlation induced by repeated measurements. Linear mixed-effects models use all available data to give an unbiased estimate of mean effect assuming data lost to follow-up are missing at random  suggesting that SSQ scores improved over time  and the 65–93 age group (p < 0.001 and p = 0.005). Differences were 0.82 points between the youngest age group and those in age groups 55–93, and 0.75 points between the 35–44-year olds and those in age groups 55–93. There was approximately zero difference  in SSQ scores between those in the 55–64 and 65–93-year-old groups.The effect of age group on SSQ scores is represented in Separate analyses of the SSQ subscale scores, speech recognition, spatial awareness, and sound quality, mirrored the pattern for SSQ total scores (not presented).p < 0.001) with a slightly smaller estimated increase from baseline to visit 3 , but there was no statistically significant difference between age groups or interaction effect  at baseline. However, SSQ scores were significantly greater for right-implanted subjects than for left-implanted subjects at 1 year  and 3 years  but not at 2 years . The difference in mean SSQ scores for the side of the implant was slightly greater than half that of the age-group effect.There was a significant effect of implant side and interaction between visit and implant side for SSQ scores  indicatip = 0.323) and no main effect of implant side (p = 0.639) indicating no evidence of an association between implant side and change in HUI scores  with overall improvements in the rate of reported tinnitus; for example, 50% reported tinnitus at 1 year compared with 58% at baseline. Tinnitus state changed in both directions such that 60 of the 201 with tinnitus at baseline reported no tinnitus at 1 year, but 34 of 145 with no tinnitus at baseline reported tinnitus at 1 year. Dizziness states also changed significantly  where more than 50% of subjects reported a less severe state and <10% a more severe state.Tinnitus states changed significantly from baseline to year 1 : 70% of those who did not use the telephone at baseline reported using the telephone at 1 year. Conversely, only 10% of those who did use the telephone at baseline stopped using it at 1 year. Telephone use did not vary significantly by age group either at baseline or 1 year after CI.Telephone use improved significantly from baseline to 1 year  and oldest (65–93 years) groups to allow for sufficiently high numbers for analysis. As shown in Self-reported health utility measured by HUI scores did not significantly vary across age groups, except for those aged >70. It is expected that older CI-users would report lower scores given the multi-dimensional weighting where just one other health problem may have an impact  evenly distributed across ages. Our study’s findings indicate a clear difference between younger and older subjects with the break-in age at 55 years, with 50.6% aged 55+. The older CI users reported lower baseline self-reported hearing performance from SSQ scores, but all groups demonstrated similar gains pre- to postoperatively and over time. There were no overall age-differences for HUI scores. Poorer speech understanding for deafened adults is experienced at all ages but is more pronounced in elderly subjects. We speculate that middle-age, or at least 55–65 years, is a time of transition with gradual reductions in upstream neural processes occurring. Hence, only partial restoration of hearing sensitivity with acoustic hearing aids in severe or profound hearing loss requires greater effort for middle-aged and older listeners than for younger listeners to manage verbal communication. In today’s research environment, the middle-aged group is receiving less attention, especially considering the great interest in implanting older patients underscored by the demographic shifts occurring in many western societies. Indeed, some researchers have considered this group designating them as “older” listeners , right-ear CI recipients reported higher SSQ scores compared with those with left-ear CI. The size of this difference was slightly less than half the age-effect difference between <45 and 55+ years. The findings that right-ear CI users have better subjective hearing performance suggests access to a more efficient listening network where signals preferentially cross lateralize to the left hemisphere for interpretation , their perceived difficulties in complex listening situations differed. The findings for our large cohort, then, bring into question whether reliance on speech discrimination scores as the gold standard for assessing candidacy and subsequent outcomes is valid. Higher postoperative scores on word and sentence testing remain a common goal but the preoperative scores may not be the definitive criterion for acceptance into a CI program, where the ultimate objective is to identify how to improve the real-life listening conditions of a hearing-disadvantaged individual. If assessments rely on speech comprehension, they may miss taking into consideration coping mechanisms needed by elderly but not younger listeners. Delaying the younger adult CI candidates may reduce their opportunity to rally active cortical regions capable of resisting negative neuroplasticity. We assert, as do Alcañiz and Solé-Auró , that inIf the aim is to better characterize the early onset of effortful listening, perhaps peripheral hearing measured by PTA thresholds will suffice by giving more consideration to the better ear. Applying the evaluation criterion of hearing in the better ear, Lin and associates , should be included routinely in assessments for CI candidacy. Degeest et al.  highlighPost-implant rehabilitation techniques for CI recipients have focused on assisting in ways to make the best use of the new auditory signals rather than on improving the entire listening network; part of which is the act of willful or motivated hearing Peelle, . ExtendiIt has been pointed out that older users do not reach the same level of performance as their younger CI peers or a normal-hearing population . This study focused on functional data derived from self-reported hearing performance (SSQ) and health-related quality of life (HUI) and indicated that younger CI users yield higher SSQ scores than older cohorts, that younger CI recipients demonstrating a greater degree of peripheral hearing loss, and that right-ear implantees of all ages obtain higher postoperative SSQ scores. Health-related quality of life varied similarly across ages. It is clear that younger people manage hearing loss better than older ones, and that the age gap occurs between 45 and 55 years. The study brings to light the need to focus on means and methods that mediate the effects of disabilities impacting the quality of life and healthy aging.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Health Research Ethics Committee 1, Stellenbosch University (reference N15/02/015). The patients/participants provided their written informed consent to participate in this study.CJ and PG analyzed and interpreted data. PG was responsible for statistical analyses. CJ conceived the initial idea for the study. DM performed a literature review and initial writing. CJ and DM both extended and revised the manuscript. The remaining authors contributed the data and ensured that it was collected in a compliant manner. All authors contributed to the article and approved the submitted version.CJ is an employee of Cochlear, manufacturer of Nucleus cochlear implants. PG and DM are paid consultants for Cochlear Europe. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Introduction: Hearing loss is one of the most common congenital disabilities in neonates. The aims of this study were to investigate the prevalence of hearing loss and identify the most significant risk factor in neonates hospitalized at the Neonatal Intensive Care Unit (NICU).Methods: This cross-sectional study involved 530 neonates admitted to NICU Abuzar Hospital with risk factors for hearing loss based on Joint Committee of Infant Hearing (JCIH). The hearing screening tests include transient evoked otoacoustic emissions (TEOAES) and the automated auditory brain stem response (AABR). For infants with abnormal AABR and TEOAE results, the Auditory Brainstem Response (ABR) and Auditory Steady-State Responses (ASSR) tests were performed.Result: Of 530 infants, 27 (5.09%) were diagnosed with different types of hearing loss. Ototoxic drugs, hyperbilirubinemia requiring exchange transfusion, asphyxia, low weight birth, Apgar score < 5, and a kinship marriage of parents were significant risk factors for hearing loss in our study population.Conclusion: Due to the high prevalence of hearing loss in the NICU, it is recommended that a hearing screening program be performed for all infants admitted to the NICU. Implement a comprehensive plan for neonatal hearing screening for early detection and intervention of hearing loss is essential. Early screening and detection of hearing loss in infants and children to intervene and reduce the adverse effects of hearing loss are essential. Delay in the process of diagnostic hearing loss will lead to adverse consequences on the development of the child's speech-language and cognitive skills .More than 80% of hearing loss in children is congenital or occurs in infancy. Bilateral deafness is reported in 1-3% of births and in 2-4% of neonates in the intensive care unit, which is more common than disorders such as congenital hypothyroidism and phenylketonuria [In 1994, 2000, and 2007, the Joint Committee of Infant Hearing (JCIH) published the risk factors for hearing loss and set standards for the identification of hearing loss .However, it requires many studies to investigate the effect of risk factors on hearing loss incidence. These factors include: birth weight less than 1250 grams, prematurity, hypoxia, Apgar score less than 3 and 6 in one and five minutes respectively, seizures, ventilation, meningitis, jaundice, asphyxia, hypoglycemia, and treatment with aminoglycosides and furosemide [Many organizations emphasize the need for a comprehensive neonatal hearing screening program at birth and before hospital discharge. Until 1990, neonatal hearing screening was performed only in high-risk neonates, which resulted in detection of 50% of infants with hearing loss. In 2000, the Joint Committee of Infant Hearing recommended that all infants participate in the screening program .According to the Joint Committee of Infant Hearing, The Automated Auditory Brainstem Response (AABR) and Transient Evoked Otoacoustic Emission (TEOAE) tests are used to screen children's hearing. Otoacoustic emission is a non-invasive, rapid, and appropriate method for assessing cochlear function. However, the diagnostic value of TEOAE alone is limited and ABR is more reliable for hearing screening .Early detection of hearing loss in the infant is an essential step in preventing family, social, welfare, speech, language and cognitive problems. The importance of early hearing screening has been recognized for many years and follows two primary goals. Its short-term goal is early detection of hearing loss and its long-term goal is to improve speech, language, and cognitive development .We aimed to determine the prevalence of hearing loss and the associated risk factors in NICUs of Abuzar hospitals, affiliated to Ahwaz University of Medical Sciences.The study was a cross-sectional descriptive study of newborns admitted into the NICU of the Aboozar Children’s Hospital , Ahvaz, Iran, between August 2019 and April 2020. Newborns whose parents gave written informed consent were included in the study. The Ethics Deputy of Ahvaz Jundishapur University of Medical Sciences provided IRB# IR.AJUMS.REC.1399.240.Five hundred thirty neonates in the NICU of Abuzar Hospital in Ahvaz via non-random convenience sampling were selected and screened based on the Welfare Organization of Iran’s protocol in parallel method. In this method, Oto-Acoustic Emission (OAE) and AABR hearing tests are performed simultaneously in one day.All enrolled neonates were screened for hearing impairment with TEOAE and AABR by Madsen Accuscreen ; Taastrup, Denmark). Audiologists performed all tests. For TEOAE click stimulus was used at the intensity of 80 dB sound pressure level (SPL). The time required for the test was about one to three minutes. The newborns were tested in a quiet (preferably in sleep or while breastfeeding) room. The pass criterion for TEOAE was 6 dB signal to noise ratio at least in three frequencies from 1000 to 4000 HZ. AABR was conducted by click stimuli at 35 dBnHL, with alternating polarity and presentation rate of 37.7/s. The AABR electrode arrangement was as follows: the negative electrode was placed on the ipsilateral mastoid, the ground electrode on the contralateral mastoid and the positive electrode on the vertex. Neonates who had abnormal results in either test or either ear were reported as fail. Neonates with fail results were tested after two weeks. Before the second screening, high frequency tympanometry was performed, and neonates with middle ear effusion were referred for medical treatment. Impedance Audiometer AZ 26  was used to record the immittance measures. A high-frequency probe tone of 1,000 Hz was utilized to measure Y-admittance tympanograms, with a positive to negative pressure sweep of 200 dapa at a pump speed of 50 dapa/s . In the In this study, association between hearing loss and risk factors such as birth weight <1500 g, family history of hearing loss, kinship marriage of parents, hyperbilirubinemia at serum levels requiring exchange transfusion, prematurity, mechanical ventilation >5 days, asphyxia, any syndrome, ototoxic drug, sepsis, hypoglycemia, and Apgar score <5 at one minute after birth was evaluated.Finally, all information was coded in Statistical Package for Social Sciences (SPSS) Statistics version 22  software and analyzed at the significance level of 0.05. Frequency distribution for descriptive statistics and Chi-square test to evaluate the association between hearing loss and risk factors were used.In this cross-sectional study, 51.32% of the subjects were females and 48.67% were males. The neonates’ mean age was 6.65 ± 6.96 days (age range: 0 - 40 days).There were 530 NICU infants who underwent AABR and TEOAE tests. Of these, 78 14.71%) infants failed in the first screening and entered the second screening. In the second screening, 28 (5.28%) of 78 infants failed and were referred for diagnostic ABR and ASSR. Three children were missing from the study due to non-referral to the second screening  infants with hearing loss, 14 cases with SNHL, seven with conductive hearing loss, and six with auditory neuropathy. At the diagnostic stage, OAE test was performed for all infants. One infant due to non-referral to the diagnostic test was missed.The percentage of hearing loss in each type of hearing loss is given in Table Results of Chi-square test revealed no significant association between hearing loss and infants’ age (P = 0.620), sex (P = 0.126), prematurity (P = 0.901), ventilation (P = 0.069), sepsis (P = 0.086), syndrome (P = 0.446), hypoglycemia (P = 0.679) and family history of hearing loss (P = 0.067). However, there was a statistically significant association between hearing loss and birth weight (P < 0.001), Apgar score < 5 (P < 0.001), hyperbilirubinemia (P < 0.001), ototoxic drug (P=0.050), asphyxia (P = 0.041) and kinship marriage of parents P = 0.036)  had hearing loss. Molini et al. reported a prevalence of 4.3% for infants at risk of hearing loss  is closeHille et al. reported a prevalence of 3.2% in NICU infants , which iIn a study by Pourarian in 2012, 13.7% of infants in NICU suffered from hearing loss, which was higher than the expected rate . This diAccording to the diagnostic test, there were 5.09% infants with hearing loss, 2.64% with SNHL, 1.32% with conductive hearing loss, and 1.13% with auditory neuropathy. In a study by Colella in 2014, the incidence of hearing loss in the sample was approximately 3%, of which 0.91% was sensorineural, 0.13% with auditory neuropathy spectrum disorder (ANSD), and 1.8% conductive [The probability of hearing loss increases with an increase in the number of risk factors . In our According to Recchia et al., the use of ototoxic drugs is one of the causes of hearing loss in infants hospitalized in the NICU . In our Also, in a study by Amini, a significant relationship was found between the mean birth weight and hearing loss; however, no statistical correlation was found between Apgar score and abnormal OAE  but, In The prevalence of hearing loss due to positive history in infants is 7.29% . In our According to previous studies, one of the most critical risk factors for hearing loss is the high bilirubin level during the neonatal period. In a study by Boo in 2008, 32 neonates (8.12%) presented with severe hyperbilirubinemia and unilateral or bilateral permanent hearing loss . In the In the study conducted by Khairy in 2017, sepsis was the risk factor for hearing loss in infants . This reOne of the risk factors studied in the present study was ventilation. A study by Gohari showed no significant relationship between a ventilation risk factor and hearing loss . This fiIn the present study, prematurity was investigated as one of the risk factors for hearing loss. Chi-square test revealed no correlation between this factor and hearing loss. Most premature infants who failed the first screening test showed normal hearing in the final audiologic tests. In addition, several studies reported that auditory maturation can affect the long-term hearing result of prematurity .Another definitive finding of this study is the effect of the kinship marriage of parents on the incidence of hearing loss. These findings have been less attention in previous studies. In the study of Gohari no significant correlation was found between kinship marriages of parents and hearing loss . In the Literature studies also found a significant relationship between hearing loss and neonatal asphyxia associated with hearing loss , like ouIt is essential to consider the risk factors of infants admitted in the NICU, not to select candidates for hearing screening, but to the most appropriate management and follow-up for each case. Hearing screening, diagnosis, and follow-up of hearing loss in risk factor infants are necessary steps of the hearing child health program. At the same time, keep in mind that targeted screening of only high-risk criteria for hearing loss may miss up to 50% of infants with hearing loss. Hence, in 1993 a National Institutes of Health Consensus Statement recommended Universal Newborn Hearing Screening (UNHS). Screening before one month of age, detecting hearing loss before three months of age, and intervention services initiated by six months of age are recommended.The strengths of the present study combination of both TEOAEs and AABR, as it can diagnose auditory neuropathy, use of one single measurement tool, and performance of evaluations by one audiologist, which could prevent measurement errors and observer biases.The limitations of this study was the lack of infants referred to a second screening and diagnostic test.We tried to minimize this limitation by calling and following up the families.It can be concluded that the prevalence of hearing loss is high among our high risk neonates and the use of TEOAE and AABR tests simultaneously is essential for these infants. The use of ototoxic drugs, hyperbilirubinemia requiring exchange transfusion, asphyxia, low weight birth, Apgar score < 5 and a Kinship marriage of parents were significant risk factors for hearing loss in our study population. Therefore, timely detection and prevention of the mentioned risk factors are highly recommended.


The spiral ligament in the cochlea has been suggested to play a significant role in the pathophysiology of different etiologies of strial hearing loss. Spiral ligament fibrocytes (SLFs), the main cell type in the lateral wall, are crucial in maintaining the endocochlear potential and regulating blood flow. SLF dysfunction can therefore cause cochlear dysfunction and thus hearing impairment. Recent studies have highlighted the role of SLFs in the immune response of the cochlea. In contrast to sensory cells in the inner ear, SLFs  have also demonstrated the ability to regenerate after different types of trauma such as drug toxicity and noise. SLFs are responsible for producing proteins, such as collagen and cochlin, that create an adequate extracellular matrix to thrive in. Any dysfunction of SLFs or structural changes to the extracellular matrix can significantly impact hearing function. However, SLFs may prove useful in restoring hearing by their potential to regenerate cells in the spiral ligament. The global prevalence of hearing impairment is increasing significantly. In 1985, around 42 million people suffered from moderate to profound hearing impairment according to the World Health Organization (WHO). This number has risen to ~466 million people in 2018 and is expected to rise to 900 million by 2050 . HearingThe auditory system is the body's sensory system responsible for hearing. It consists of three main parts: the outer ear, the middle ear and the inner ear. The outer ear is the external part of the ear and consists of the pinna and the ear canal. It ends at the tympanic membrane, which is the beginning of the middle ear. This contains three ossicles  which are responsible for transferring the vibrations of the tympanic membrane into the inner ear. The inner ear consists of the vestibular apparatus and the cochlea, necessary for balance and sound detection respectively. Defects in the outer and middle ear cause conductive hearing loss, while defects in the inner ear lead to sensorineural hearing loss (SNHL) , 6.via the vestibulocochlear nerve  and includes the spiral ligament and the stria vascularis .+ ions from the intrastrial space (IS) and export them via KCNQ1 channels to the scala media. Intermediate cells are located below the marginal cells and form a network of processes with the marginal cells to maximize the surface for ion exchange. The third cell population are the basal cells which line the lateral surface of the stria. The basal cells are connected to each other by tight junctions that form an ionic barrier between the intrastrial space and the spiral ligament that is filled with perilymph . This r2. Furthermore, COX-1 is selectively expressed in type V SLFs but not in vascular cells, confirming the role of the SLF in CBF regulation . The CBF is regulated by the end-arterial system of the cochlea  and by a capillary-based control system. There are two distinct capillary networks in the cochlea. The capillaries of the stria vascularis form the blood-labyrinth barrier, which is crucial for the homeostasis in the cochlea. The second network consists of the capillaries of the spiral ligament, which regulate the CBF. A study by Dai et al., showed evidence of a physical connection between fibrocytes in the suprastrial area (type V SLFs) and capillaries in the spiral ligament through end-foot structures. Moreover, SLFs and vascular cells are also suggested to be coupled by local metabolic signals. Sound stimulation, for example, causes a release of calcium in SLFs and activates the cyclooxygenase (COX) signaling pathway. Consequently, blood vessels are dilated by conversion of arachidonic acid into prostaglandin PGEgulation . Anothergulation , which cgulation .+-dependent transporter. Glutamate is the major excitatory neurotransmitter between inner hair cells and the spiral ganglion neurons (SLFs are very susceptible to changes in glutamate concentration. The major glutamate transporter of the cochlea is the glutamate-aspartate transporter (GLAST), a high affinity Na neurons . Nonethe neurons . In mice neurons , 38. How neurons . GLAST e neurons . Further neurons .Collagen and cochlin are the most abundant proteins, secreted by SLFs to create a healthy extracellular matrix.COL2A1, encoding CII, have been reported to contribute to hearing disorders, such as Stickler syndrome  is the most abundant throughout the cochlea and the SL. CII is a fibrillar collagen and the main component of cartilage but is also found in non-cartilaginous tissue such as the cochlea . In the syndrome . CII hassyndrome . It caussyndrome . Other tsyndrome .COCH gene, is a protein that is abundantly expressed in the inner ear, spleen and eye. In the inner ear it is predominantly situated in the spiral ligament and spiral limbus. Next to collagen, it is the most abundant protein in the extracellular matrix of the inner ear. Cochlin is highly conserved among species suggesting that it has crucial functions in cellular processes. However, the exact function of cochlin in the inner ear is not yet fully understood  domain, an intervening domain (ivd1), and two von Willebrand factor A-like domains (vWFA1 and vWFA2), separated by a second intervening domain (ivd2) , a n (ivd2) . The vWFn (ivd2) . The LCChoe crab , 51.COCH gene cause DFNA9, an autosomal dominant disorder that causes progressive sensorineural hearing loss associated with vestibular dysfunction  are exclusively found in the stria vascularis and play a role in the immune defense to local noise-induced damage and consecutive repair. PVMs are also responsible for the integrity of the intrastrial fluid-blood barrier which separates the stria vascularis from the peripheral circulation. After acoustic trauma, PVMs can detach from the stria vascularis and cause a significant downregulation of pigment epithelium growth factor (PEGF), which regulates the expression of several tight junction-associated proteins. As a consequence, the permeability of the fluid-blood barrier increases which may lead to influx of toxic substances into the cochlea and a drop in EP , 63.Noise exposure can cause damage to both sensory and non-sensory cells in the inner ear which may lead to decreased hearing function and tinnitus, both reversible and irreversible. Previous research has shown that type IV SLFs are most sensitive to noise exposure and degenerate before hair cells do , 64. Noi+ concentration in the endolymph decrease dramatically. This decrease can be explained by two mechanisms. First, as the result of an unrestricted movement of K+ and Na+ between endolymph and perilymph due to uncoupling of the tight junctions through cellular damage in the reticular lamina. Secondly, due to a disrupted ion transport in the stria vascularis and the spiral ligament  , 72. GCsThere are acute  and chronic changes visible after noise exposure. In the spiral limbus, degeneration of SLFs can be observed, starting within the apical turn of the cochlea. This degeneration is characterized by nuclear pyknosis and cytoplasmic vacuolation, which are the result of apoptosis. A possible explanation for this loss of SLFs is that noise exposure can lead to insufficiencies of CBF, causing ischemia and damage to the capillaries. This results in an increased NO production that harms the cochlear cells .In the spiral ligament, loss of type IV SLFs can be observed at all levels of noise exposure starting from 94 dB and no signs of regeneration have been observed. In contrast, loss of type II SLFs is only observed at 116 dB in the entire basal turn and there are signs of regeneration after 8 weeks. In acute circumstances, intracytoplasmic vacuoles are observed and in chronic cases, type II SLFs have mostly disappeared from the spiral prominence and the more inferior part of the ligament.Immediately after noise exposure acute swelling can be observed in the stria vascularis due to increase of the extracellular space between marginal and intermediate cells and swelling of marginal cells. There is also irreversible degeneration of intermediate cells visible. Basal cells that normally form a continuous layer, are more separated and form gaps separating the strial component of the lateral wall from the spiral ligament .An interesting observation is that type III SLFs do not degenerate significantly after noise exposure. In fact, the number of proliferating cells increase in the type III SLF region. These findings suggest that type III SLFs have some type of self-protecting ability. A possible mechanism of this self-protection is that type III SLFs have a strong antioxidant and antiapoptotic function as low immunoreactivity for oxidative stress and apoptosis is observed after trauma . FurtherBrn-4/Pou3f4, encoding a POU transcription factor, have been identified as the underlying cause  resulting in an abnormal morphology of cell-to-cell adhesion of SLFs. Cx26, and Cx30 expression is remarkably reduced and GJPs were significantly shorter, suggesting a degradation of the gap junctional macromolecular complex  as recessive (DFNB1). However, there is also an association in syndromic hearing loss . MSCs are multipotent cells that can be isolated from bone marrow , 91. Theignaling .SLFs are crucial in the cochlea as they are involved in ion homeostasis, regulation of cochlear blood flow, immune response, recovery after drug toxicity or noise, and maintaining a healthy extracellular matrix. Any dysfunction of SLFs or structural changes to the extracellular matrix can significantly impact hearing function. However, SLFs may prove useful in restoring hearing by regeneration of cells in the spiral ligament.NP took the lead in writing the manuscript. All authors provided critical feedback, helped shape the research, analysis, and manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Cochlear implantation has become known as “the treatment of choice” for adults with severe to profound hearing loss. Wide variability exists, however, in the way hearing loss severity is measured and in the candidacy criteria used to recommend cochlear implantation.This study aimed to provide a descriptive analysis of recent evidence available in the literature in relation to the efficacy of unilateral cochlear implantation in adults, the general findings of these studies, and the populations to which these findings apply. It also aimed to appraise the individual success rate and the magnitude of benefit following implantation.A scoping review was conducted to identify English-language, peer-reviewed journal articles published between 2000 and 2018 assessing the outcomes of cochlear implantation in adults who received their first cochlear implant from 2000 onwards. To be included, studies had to report speech perception or self-reported measures of listening or quality of life at least three months after implantation. Systematic searches were conducted in Medline, Embase, Web of Science and Google Scholar. A two-stage screening approach was used, with seven reviewers independently screening titles and abstracts against inclusion criteria and three from this group further reviewing full-texts. A data charting form was developed and trialled, with 10% of the study data extracted in duplicate to compare results and further refine the form. Data relevant for efficacy analyses were extracted from studies with sample sizes of at least 10 participants.A total of 4182 abstracts were screened against inclusion criteria, and of these, 603 full-texts were further screened. After exclusion of non-eligible articles, 201 articles were included in the first part of this scoping review. The majority of these articles were case series or comparative studies without a concurrent group, and had small sample sizes. Data synthesis conducted with the 102 articles with more than 10 participants highlighted that the average word perception ability improved from 8.2% to 53.9% after implantation. Self-reported benefit improved by 21.5 percentage points. At the individual level, 82.0% of adults with postlingual hearing loss and 53.4% of adults with prelingual hearing loss improved their speech perception ability by 15 percentage points or more. A small proportion had poorer ability after implantation or had stopped using the cochlear implant.Despite broad inconsistencies in measurement, research design, and reporting across articles, it is evident that cochlear implantation is beneficial to the majority of adults of any age who have limited aided speech perception abilities. While many adults with severe-to-profound hearing loss may also have poor speech perception abilities with hearing aids, the validity of using hearing loss severity as a criterion for cochlear implantation has not been demonstrated. Clinical and research recommendations derived from this review are provided. The use of electrical stimulation of the auditory nerve to restore hearing dates back more than 60 years with the first medical report of auditory percepts in a deaf subject in 1957 . There rA further complicating factor is the contrast between assessing hearing using sound detection thresholds , and the functional use of hearing for communication, generally demonstrated by measuring speech perception with various materials and under various conditions. Hearing threshold tests are useful when prescribing conventional hearing aids, but for those using cochlear implants, they provide little information about functional hearing for communication. Specifically, while audibility after implantation is restored within a relatively narrow range across the population, variability in speech perception outcomes is much broader and does not appear to relate directly to hearing thresholds. To a large extent, it is improvement in speech perception that is the primary goal of cochlear implantation, as this will in general facilitate improved communication and concomitant quality of life. Accordingly, cochlear implantation outcomes are generally assessed using a number of speech perception tests along with measures of quality of life, which can be broadly defined as the subjective experience of both positive and negative aspects of life across different domains.The relative success of cochlear implantation in restoring functional communication has seen an expansion of their application from the relatively small population of totally deaf individuals with little or no residual hearing, to the much larger population of people with cochlear hearing loss who have difficulties understanding speech with acoustic hearing aids in one or both ears , 8. AlonWithin the literature, cochlear implantation is frequently referred to as the “standard of care” , 10, “trCochlear implant candidacy is commonly assessed using aided speech perception scores as a representation of functional hearing difficulties, together with measures of hearing thresholds to confirm the diagnosis of hearing loss. However, a recent survey of cochlear implant candidacy criteria conducted across 20 countries revealed that guidance for implantation varied greatly and was largely related to the availability of funding, with publicly funded regions often applying more conservative audiometric criteria with little flexibility , 17. As Given the relatively low penetration rates for cochlear implantation that have been reported in recent years , 19, it This scoping review aimed to appraise and integrate recent evidence of the outcomes of cochlear implantation in adults. In particular, it aimed to provide an overview of:the study design characteristics of recent sources of evidence;the characteristics of the participants included in these studies (thus describing the population to which these findings apply); andthe efficacy and effectiveness of cochlear implantation at the individual and group level.It is hoped that this knowledge will inform the design and reporting of future studies.This scoping review complies with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews [PRISMA-ScR; http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42018089401. This scoping review is part of a larger project examining predictive factors of cochlear implantation outcomes.The protocol for this review was prospectively registered with PROSPERO International Prospective Register of Systematic Reviews (CRD42018089401) in July 2018 and is available online from: Eligible studies were English-language, peer-reviewed journal manuscripts published between 2000 and 2018 that assessed cochlear implantation outcomes in adults.Eligible studies included those assessing adults (≥18 years of age) with hearing loss in either ear who received their first cochlear implant from 2000 onwards. Studies were excluded from the review if adult data was not reported separately from children data. Where only a portion of participants met the eligibility criteria and their results were reported individually, data from those eligible participants were included in the review.Eligible studies reported on outcomes of cochlear implant systems with full-length electrode arrays implanted from 2000 onwards to ensure that outcomes from comparable technologies were reported in the review. Studies reporting on date of implantation prior to 2000 were included only if data from 2000 onwards was reported separately. Other information was used to estimate the implantation date when it was not reported, including the release date of device models and the development date of outcome measures reported in the articles. When none of these were available, studies were excluded.Outcome measures included behavioural speech perception tests performed in quiet or in noise with the first side implantation surgery, as well as formal self-report assessments of listening or quality of life . To be included, outcomes had to be assessed at least three months postoperatively. Speech perception outcomes for bilaterally implanted individuals were not included if separate ear outcomes were not reported.Searches were conducted in Medline, Embase, Web of Science, and Google Scholar; for the latter, only the first 200 search results were retrieved. The selection of databases was based on recommendations from Bramer et al. , which sStudies were screened in two stages. First, two of seven reviewers in the team  independently screened study titles and abstracts against the inclusion criteria to determine their eligibility for inclusion in the review. Full texts of potentially relevant articles were then independently assessed for eligibility by two of three reviewers . Where any conflicts arose regarding eligibility of studies, the three reviewers reached a final decision through discussion and consensus. The exclusion criteria for type of intervention was revised partway through the selection process to include studies that did not explicitly report on date of implantation if this information could be estimated based on device models or date of development of outcome measures. The risk of revising the protocol at the selection stage was minimised as this was modified after only one reviewer had commenced full text screening (see PROSPERO registration for differences between the protocols).A data-charting form was jointly developed by three reviewers  in Microsoft Excel to determine variables to be extracted from studies. Following recommendations from Levac et al. , data frData charting categories included publication characteristics  and study characteristics .More extensive data charting was conducted for studies with eligible data for 10 or more participants, including: participants’ age at cochlear implantation, preoperative pure-tone average thresholds and speech perception scores, and postoperative outcomes, such as speech perception outcomes in quiet and in noise, and self-report measures of listening and quality of life. Where multiple postoperative time points of outcome measures were reported, the data for the follow-up closest to 12 months postoperatively was extracted. Where available, data relating to device non-use was also extracted.In addition to group-level data, individual speech performance outcomes were also extracted when reported in studies. These were charted as a proportion of the population that presented a change in relation to preoperative performance, where change of 0–14 percentage points represented limited change, a decrease greater than zero percentage points was considered a decrease in performance, and change greater than 14 percentage points was considered a clinically significant improvement in performance. These criteria are consistent with those previously reported in cochlear implantation efficacy reports .Evidence was mapped by describing frequencies for year and journal of publication, country of data collection, and study design for all included articles. An identification number (ID) was assigned to each article to facilitate reporting of results. These are provided along with data extracted for each article in the supplemental material see . StudiesTo increase the level of evidence and applicability of the synthesis, only articles with ten or more participants with eligible data were further synthesised. This synthesis encompassed data relating to age at implantation, preoperative pure-tone average thresholds, preoperative speech perception), as well as efficacy  and effectiveness  measures of cochlear implantation outcomes.Speech perception outcomes across studies were summarised according to the onset of hearing loss of individuals included in studies. Because of their specificity, outcomes for individuals with single-sided deafness were also synthesised separately. Only total scores of self-report measures were summarised in this review. When articles only reported on results for each questionnaire subdomain, these were extracted to calculate total scores.Analysis of extracted data was conducted by averaging summary measures of different studies and weighting these by the number of participants in each individual article to account for different sample sizes across studies. Factors such as study design, however, were not accounted for when examining individual outcomes. Reporting of scoring methods for monosyllabic word tests varied across studies. To decrease the risk of bias in the review, these were only summarised when full word scoring was conducted, as this was the method reported in most studies (as opposed to phoneme scoring). A conservative approach was used to calculate effect size measures [Cohen’s d, The database searches yielded a total of 7929 records. After removal of duplicates, 4182 abstracts were reviewed and the full texts of 603 articles were screened against the inclusion criteria. After the exclusion of 402 articles , 201 artThe 201 included articles were published between 2000 and 2018, with the majority of articles published from the year 2010 . DatasetArticles included in this review were published across 45 scientific journals . The 5-yThe included articles encompassed evidence levels from III to IV as classified by the NHMRC levels of evidence hierarchy . These cThe total number of participants with eligible data ranged from 1–382 participants per study (median: 10). Out of the 201 articles, 99 (49.3%) included less than 10 participants (ID 103–201). The majority of articles with these small sample sizes targeted a specific population characteristic in relation to cochlear implantation outcome, as presented in The specific etiologies targeted within the small sample size articles are further described in The proportion of case series (level IV evidence) decreased from 47.5% to 14.9% after excluding articles with n<10, to the benefit of level III evidence. To increase representability of the general population using cochlear implants, as well as confidence in the data synthesis, further extraction and analyses were conducted only with the 102 articles that included at least ten participants (ID 1–102).(102 articles with n ≥10 participants).Mean age at implantation was found in 95 articles, including 4994 participants. Across articles the mean age at implantation was 61.4 years and the median 63.3 years . Half the articles included at least one participant implanted after 77 years of age.Adults with a postlingual hearing loss constituted at least 74.7% of participants included across all articles, whereas only 5.1% of all participants were represented in articles that reported exclusively on adults with prelingual hearing loss. The onset of hearing loss was not reported for 7.9% of the included articles .th percentile of speech perception performance of adult cochlear implant users with postlingual hearing loss, independent of hearing loss severity measured with pure-tone thresholds. As such, the article included participants with maximum phoneme perception scores of 46%, sentence perception scores of 88%, and a minimum reported PTA in the ear to be implanted of 57dBHL. The two other articles  specifically aimed to assess outcomes in adults with more residual hearing, based on preoperative speech perception performance.Preoperative average pure-tone detection thresholds (hearing loss severity) in the ear to be implanted were reported across various combinations of frequencies in 56 articles. The most common combinations reported were a 4-frequency average  and a 3-frequency average . Mean and range of hearing loss severity are shown in Hearing loss severity for the non-implanted contralateral ear ranged from total hearing loss to normal hearing levels. Most articles included individuals who would be considered typical cochlear implant candidates, i.e. participants with a symmetrical severe-to-profound hearing loss bilaterally. Fifteen articles included a total of 345 participants (8.4%) with single-sided deafness (SSD), i.e. participants who had normal hearing or mild to moderate hearing loss in their non-implanted ear.Different measures of preoperative aided speech perception ability were available in 72 articles . For 44 Many different types of speech perception test were used to report on postoperative outcomes, generally for the implanted ear alone. The most frequently reported speech perception measures used after implantation were monosyllabic words (46 articles), sentences in quiet (34 articles), and sentences in noise . The more residual hearing present in the contralateral ear, the more likely the outcomes were also reported in the best-aided condition. For the majority of articles that included patients with SSD, sentence perception in noise tests were conducted binaurally, in different configurations of separated speech and noise.Two articles  presented sentence in noise perception results as a signal-to-noise ratio required to obtain 50% correct with the cochlear implant alone, in the S0N0 noise configuration. It can be assumed that this test is only conducted when patients obtain a minimum score of 50% correct on sentence perception in quiet, and therefore these results would not be representative of the lowest performing quarter , whereas 2.5% included only adults with prelingual hearing loss. Another 2.5% evaluated both populations together, and 3.3% articles did not report onset of hearing loss for their study participants. Nine articles  reported on outcomes of adults with SSD.In general, postoperative improvement in self-report measures of listening or quality of life was shown in most articles, except for one (ID 60) that showed no mean postoperative change on the Nijmegen Cochlear Implant Questionnaire in adults with SSD see . ResultsFourteen articles reported on individual change post cochlear implantation. A typical population of adults with postlingual bilateral hearing loss  was represented in five articles . 82.0% of this population showed a greater than 14 percentage point improvement in speech perception scores in quiet following cochlear implantation . LimitedFour articles that presented individual change focused specifically on adults with prelingual hearing loss . The proportion of adults who improved >14 percentage points was smaller in this population compared with adults with postlingual hearing loss. Specifically, for speech perception performance in quiet, 53.4% improved, 38.3% maintained similar scores, and 8.3% obtained poorer scores post-implantation. Speech perception in noise was reported for a subgroup of 19 participants with prelingual hearing loss , showing an improvement in 52.6%, similar scores in 42.1%, and a decrease in performance in 5.3% of this group. For adults with prelingual hearing loss, individual change in self-reported measures was only available for 1 study (3 participants) and is therefore not reported here.Twenty articles reported on device use post-implantation, including 992 participants. Non-users were reported in 10 of these articles . More than half of the non-users were adults with prelingual hearing loss , followed by adults with neurofibromatosis type II .This scoping review aimed to appraise and integrate recent evidence of cochlear implantation outcomes in adults. This knowledge was gathered to support the further development of consistent and clinically aligned candidacy criteria, as well as the design and reporting of future clinical studies.After a thorough database search and eligibility assessment, 201 articles were initially included in the review. While this is a large amount of recent evidence regarding cochlear implantation outcomes in adults, this evidence is mainly based on case-series study designs (NHMRC level IV) or small sample sizes (<10 participants). No randomised controlled trials have been published on the efficacy of cochlear implantation in adults with severe-to-profound hearing loss, without a predefined selection criteria using speech perception with hearing aids. Current knowledge about cochlear implantation efficacy is therefore derived from the postoperative performance of adults who have most likely received a cochlear implant because of poor aided hearing, as determined by clinics who may be applying inconsistent criteria . In addiThe majority of adults included across these articles were aged above 60 years old. The majority also had an acquired  hearing loss, which has been demonstrated to lead to significantly better outcomes in comparison to early onset  hearing loss. On average, included participants had very poor speech perception performance with their hearing aids before receiving a cochlear implant. This average level of pre-implant performance was considerably below the range of current criteria used across different countries for recommending a cochlear implant c.f. . This suBased on the available articles that reported on device use, a very high majority of adults (97%) who undergo cochlear implantation continue to utilise the device consistently in their everyday life. This usage rate is similar to an earlier report with participants with more severe hearing losses that found a usage rate of 98% within one cohort of 313 postlingually deafened adults in the UK [Two pre/post comparisons of speech perception performance were mainly found in the included articles: the difference between word perception scores for the ear implanted, and the difference in the “best-aided” condition that will often involve the binaural use of conventional hearing aids during the pre-implant assessment. Across the articles, group-level word perception scores improved from 8.2% pre-implant to 53.9% post-implant for the implanted side, corresponding to a large effect size. This confirms the overall efficacy of the intervention, but also the known limitations of cochlear implantation in restoring a perception of normal hearing. Furthermore, a majority of adults (82%) with postlingual hearing loss obtained an individual speech perception improvement of 15 percentage point or greater in the implanted ear. This proportion was smaller for adults with prelingual hearing loss (53.4%). Articles reporting pre-and post-implant scores for the best-aided condition indicated a mean improvement of 44.4%. These results also implied that recipients with very poor speech perception before implantation have a high probability of improvement. This probability—and the magnitude of improvement—decreases with better functional hearing prior to implantation. For instance, a number of studies included in this review investigated cochlear implantation for single-sided deafness, where the non-implanted ear has effectively normal hearing and speech perception. While efficacy has been demonstrated with improvement in speech perception in the implanted ear , 33, theA large range of questionnaires mainly focusing on hearing and communication benefits have been used to assess quality of life and functional hearing in adult cochlear implant recipients. This makes it difficult to integrate these outcomes in a concise way. In this scoping review, a weighted average of the available self-reported benefit measures confirmed the effectiveness of the intervention across recently implanted adult populations, with a mean improvement across 933 recipients of 21.5 percentage points. A more modest 12 percentage point improvement is seen for the studies utilising a general quality of life measure (HUI3). Nonetheless, consistent self-reported functional benefit is well-demonstrated across the adult cochlear implant population, despite the relaxation of candidacy criteria as shown in this review.The articles in this review included adults of all ages, with pre and postlingual hearing loss, bilateral and single-sided deafness, and a range of residual hearing abilities in the implanted ear. The results highlight a considerable effect of onset of deafness on outcomes as measured by speech perception tests. Adults with severe bilateral hearing loss from birth or early childhood  show significantly poorer implant scores and pre/post improvement than those with acquired  deafness , 40. WhiA formal quality appraisal of the included articles was beyond the scope of the current review. To decrease the risk of bias, this review analysed cochlear implant usage, effectiveness, and efficacy in articles that included at least 10 eligible participants. This scoping review also did not consider complications of cochlear implant surgery, although available reports suggest an eventual surgical success exceeding 98% –46. A poThis scoping review provides an integrated descriptive analysis of the current published evidence base for cochlear implantation in adults, yielding the following recommendations:Cochlear implantation can be considered an effective treatment of hearing loss for adults of any age who have limited speech perception. Limited speech perception is currently measured with speech perception tests in the ear to-be-implanted, using the best alternative treatment, typically, an acoustic hearing aid. Based on this scoping review, 75% of adults (25th percentile) using a cochlear implant obtained ≥42% on word perception and ≥60% on sentence perception in quiet. Surgical considerations and the integrity of the auditory pathway beyond the cochlea need to be addressed carefully for individual cases.Approximately 82% of patients with postlingual hearing loss, and 53% of patients with prelingual hearing loss will have improved speech perception performance by 15 or more percentage points in the implanted ear.Very few patients (5–8%) will obtain poorer speech perception with their cochlear implant in comparison to their preoperative performance, but a number may experience no significant change or limited improvement.The greater the preoperative speech perception performance, the smaller the postoperative change. On average, adults obtain a 50 percentage point improvement in their performance.Having a prelingual hearing loss or neurofibromatosis type II/vestibular schwannoma increases the probability of becoming a device non-user.Patients and clinicians can expect that after implantation:Cost-effectiveness analyses can support decisions related to resource allocation.The development of local candidacy criteria should consider the available resources for the population and the consequences of non-treatment. While cochlear implants have been shown to be effective for adults with more residual hearing (including SSD), the largest benefits of cochlear implantation are found with bilateral hearing loss, when speech perception is poor for both ears. complementary or alternative interventions may be required even after implantation to support effective communication for all adults with hearing loss .While cochlear implants are highly effective in most cases, there is significant variability in outcomes, and some adults will not obtain benefit from them. As such, minimum reporting standards need to be considered:Increase standardisation of test material and conditions. From this scoping review, recorded monosyllabic words (scored at the full word level), sentences in quiet, and sentences in noise (+10dB SNR), presented at a level of 65dB SPL (60dBA) from a single loudspeaker in front of the participant were the most commonly used tests. This is aligned with recommendations proposed by Adunka et al. .With a considerable increase in the number of adult cochlear implant users having useful hearing in the non-implanted ear , standards for monaural and binaural testing also need consideration.Current evidence may be somewhat biased towards high performers who are more likely to be tested with standardised material and included in research studies. To limit this bias, the minimum test battery should be conducted with all patients. In addition, authors should report when participants are excluded because of missing outcome data, and indicate whether the tests used in the study are systematically used with all patients. For example, adaptive speech in noise tests can only be conducted with patients that obtain scores above 50% in quiet, excluding poorer performers from analyses.Individual change in performance should be reported in addition to group data. This recommendation described by Gurgel et al.  is also To further increase the knowledge base, strengthen the knowledge base:Limit small sample size studies to specific conditions that are rare and understudied.Conduct meta-analysis of data from existing small sample size studies, for example combining specific aetiologies, to increase reliability of conclusions.Conduct meta-analysis of predictive factors studies to increase prognostic precision.Further initiatives that can S1 DataPRISMA-ScR.(DOCX)Click here for additional data file.S2 Data(DOCX)Click here for additional data file.S1 Table(XLSX)Click here for additional data file.S2 TableSpecific aetiologies targeted in articles with small sample sizes grouped by hearing loss categories.(DOCX)Click here for additional data file.S3 TableWord perception scores across different subgroups.(DOCX)Click here for additional data file.S4 TableSentence perception in quiet scores across different subgroups.(DOCX)Click here for additional data file.S5 TableSentence perception in noise scores across different subgroups.(DOCX)Click here for additional data file.S6 TablePostoperative improvement in self-report outcome measures and change in relation to preoperative performance.(DOCX)Click here for additional data file.


The widespread use of face coverings has impeded communication by blocking the listener’s view of the lips.2 By forcing the wearing of masks and increasing the use of telemedicine, the COVID-19 pandemic has focused the minds of healthcare professionals on communicating with people with hearing loss.4 In this article we offer practical tips and resources for busy GPs, including the new Royal College of General Practitioners (RCGP) Toolkit for Deafness and Hearing Loss.Hearing health and effective communication is more important than ever. Since the COVID-19 pandemic resulted in wide scale social distancing in the UK, advice from the government has been to limit contact with others, and for older people and those with underlying health conditions to shield.5 It affects one in six of the UK population; one in two over the age of 70. Hearing loss is associated with poor social interaction, isolation, depression and anxiety, reduced quality of life, and increased risk of dementia. Treating hearing loss may be one of the most cost-effective ways of reducing someone’s risk of dementia.6 The wearing of a face mask may result in unintended consequences such as social isolation and poor mental wellbeing. This may predispose a large section of society to mask misery.7Hearing loss is one of the commonest disabilities seen in primary care. Between 20% and 50% of primary care appointments are related to ear, nose, and throat (ENT) conditions.Acquired, age-related hearing loss occurs gradually. Your patients with deteriorating hearing may have noticed subtle clues such as the gradual fading of birdsong, increasing the volume on the television, muffled speech, or difficulty hearing in background noise. Often, it is the person’s relatives or friends that notice changes in their loved one’s hearing. The author Helen Keller pointed out that hearing loss cuts you off from people, and those with the condition will confirm this hasn’t changed despite the use of increasingly sophisticated hearing aids. The hearing mechanisms themselves are damaged, reducing the value of amplification, so patients must increase their reliance on other communication cues such as lip movements, body language, and understanding of context. The extra processing required results in both slower communication and fatigue.Communication is more than just spoken language. Communication between humans occurs most successfully when all the elements of body language, speech, and hearing are deployed. Consider wearing earplugs and placing yourselves in the shoes of this large group of your patients. Good communication techniques and awareness encourages inclusivity which can address the isolation and marginalisation of people with hearing loss. Knowing how to communicate well will increase patient satisfaction and, importantly, lead to vastly improved communication (and trust) between healthcare professionals and patients.8 The Access All Areas report collected the experiences of people with hearing loss accessing health care, including contacting and visiting their GP surgery. Responders with varying levels of hearing loss completed the survey and the findings were eye-opening.9 GP appointments were made in person by 47% of responders, yet only 14% identified this as their preferred method of contact. During GP consultations, 49% of responders said that their GP surgery had a visual display screen, but one in seven responders had missed an appointment because they had missed being called from the waiting room. NHS England estimated that the cost of people who are Deaf or have hearing loss missing NHS appointments could be as high as £15 million every year. After attending their appointment, more than a quarter (28%) of patients were unclear about their diagnosis and the health advice they had been given.For some time, patients (and more recently GPs) have identified a lack of GP training in the necessary skills to communicate effectively with people who have hearing loss.’did not feel confident that their communication needs would be met during a remote appointment’ and over half admitted they had ’put off’ seeking advice from their GP because of remote care, meaning they were at risk of missing out on vital medical care. An awareness of the potential barriers to effective communication and the implementation of some simple strategies will dramatically improve communication with your Deaf and hard of hearing patients. The RCGP, in conjunction with the charity RNID and NHS England and NHS Improvement, have developed a toolkit of learning materials to fill this lacuna , more than 70% of responders said they cuna see .Box 1https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/deafness-and-hearing-loss-toolkit.aspxhttps://www.rcgp.org.uk/hearinglossRCGP Deafness and Hearing Loss ToolkitRCGP Accredited Deaf Awareness Online Training Coursehttps://www.rcgp.org.uk/learning/rcgp-educational-accreditation-for-education-providers/accredited-activities.aspxhttps://www.rcgp.org.uk/-/media/Files/GP-training-and-exams/Curriculum-2019/Curriculum-Topic-Guides-300819.ashx?la=enThe RCGP Curriculum Topic Guides: Ear, Nose and Throat, Speech and Hearing. London, Royal College of General Practitioners: 2019. pp 133–141.Designed to bring together resources for healthcare professionals, it includes case studies and teaching material suitable for use in training schemes as well as in the GP surgery. In addition, the RCGP Core Curriculum on hearing loss has been expanded and brought up to date. The GP curriculum now stresses the importance of early intervention, effective communication, and improved access for people who are Deaf or have hearing loss. The RCGP has also accredited a Deaf awareness online course for doctors, developed by UCL Deafness Cognition and Language Research Centre. This 2-hour self-directed course will help you understand the communication needs of Deaf and hearing-impaired patients. It provides practical workplace strategies to help meet the Accessible Information Standard. There are videos of patients' and doctors’ real-life experiences to make the learning relevant and engaging.10 They may also carry exemption cards to show that they do not need to wear a face covering, or to highlight where they might need others to lower theirs.Communication is a key skill for our specialty see . RemembeBox 2Before you startExclude background noiseFace the cameraEnsure your face is well lit and they can see your lipsCheck they are wearing their hearing aidsDuring the consultationSpeak clearly, use plain language, do not shoutSpeak at a normal pace, not too slow or too fastUse normal lip movements, facial expressions, gesturesTell he patient if live speech to text is availableConfirmationIf asked to repeat something more than once, use different wordsOR write things down: pen on paper, text on screen, or whiteboardAsk if the patient understood what you said; offer to repeat if they did notRelay UK11 for people with hearing loss; use video relay services (VRS), such as Interpreter Now, for British Sign Language (BSL) users. BSL Health Access12 provides immediate, on-demand access to BSL interpreters for communication with Deaf people free of charge during this pandemic. Access to BSL interpreters takes place through two methods: VRS, where a BSL interpreter relays information over a telephone call between a BSL user and the hearing person receiving or making the call; and video remote interpreting (VRI), where a remote interpreter is used to facilitate communication with a Deaf and hearing person in the same location. Additionally, speech-to-text apps are very useful during consultations; these are widely available and many are free to download. It converts the clinician’s voice into written text which can be read by the patient during the consultation.With the introduction of remote consulting, it is essential to equip GPs with the tools and knowledge to assist in communicating with patients who have a hearing impairment. Instead of using the telephone, which relies on sound alone, where possible use video conferencing tools and add live captioning through video conferencing software. Utilise The RCGP Hearing Loss Toolkit will improve GPs ability to communicate with this large group of patients. We will all benefit; hearing loss is one condition from which almost every one of us will eventually suffer.