The extent of vestibular end organ dysfunction associated with genetic pediatric hearing loss is not well-understood. We studied children with a known genetic cause of hearing loss who underwent routine preoperative vestibular testing prior to cochlear implantation between June 2014 and July 2020. Vestibular testing included videonystagmography, rotary chair, video head impulse testing, and/or vestibular evoked myogenic potentials. Etiology of HL was determined through history, physical examination, imaging, laboratory testing, and/or genetic testing. Forty-four children  met inclusion criteria; 24 had genetic non-syndromic and 20 had genetic syndromic forms of HL. Mean age at the time of testing was 2.8 ± 3.8 years (range 7 months−17 years). The most common cause of non-syndromic HL was due to mutations in GJB2 (n = 13) followed by MYO15A (3), MYO6 (2), POU3F4 (2), TMPRSS3 (1), CDH23 (1), TMC1 (1), and ESRRB (1). The most common forms of syndromic HL were Usher syndrome (4) and Waardenburg (4), followed by SCID/reticular dysgenesis (3), CHARGE (2), CAPOS (1), Coffin-Siris (1), Jervell and Lange-Nielsen (1), Noonan (1), peroxisome biogenesis disorder (1), Perrault (1), and Trisomy 21 (1). Overall, 23 patients (52%) had PVL. A larger proportion of children with syndromic forms of HL had PVL  compared with children with genetic non-syndromic HL , though without statistical significant (p = 0.3). The occurrence of PVL varied by affected gene. In conclusion, PVL is a common finding in children with syndromic and non-syndromic genetic HL undergoing vestibular evaluation prior to cochlear implantation. Improved understanding of the molecular physiology of vestibular hair cell dysfunction is important for clinical care as well as research involving vestibular hair cells in model organisms and in vitro models.Hearing loss (HL) is the most common sensory deficit in humans and is frequently accompanied by peripheral vestibular loss (PVL). While often overlooked, PVL is an important sensory dysfunction that may impair development of motor milestones in children and can have a significant negative impact on quality of life. In addition, many animal and  Hearing loss is the most common sensory impairment in humans, affecting nearly 5% of the world population . In chilvia the same nerve , and contain paralogous structures that are responsible for mechanotransduction of stimuli (hair cells). As such, it follows that pathology that causes hearing loss can also frequently cause PVL.Peripheral vestibular loss (PVL) frequently accompanies hearing loss, and vestibular impairment is estimated to affect around 50% of patients with sensorineural hearing loss (SNHL) –6. Such GJB2 gene  an identified genetic cause of hearing loss, and (2) completion of vestibular testing prior to cochlear implantation at our institution between June 2014 and July 2020. Patients were identified through our internal REDCap database of patients who have undergone cochlear implantation at our institution , 22. FurGJB2), multi-gene panels including dozens to hundreds of genes sequenced, and exome sequencing. Test interpretation was performed in accordance with consultation from a geneticist, when necessary.Hearing loss etiology was determined through history, physical examination, imaging, laboratory testing, and clinical genetic testing. Genetic testing was not standardized and was performed on a case-by-case basis based on clinical judgement and test availability. Genetic tests performed included single-gene sequencing  if results of at least one vestibular test were abnormal.Toys with flashing lights were used to attract young childrens' attention during testing, when needed, including to control direction of gaze during VNG testing and to maintain appropriate neck turning and tension during cVEMP testing. Continuous electromyography was monitored during cVEMP and oVEMP testing to ensure continued sufficient muscle contraction throughout the test. The acquisition software automatically rejected any VEMP response with inadequate muscle tension.Many patients also underwent routine motor evaluation by a licensed physical therapist prior to cochlear implantation. Patients <5 years of age were assessed using the Peabody Developmental Motor Scales, Second Edition (PDMS-2) Gross Motor Quotient (GMQ) . The GMQPatients ≥5 years of age were assessed using the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2) body coordination composite score. This is derived from the BOT-2 bilateral coordination subtest and balance subtest, which consist of 7 and 9 items, respectively . The tott-test was used to assess differences in motor function outcomes between patient groups. A Mann–Whitney U-test was used to assess differences in age between patient groups.Statistical analyses were conducted using R version 3.6.3 . Differences in characteristics between patient groups were assessed using a chi-square test for categorical variables. An independent-samples We initially identified 149 patients who underwent routine pre-cochlear implant vestibular testing at our institution during the study timeframe. Of these, 44 patients had a known genetic cause of their hearing loss and had not previously undergone cochlear implantation. Demographics and clinical features of the study sample are summarized in GJB2 (n = 13) followed by MYO15A (3), MYO6 (2), POU3F4 (2), TMPRSS3 (1), CDH23 (1), TMC1 (1), and ESRRB (1). The most common forms of syndromic hearing loss were Usher syndrome (4) and Waardenburg (4), followed by SCID/reticular dysgenesis (3), CHARGE (2), CAPOS (1), Coffin-Siris (1), Jervell and Lange-Nielsen (1), Noonan (1), peroxisome biogenesis disorder (1), Perrault (1), and Trisomy 21 (1). A full summary of causative genetic variants identified in the patient sample can be found in the As shown in All patients had at least one imaging study performed. These included magnetic resonance imaging (MRI) of the temporal bones in 39/44 (89%) subjects and fine cut non-contrast computed tomography (CT) of the temporal bones in 39/44 (89%). Both forms of imaging were obtained in 34/44 (77%) subjects. No imaging abnormalities were identified in 37/44 (84%) subjects, a cochlear abnormality was identified in 3/44 (7%), and a cochleo-vestibular abnormality was identified in 4/44 (9%) .All patients underwent cVEMP testing as part of their vestibular evaluation, and 43/44 (98%) also underwent rotary chair testing. Additionally, VHIT was performed in 6/44 (14%) patients and oVEMP testing in 7/44 (16%). Patients who underwent VHIT testing ranged from 5.0 to 17.5 years of age. Patients who underwent oVEMP testing ranged from 2.5 to 17.5 years of age. No patients underwent caloric testing.p = 0.3). There was not a significant difference in age between patients with syndromic hearing loss (median = 11.6 months) compared to those with non-syndromic hearing loss . Patients with syndromic hearing loss were significantly more likely (p = 0.02) to have abnormal cVEMP outcomes  than patients with non-syndromic hearing loss .Results of these specific vestibular tests are summarized in n = 27, 84%) were evaluated using the PDMS-2 while the remainder were evaluated using the BOT-2. Among patients evaluated with the PDMS-2, the mean gross motor quotient (GMQ) percentile rank was 36.6 (SD 21.3). Among the five patients evaluated with the BOT-2, the mean body coordination percentile rank was 39.4 (SD 33.7). Patients with normal vestibular testing findings had a greater Peabody GMQ percentile rank score  compared to patients with evidence of PVL , though this difference did not reach statistical significance   compared to patients with non-syndromic hearing loss . This result also did not reach statistical significance  . The results from this study expand the genotype-phenotype correlations of prior studies with respect to genetic mutation and vestibular dysfunction in the setting of genetic hearing loss. In particular, we show measurable effects on the peripheral vestibular system for mutations in six of eight causes of apparent genetic non-syndromic hearing loss. Further research should focus on expanded testing of the vestibular system in children and adults with hearing loss. This study also demonstrates trends toward delayed motor development in patients with PVL vs. those with normal vestibular function, as well as patients with syndromic forms of hearing loss. Our results further emphasize the importance of early identification and rehabilitation of vestibular deficits in patients with genetic hearing loss. Delayed motor development in patients with syndromic hearing loss may be multifactorial and result from dysfunction in systems other than or including the vestibular system.in vitro studies of human cochlear hair cell function (A gene-specific understanding of the effect of mutations on the cochleovestibular system is necessary to improve pre-operative counseling for children with severe to profound hearing loss and to guide subsequent rehabilitation. Further insight into the effects of specific genetic mutations on PVL will also have important implications for future research on genetic hearing lossMany scientists use vestibular hair cells as a proxy for function , 29. Thifunction .jacob.brodsky@childrens.harvard.edu.This study is a retrospective analysis of confidential clinical genetic analyses that were analyzed in an anonymized fashion for the purposes of this study. The raw data from the anonymized analyses are available from the corresponding author upon request. Requests to access these datasets should be directed to Jacob R. Brodsky, AW, AS, GZ, MK, DP, GL, and JB: study concept, design, manuscript review, revision, and approval. AW, AS, MK, and JB: data collection and analysis and manuscript composition. All authors contributed to the article and approved the submitted version.All financial support for this study was provided by the Department of Otolaryngology and Communication Enhancement at Boston Children's Hospital.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Hearing was assessed in each of the subjects by means of PTA, IA (tympanometry), and transient-evoked OAEs (TEOAEs). Otoscopy was also performed. (3) Results: There were significantly fewer abnormal results in children from urban than rural areas: they were, respectively, 10.1% and 23.1% for IA, 3% and 9.7% for PTA, and 17.3% and 31.8% for TEOAEs. For hearing-impaired ears in rural areas (failed TEOAE), hearing thresholds were, on average, 11.5 dB higher at 0.5 kHz than for children in urban areas. Comparison of each PTA result with the corresponding IA showed that all cases of hearing loss were related to malfunction of the middle ear. (4) Conclusions: The results of all three hearing tests were significantly worse in children from rural areas compared to those from urban areas. This indicates that audiological healthcare in rural areas needs improvement and that universal hearing screening programs for school-age children would be helpful.  According to the World Health Organization (WHO), over 6% of the world’s population has various types of hearing impairment . This isUnfortunately, access to hearing diagnostics is not equal everywhere. Healthcare in rural areas is definitely worse than in larger cities, both in Poland and in the rest of the world ,12,13,14This imbalance can be somewhat restored if a country has a universal newborn hearing screening (UNHS) program in place, by which all children, regardless of their place of residence, undergo a hearing test for detection of congenital hearing defects ,18,19,20The data in the literature show that, for various reasons, the percentage of hearing impairment in school-age children is greater in rural areas than in built-up areas ,23 and iMost of the cited studies have used screening audiometry, e.g., ,27,33,38The aim of this study was to assess the prevalence of hearing loss in school-age children from rural and urban areas of Poland using standard diagnostic tests—pure tone audiometry, IA (tympanometry), and OAEs.Measurements were performed in a group of 250 children  aged 8 to 13 years , made up of 122 children from urban areas  and 128 children from rural areas  of mid-eastern Poland (Masovian and Łódź Voivodships). For the final analysis, only the ears on which a complete test battery was performed were considered—392 ears in total. The dataset was divided into two groups: Group_u—197 ears of children from urban areas; and Group_r—195 ears of children from rural areas. In Poland, there is a clear administrative division into town (and city) and village which was the basis of classification for the urban and rural groups. In short, for a town to receive municipal rights, over 2000 people must be registered in it, there must be municipal buildings (not farm buildings), and at least two-thirds of the residents must be employed outside agriculture. Nevertheless, generally, by rural areas we mean areas characterized by smaller settlements (villages) and of an agricultural character, while by urban areas we mean areas with larger settlements (towns and cities) and industry.The tests were carried out as part of a hearing screening program of school-age children which was organized by our center ,26,27. HPTA was performed using the Madsen Astera clinical audiometer . Air conduction hearing thresholds were determined for the frequency range 0.5 to 8 kHz using Sennheiser HDA-200 headphones . A standard test tone of 226 Hz was used. The shape of the resulting tympanograms was assessed on the basis of the criteria proposed by Jerger and Liden in which there are 7 types of tympanograms  ,43. TympThe Otodynamics ILO 292 system  was used to record TEOAEs. A broadband click of 80 μs at 80 ± 3 dB SPL (using the non-linear protocol) was used as stimulus, and a 20 ms analysis window was used. The recording was terminated after obtaining 260 averages. The record was assessed as ‘pass’ by taking account of the total repeatability parameter, which had to be higher than 70%, and the signal-to-noise ratio, which needed to be ≥3 dB SPL in at least three half-octave bands with center frequencies of 1, 1.4, 2, 2.8, and 4 kHz ,47,48,49The child’s parents gave written informed consent. The research procedures were approved by the Ethics Committee of the Institute of Physiology and Pathology of Hearing, Poland .p < 0.05) was chosen. The figures were created in Matlab .For analyses we used Statistica v. 12 . For all measured parameters, the statistical significance of mean differences was evaluated using analysis of variance (ANOVA). As a criterion of significance, a 95% confidence level (F(1.368) = 0.04; p = 0.85) or ear (left/right) (F(1.368) = 0; p = 0.99); therefore, all results are presented without taking these factors into account.Initial ANOVA analysis did not reveal differences in terms of gender  = 5.7; p = 0.02). Furthermore, there was also a significant effect of age (F(5.380) = 3.7; p = 0.00) and interaction of place of residence and age (F(5.380) = 3.7; p = 0.003).A two-way ANOVA revealed a significant effect of place of residence on the tympanometry result  = 4.8; p = 0.0003), and also of age (F(5.25) = 1.8; p = 0.01), and there was also an interaction between place of residence and age (F(5.25) = 2; p = 0.002).Repeated measures ANOVA revealed an effect of place of residence on PTA (F(5.25) = 3.8; p = 0.002), effect of age (F(5.25) = 1.7; p = 0.02), and no interaction between place of residence and age (F(5.25) = 1.1; p = 0.3) on SNR.A two-way ANOVA showed an effect of place of residence , there were significantly more refer results in rural areas than in urban ones. Taking both groups together, the criterion of the presence of a response was not met for 96 ears, which comprised 24.5% of all examined ears, a much higher figure than in other studies ,31. ThisAn overall analysis showed that a “refer” result was found in all three tests  for 38 of 197 ears in children from the urban group (Group_u), and in 66 of 195 ears from the rural group (Group_r). Taking both groups together, the greatest number of “refer” results was obtained for TEOAEs, and the lowest for PTA. This may be because school-age children are constantly exposed to noise, which may lower OAE responses before changes are noticeable audiometrically ,61, espeIn the present study a screening PTA test was used. Our results show that all cases of childhood hearing loss diagnosed at school age are those with a conductive component. Because the screening audiometer does not allow bone conduction threshold to be evaluated, which allows the type of hearing loss to be determined, the gold standard (next to PTA) should be IA, since it can allow the status of the middle ear to be assessed. That is, an IA test could reduce the time it takes for a child to receive treatment. The IA test can be considered essential, since hearing defects may result in cognitive impairment and learning problems. This is particularly important for rural children, where access to a specialist is more difficult to obtain. Chan et al.  point ouThis study focused on a public health problem that affects a large majority of countries. It is urgent to have a policy to implement screening in different age groups  for early detection of hearing loss in children. There are some recommendations, but more action is needed . The idAcquired hearing impairments in school-age children can result in limited cognitive functions and learning problems. Due to more difficult access to specialists in rural areas, universal hearing screening programs need to detect childhood hearing loss as early as possible and help the child receive prompt treatment. As this research has shown, the best solution would be if the screening tests were based not only on PTA, but also included IA, which allows the condition of the middle ear to be objectively assessed.Results of the present study confirm prior suggestions that in order to provide equal opportunities for children in rural and city areas, the health system in Poland (and elsewhere around the world) needs to be improved and extended. We suggest that medical personnel in rural areas need better access to training and career development, and that health awareness needs to be increased using appropriate promotional methods. Furthermore, in general, the presence of an audiologist in primary healthcare seems crucial in order to reduce the time taken to diagnose hearing loss in children, and thus promote early intervention.


The regeneration of a diseased heart is one of the principal challenges of modern cardiovascular medicine. There has been ongoing research on stem-cell-based therapeutic approaches. A cell population called telocytes (TCs) described only 16 years ago largely contributed to the research area of cardiovascular regeneration. TCs are cells with small bodies and extremely long cytoplasmic projections called telopodes, described in all layers of the heart wall. Their functions include cell-to-cell signaling, stem-cell nursing, mechanical support, and immunoregulation, to name but a few. The functional derangement or quantitative loss of TCs has been implicated in the pathogenesis of myocardial infarction, heart failure, arrhythmias, and many other conditions. The exact pathomechanisms are still unknown, but the loss of regulative, integrative, and nursing functions of TCs may provide important clues. Therefore, a viable avenue in the future modern management of these conditions is TC-based cell therapy. TCs have been previously transplanted into a mouse model of myocardial infarction with promising results. Tandem transplantation with stem cells may provide additional benefit; however, many underresearched areas need to be addressed in future research before routine application of TC-based cell therapy in human subjects. These include the standardization of protocols for isolation, cultivation, and transplantation, quantitative optimization of TC transplants, cost-effectivity analysis, and many others. Ischemic heart disease is at the top tier of unflattering global health statistics. Despite an unparalleled achievement in diagnostic and therapeutic measures over the recent years, which have caused a decline in mortality, it is the leading cause of death around the globe, nevertheless. In Europe, 20% of all deaths are attributed to ischemic heart disease . The resThere are two main strategies for achieving these goals: the first is the implementation of different types of stem cells, most notably embryonic stem cells and induced pluripotent stem cells, with promising results from animal studies. The second approach is the targeting of endogenous pathways in cardiomyocytes themselves, via which they can acquire the regenerative capacity seen in lower animals, e.g., zebrafish . A novelOne cell population has been largely overlooked but might be “the last piece of the puzzle” necessary for successfully integrating all the approaches mentioned above—telocytes (TCs).The most common definition of TCs found in most papers on this peculiar cell population is that TCs are recently discovered  and bestOn the other hand, the definition of TCs as cells with telopodes  is entirTo this date, more than 450 papers on TCs have been indexed in Web of Science, SCOPUS, or Medline/PubMed databases. These papers have covered almost all the aspects of TCs, including their physiological functions, molecular characteristics, and role in the pathogenesis of countless diseases in virtually all organs of the human body and many different animal species ,10,11. TThis review article aims to summarize all the knowledge on cardiac TCs concisely from their initial description to this date, with the main focus on applications in cardiovascular regenerative medicine.The most prominent morphological features of TCs are a small inconspicuous spindle-shaped, star-shaped, triangular or oval cell body and very long, yet contrastingly thin telopodes, which make TCs difficult to study using common techniques of light microscopy, since the thickness of telopodes is roughly about the resolving power of the light microscope . Due to + stromal cells [Although TCs do not have a specific immunophenotype, i.e., no single immunohistochemical marker can unambiguously distinguish TCs from other cell populations, immunohistochemistry is a practical and frequently employed method of TC study. One of the most cited markers of TCs is CD34. For this reason, TCs are sometimes referred to as CD34al cells . TCs alsal cells .As of today, TCs have been described in all layers of the heart wall. In the endocardium, TCs were identified in the subendocardium in both the atria and the ventricles. Using the TEM, subendocardial TCs were observed to make gap junction-like contacts with fibroblasts. Moreover, the processes of TCs were in close vicinity to about one-third of endothelial cells, suggesting a role in the formation of a counterpart to the blood–brain barrier dubbed the blood–heart or blood–myocardial barrier . The layIt will be no exaggeration to say that TCs are unmatched in the vastness of their possible roles in the pathogenesis of different diseases, regardless of which animal species or organ we are referring to. In the heart alone, TCs have been studied in myocardial infarction , heart fMultiple studies have demonstrated that the normal function and morphology of cardiac TCs are severely disrupted during myocardial infarction ,49,50. AArrhythmias of different etiologies have also been discussed in relation to the possible role of TCs in their development. It is not at all surprising, given that TC discovery is closely linked to ICCs—pacemaker cells of the gut. TCs, formerly known as ICLCs, have been previously described in various organs participating in electrophysiological processes, including mechanoelectrical transduction and pacemaking . DeSimonThe potential of cardiac TCs as important players in cardiovascular regeneration is substantiated by the research focused on the integrative, regulative, and nursing functions of TCs in the heart wall. As mentioned earlier, one of the most promising findings is that TCs are located in the epicardial stem-cell niches. Bei et al. comprehensively reviewed the role of TCs in the homeostatic regulation of the whole stem-cell niche, where they are capable of regulating the functional characteristics, dynamics, commitment, and other aspects of stem-cell physiology. In addition to stem cells, the authors provided an excellent overview of the other important heterocellular connections imperative for successful TC-mediated cardiac regeneration. These include connections with cardiomyocytes and different populations of interstitial cells, including fibroblasts, immune cells, pericytes, and endothelial cells, which are also important in the whole orchestration of the regeneration and repair of the heart .For a better understanding of the role of TCs during repair and regeneration, the data from embryonic studies can provide valuable insights. Faussone-Pellegrini and Bani conducted an immunohistochemical and electron microscopic study of a mouse myocardium during the E14 and E17 stages of embryonic development. According to the morphological findings of TCs in close vicinity to immature components of the developing heart, the authors concluded that TCs possibly perform significant tasks during cardiogenesis, including the organization of the cytoarchitecture of the myocardial constituents, mechanical support, and supervision of the correct sequence of stem-cell differentiation . Papers Experimental data also shed light on the prospects of the actual use of TCs in human regenerative medicine. A recent original article by Liao et al. presented a yet unknown mechanism of the regenerative potential of cardiac TCs. The authors found out that cardiac TCs produce exosomes containing miRNA-21-5p, which can inhibit apoptosis in cardiac microvascular endothelial cells. It is essential in the process of angiogenesis, which is necessary for favorable regeneration after myocardial infarction. These paracrine-acting molecules show another fascinating future avenue in the form of cell-free therapy, which would not require the cells themselves since it has been progressively clear that, in many instances, the regeneration happens not via a direct proliferation and differentiation of stem cells but via paracrine signaling through molecules from cell-derived structures  . CardiacIn addition to the paracrine action mediated by extracellular vesicles, TCs make direct cell-to-cell contacts with cardiac stem cells, as observed by Popescu et al., who established a coculture of these two cell populations. They formed classic cell-to-cell junctions but also unusual junctions such as puncta adherentia and stromal synapses. The authors recognized a significant obstacle in the successful implementation of cell therapy in cardiovascular regenerative medicine. The tissue, e.g., after myocardial infarction, has specific characteristics resulting from the damage associated with the pathological process, making it especially challenging for the grafted cells to survive in this inhospitable microenvironment. These include ischemia, inflammation, proapoptotic signaling, and disintegrated extracellular matrix. Therefore, it is vital to thoroughly understand the exact interaction of stem cells and TCs through in vitro reproduction of the processes occurring in the stem-cell niches. Perhaps this is an inevitable step for successfully applying the cell therapy in vivo .Xenopus tropicalis). Lv et al. used electron microscopy and immunofluorescence to visualize TCs in this species. Moreover, they surgically removed the apex of the frog’s heart to study cardiac TCs on this injured site. Interestingly, after 8 days, the damaged TCs were among the first cells to regenerate fully. This quick recovery suggests that TC renewal might be the first essential step in any further fruitful regeneration of the tissue architecture ad integrum [In elucidating the role of TCs in cardiac regeneration, a highly valuable course of research is that focused on animals with almost perfect cardiac regenerative capacity. One such experimental paper was published in 2020, describing TCs in the heart of the western clawed frog (integrum . As mentintegrum . TC tranintegrum . Focusinintegrum . TCs werintegrum .The importance of TCs in cardiac regeneration was also recognized in studies whose research goal was to scrutinize other cell populations with regenerative capabilities. Miao et al. attempted to investigate the effect of the transplantation of induced pluripotent stem cell-derived mesenchymal stem cells in a mouse model of myocardial infarction. Although TCs were not the prime experimental focus in this study, the authors found out that the beneficial effect of the transplanted cells was reinforced by TCs, which contributed to supporting the tissue architecture, mechanotransduction, and elasticity . SimilarTerminologia Histologica [+/PDGFRα+/podoplanin−/LYVE-1−, while lymphatic endothelial cells were CD34−/PDGFRα−/podoplanin+/LYVE-1+. This comparative study not only demonstrated the uniqueness of TCs, it also showed that TCs possibly regulate microlymphatic circulation [+/CD31+, from CD34+/CD31− TCs [It is necessary to point out one peculiar fact about TCs. They are still considered controversial among scientists. Many do not recognize them as an individual cell population. To the best of our knowledge, TCs are still not included in any histological textbook, histology curricula at the universities, or the official histological nomenclature tologica . In our tologica . Some retologica . These oculation . AnotherD31− TCs . HostiucD31− TCs . To avoiD31− TCs . On the D31− TCs .+/CD31− immunophenotype of TCs [The standardization of protocols for TCs isolation, cultivation, and transplantation (although standardized protocols for the isolation of cardiac TCs are yet to be established, Romano et al. previously successfully isolated TCs from human skin using a novel two-step immunomagnetic microbead-based cell separation, taking advantage of the CD34e of TCs ; this meFiguring out the applicability and extrapolation of the results of animal model studies to human medicine;Viability assessment of transplanted TCs;Quantitative optimization of transplanted cells for each patient;Cost-effectiveness analysis.TCs are a remarkable cell population whose potential is enormous from many different perspectives. They are possibly the “last piece of the puzzle” in understanding the etiopathogenesis of many diseases, including the elucidation of the processes occurring during the development of cardiovascular diseases. TCs provide clues for a more detailed and elaborated grasp of how the processes during cardiovascular regeneration unfold. Transplantation of TCs, either solitary or in tandem with stem cells, might be an important therapeutic measure that will positively influence the unfavorable capacity of the heart to repair itself after disease or injury. However, there are still many unanswered questions and underresearched areas that have to be addressed in future experiments in order to routinely use TCs in cell therapy of cardiovascular diseases in human subjects. These include the following:


Hearing loss is associated with decreased speech perception as well as with changes in the auditory pathway. The effects of those changes on binaural speech perception with hearing aids are not yet fully understood. To provide further evidence on the functional changes of the auditory pathway, several speech perception tests  were conducted in a population of 370 bilateral hearing aid users covering the entire range of the World Health Organization’s most recent classification of hearing loss. To characterize the effects of asymmetric hearing thresholds, a generalized linear model was used for regression analysis. The model revealed a detrimental effect of the poorer ears’ thresholds on both the unaided and the aided unilateral word recognition scores that were attained by the better ear. Moreover, aided binaural word recognition (in quiet and in noise) was affected to a degree that cannot be explained on the sole basis of bilateral summation. Thus, this study provides evidence that there is reorganization and altered functioning of the afferent and efferent auditory pathways due to asymmetric hearing loss. Consequently, more attention should be paid to provision with a hearing aid as early as possible, and separately for each ear. Hearing loss is associated with a number of negative effects  and reprFor many patients with hearing loss, its etiology is unknown. Though genetics play an important role, hearing decline generally starts in adult age and progresses over the years, either in steps or smoothly. Typically, hearing loss affects both ears in a similar way, and large asymmetries are rare. Asymmetric hearing loss has been estimated to affect 8.5–13.3% of the general population . The cauIn summary, for both symmetric and asymmetric hearing loss, causal therapies are often not available and bilateral HAs are recommended in order to obtain best hearing outcomes. Unfortunately, for hearing loss that progresses over the years, it is quite usual for the better ear to be provided with an HA later than the worse ear. This assumption is supported by monaural and binaural HA adoption rates in Germany of about 29 and 71%, respectively . Hence, max) for the participants’ ears separately. They found that the worse ears exhibited significantly reduced WRSmax when compared with ears of persons with symmetric hearing loss for given  pure-tone hearing thresholds. They concluded that decreased auditory utilization of the worse-hearing ear may impair speech discrimination ability, and they identified a need for special rehabilitation. Their findings strengthen the deprivation hypothesis , with reference to the most recent WHO classification. Another established reference measure for HAs and other technical interventions, WRSmax . All participants provided written informed consent before participation in the study.In this retrospective study, more than 2,000 HA examinations were screened; they were performed between August 2012 and September 2017 in the Erlangen ENT Clinic. Bilateral HA users with at least 3 months of HA experience, German as mother tongue, and a minimum age of eighteen were included. The exclusion criteria were a mean air–bone gap at 0.5, 1, 2, and 4 kHz of more than 5 dB and any technical defects of the patients’ HAs. Prior to measurements, otoscopy was performed and, if needed, cerumen was removed. The test results of 370 bilateral HA users  aged 21–98 years  were eligible for assessment.Thresholds were measured for frequencies between 0.125 and 8 kHz, and bone-conduction thresholds between 0.25 and 6 kHz, by using a standard clinical audiometer  with appropriate headphones . For each patient and ear, the pure-tone threshold was summarized by averaging the thresholds found at 0.5, 1, 2, and 4 kHz; these thresholds are referred to hereinafter as PTAs.Speech recognition was assessed by using the Freiburg number test and the Freiburg word test . Both wemax): Starting with 65 dB SPL, the presentation level was increased in increments of 5–15 dB until 100% speech intelligibility was attained, unless the sound level became intolerable for the user or the audiometer limit of 120 dB SPL was reached. The uncomfortable level corresponds to speech presentation at the lowest SPL that is no longer tolerated. For analysis, we used the variable “better ear WRSmax,” defined as WRSmax for the ear with the better PTA.This relationship is an established measure in German speech audiometry to check the consistency of audiometric findings. The Freiburg monosyllable test was used to measure speech-recognition scores at higher levels and in particular the maximum word recognition score (WRS65 (HA). For the monaural measurements, the contralateral side was adequately blocked with earplugs. Additionally, binaural measurements for WRS65 (HA) were performed in quiet and with masking noise at a signal-to-noise ratio of +5 dB.Additionally, the Freiburg monosyllable test was used to assess aided speech recognition in free sound field. Word recognition scores in quiet were determined with HA for the left and right ear separately, WRSBefore performance of the speech perception measurements, HAs were checked by visual inspection and dynamic elicitation of acoustic feedback by shifting the earmolds, removing HA, and cupping the HA in hand. In addition, qualified personnel (HA acousticians) checked whether the type and model of the HA provided, and the amplification, were appropriate for the individual’s hearing loss. Amplification was checked by real-ear measurements .MATLAB software version R2019b  was used for all calculations and figures. A generalized linear regression model (GLM) was applied to the data. For speech recognition scores, model data for sigmoid regression were calculated according to equation 1. For speech recognition threshold, a linear fit was derived by using equation 2.BEA (better ear average) refers to the better-ear four-frequency average of the pure-tone thresholds. The asymmetry refers to the difference between BEA and the poorer-ear four-frequency average.p-value was below 0.05.Any effects of hearing thresholds and asymmetric hearing loss on speech perception measures were considered significant if the Spearman = 0.07, p = 0.18). For WHO Grade 6, the mean PTA difference was smaller because of audiometer limits; thresholds beyond the audiometer limits were set to the limit values.The results of the speech perception measurements are shown in max in dependence upon the BEA. BEAs were grouped according to WHO Grades 0–6. The scores show the largest variability of around 90 percentage points (pp) for WHO Grades 4 and 5. The model regression revealed a decrease in WRSmax of up to 20 pp; the greatest decrease was seen for an asymmetric hearing loss of 30-dB interaural PTA difference at a better-ear PTA of around 60-dB hearing loss (HL).65(HA), plotted against BEA. The scores show the largest variability, around 90 pp, for WHO Grade 3. For asymmetric hearing loss, with BEA around 60 dB HL and poorer-ear PTA around 90 dB HL, the model regression revealed a decrease of up to 24 pp in aided unilateral score. For the bilateral score  in quiet, and bilateral WRS65 (HA) in noise, depend on asymmetry. This was not found for the near threshold measure of the unilateral better-ear SRT.In summary, the suprathreshold measures, unilateral WRSHearing outcomes for a large group of bilateral HA users were investigated within the context of routine clinical measurements. The population covered the degrees of hearing loss from WHO Grades 0–6. Outcome measures with and without HAs in quiet and in noise were found to depend significantly on the degree of asymmetry. For bilateral conditions, this is a well-known finding . Howevermax with age. max and WRS65 (HA)] of the order of 10–20 pp. Regrettably, neither of these studies considered contralateral hearing or included binaural measurements.For the clinically relevant measures of the unilateral maximum word recognition score and the unilateral score with HAs, our results were similar to those of earlier studies . Unilatemax, there were effects of the order of 20 pp. The PTA range in which this effect was the greatest is obviously determined by the ceiling effects of the speech material used and the presentation levels applied. WRSmax is typically measured near the discomfort level, while SRT is measured at a low level; the different presentation levels are probably the root cause of the different findings; as for SRTs in quiet, the asymmetry did not show significant effects in our study population.For our study population, there was no correlation between age and degree of hearing asymmetry. Otherwise, the detrimental effect of age on speech perception would have been superimposed upon, or even have masked, the effect of asymmetric hearing. Most remarkably, even for unilateral WRSFor the purpose of simplification, the impact of hearing loss can be attributed in terms of functionality to two different components : (i) TheComplementary to this functional description of the impact of hearing loss, there is pathophysiological classification for hearing loss, which was originally applied to different types of presbyacusis. max at the near-uncomfortable presentation level, we found an effect, but not for the SRT, which is measured at near-threshold levels. The effects of the efferent system are believed to begin significantly above the hearing threshold if they are to be measurable. Hence, it is reasonable to consider that WRSmax is influenced by asymmetry while SRT is not. Therefore, one may at least partially assign the lower scores for the asymmetric PTA cases to a compromised efferent system in those patients. Unfortunately, the objective assessment of such effects by otoacoustic emission in individuals with hearing impairment presents a Gordian knot. Following the discovery of otoacoustic emissions (One possible cause for the observed detrimental effect of asymmetric PTA on unilateral better-ear scores could be the deprivation of the contralateral ear . Our datmissions , their mmissions . In patiThe GLM revealed detrimental effects of asymmetric hearing, namely, the effect of the poorer-ear PTA on speech perception by the better ear. However, such a model does not permit a more detailed analysis. It remains unclear whether those effects can be attributed exclusively to interaural asymmetry. For higher degrees of hearing loss in the better ear, the poorer-ear PTA is subject to “numerical” saturation effects due to the limits of the audiometer. It is reasonable to assume that higher degrees of hearing loss have a detrimental effect on the efferent system as well.The binaural summation effect might be regarded as a result of the loudness increase from one to two ears for unimodal bilateral and symmetric listening . It is wper se an average-based model. The average model output was based on many different patients with highly variable progress of hearing loss, in some cases differing very strongly between the ears of the same study participant. Attempts at in-depth analysis, especially if retrospective, can easily result in an overfit of a model if it includes too many parameters. Even though in our study the GLM yielded significant effects of asymmetric PTA, it has to be stressed that these findings are preliminary owing to the retrospective study design.The retrospective approach of this study certainly needs confirmation from prospective studies. Even though the number of HA users included was relatively high, the large variability in age, in hearing loss, and in experience with HAs prevents a more sophisticated evaluation. The GLM is According to clinical routine at our institution, HA users undergo unilateral assessment of speech perception on each side in quiet. Speech in noise is assessed bilaterally only. Altogether, each HA user routinely undergoes six different speech tests. Consequently, one cannot exclude the possibility that in some patients fatigue effects may have played a role, and thus increased the variability in the data. Probably the most important shortcoming of this study with respect to the hypothesized root causes of the effect of asymmetry, namely deprivation of afferent and efferent pathways, is the lack of detailed knowledge about the progress of individuals’ hearing loss. In a first attempt, it seems to be obvious to assign larger detrimental effects of asymmetry to a longer period of asymmetry. However, although this may fit in better with what we know so far, one cannot exclude the possibility that, after asymmetry has set in, reorganization of the auditory pathway may help in overcoming such detrimental effects. Recent findings in unilaterally deaf patients indicate such reorganization within as little as 1 year . The preThe results of this study suggest strongly that early treatment of hearing loss may be beneficial, even if the hearing loss is asymmetric and the prescription of an HA for both ears may not be considered urgently needed by the patient. Reimbursement criteria should reflect the detrimental effects of asymmetric hearing loss such that “in cases with bilateral hearing loss, candidacy for binaural amplification should be determined from each ear independently, and the combined effect of both aids” .In a population of hearing-aid users, including symmetric and asymmetric PTA, the asymmetry exerts a detrimental effect on both unaided and aided word recognition by the better ear. Also, the binaural speech perception with HAs worsens with increasing asymmetry. This decrease exceeds the limits of a missing binaural summation by far. More attention has to be paid to provision of an HA as early as possible. There is an evident need for more research on the short- and long-term effects of asymmetric hearing on the afferent and efferent auditory pathways in individuals with hearing impairment.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 Ethik-Kommission der Friedrich-Alexander-Universität Erlangen-Nürnberg. The patients/participants provided their written informed consent to participate in this study.UH: conception and design, acquisition and interpretation of data, and final approval. AH: revision and final approval. TH: drafting and design, figure preparation, and final approval. All authors contributed to the article and approved the submitted version.TH was employed by Cochlear GmbH & Co. KG, Germany. 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Translation and cultural adaptation of health resources is an integral part of good health-policy development and health program implementation. As part of our efforts to address ear disease and hearing loss in the Pacific Islands, we promote the translation an cultural adaptation of hearing-related questionnaires into local languages and cultural contexts. The Pacific Islands have among the highest rates of ear and hearing disorders in the world and, given the scarcity of ear/hearing health professionals in the region, a public health approach that uses appropriately translated ear/hearing health resources is highly recommended to tackle this health issue.Although formal translation and culturally adaption of hearing-related questionnaires may seem a cumbersome process, the aim of this commentary is to illustrate the potential benefits of translating two audiology questionnaires for our use in Samoa. We have carefully selected questionnaires that will serve multiple purposes , thus making the process ultimately beneficial and worthwhile.The leading cause of preventable hearing loss among Samoan adolescents and young people is excessive noise exposure to recreational and environmental noise. The Youth Attitude to Noise Scale is a validated tool that assess knowledge and attitudes of adolescents towards recreational and environmental noise, and a Samoan version should provide preliminary data to guide health promotion activities for adolescents on noise-induced hearing loss.The leading cause of hearing disability among older adult Samoans is age-related hearing loss. The Revised Hearing Handicap Inventory is a tool that assess the emotional and social/situational impact of hearing difficulty among older adults, and a Samoan version should provide preliminary data to guide the development of auditory rehabilitation services.Investment in quality translations and cultural adaptations of hearing-related questionnaires is essential for the development of audiology services that are relevant to their Pacific Island context. The use of formally translated audiology questionnaires in research studies will optimise data quality, leading to improved hearing health promotion activities, as well as provision of evidence for advocacy for public health noise policy legislation. Translation and cultural adaptation of health resources is an integral part of good health-policy development and health program implementation. As part of our efforts to address ear disease and hearing loss in the Pacific Islands, we promote the translation an cultural adaptation of hearing-related questionnaires into local languages and cultural contexts . The PacThe Ear, Nose and Throat (ENT)/Audiology Department of the Tupua Tamasese Meaole Hospital in Samoa is currently engaged in a research project that aims to address ear/hearing disorders in the country through clinical, public health, and health promotion services. A review of the literature indicates that there are a number of validated audiology questionnaires that should prove useful to achieve our goals. The advantages of questionnaires in a low-resourced context such as Samoa include: administration does not required ENT/Audiology specialists, rapid assessment possible, procurement of data to inform the development of public health initiatives, procurement of data to inform the development of ENT/Audiology services, and a tool that enables procurement of baseline data, followed by updated data at a later time for monitoring and evaluation purposes. To optimise these objectives, it is imperative to translate and culturally adapt selected questionnaires for our Samoan context.Although formal translation and culturally adaption of hearing-related questionnaires may seem a cumbersome process, the aim of this commentary is to illustrate the potential benefits of translating two audiology questionnaires for our use in Samoa. We have carefully selected questionnaires that will serve multiple purposes , thus making the process ultimately beneficial and worthwhile.The leading cause of preventable hearing loss among Samoan adolescents and young people is excessive noise exposure to recreational and environmental noise. According to the World Health Organization, nearly 50% of people aged 12–35 years worldwide are at risk of developing permanent noise-induced hearing loss [In order to build on this hearing health message, we are collaborating with the health promotion department to develop health education activities specifically for adolescents about recreational noise exposure. The Youth Attitude to Noise Scale (YANS) is a validated tool that should assist our team in this endeavour, given that it assess knowledge and attitudes of adolescents towards recreational and environmental noise . It consA review of the literature found formal studies on the translation and cultural adaptation of the YANS to Brazilian Portuguese  and ChinThe results of the Samoan YANS research study should provide preliminary evidence for the development of health promotion activities for adolescents on noise-induced hearing loss. It should also prove a valuable resource for hearing health advocates in their efforts to influence implementation of public health noise policies. For example, the results of the study may lead to initiatives that reduce noise levels in the educational setting, and thereby promote a more positive and improved learning experience. Following implementation of any noise-related interventions, the Samoan YANS should be repeated in order to assess the impact of initiatives on the listening experience of students: in this way, the translated questionnaire serves an on-going purpose of monitoring and evaluation of health promotion programs for addressing permanent hearing loss among adolescents in Samoa from excessive recreational/environmental noise exposure.The leading cause of hearing disability among older adult Samoans is age-related hearing loss. According to the World Health Organization, approximately a third of adults over 65 years of age experience disabling hearing loss . There aThe Revised Hearing Handicap Inventory (RHHI) emerges as a suitable candidate for our situation in Samoa . It consSimilar to the discussion above, we aim to develop a Samoan version of the RHHI in collaboration with the Centre for Samoan Studies at the National University of Samoa in accordance with the procedures described by Hall and colleagues . The SamThe results of the Samoan RHHI research study should provide preliminary evidence on the social and emotional impact of hearing disability among older adults in Samoa. It should also inform the development of ENT/Audiology services for this population. Auditory rehabilitation services are limited but evolving in Samoa, and the results of the RHHI study should guide our clinic towards the most effective strategy for improving the listening enjoyment of older adults. Samoan culture is characterised by collectivism, and it may be more acceptable to the community to develop hearing health policies that promote expenditure on technology that benefits the entire community  rather than individual hearing health plans . Similar to the discussion above, the Samoan RHHI study should be repeated at a later time to assess the effectiveness of any interventions: again, the translated questionnaire will serve an on-going purpose of monitoring and evaluating the hearing health of older adults in Samoa.Investment in quality translations and cultural adaptations of hearing-related questionnaires is essential for the development of audiology services that are relevant to their Pacific Island context. The use of formally translated audiology questionnaires in research studies will optimise data quality, leading to improved hearing health promotion activities, as well as provision of evidence for advocacy for public health noise policy legislation.


Regional maintenance garages were randomized to control (n = 6); HearWell (n = 4) or HearWell Design Team (n = 2) arms. Maintainer representatives from the HearWell Design Team garages identified barriers to hearing health and collaborated to design interventions including a safety leadership training for managers, a noise hazard management scheme to identify noise levels and indicate the hearing protection device (HPD) needed, and a comprehensive HearWell training video and protocol. These worker-designed interventions, after manager input, were delivered to the HearWell Design Team and the HearWell garages. Control garages received standard industry hearing conservation training. Periodic surveys of workers in all 12 garages collected information on the frequency of HPD use and a new hearing climate measure to evaluate changes in behaviors and attitudes over the study period and following interventions. An intention-to-treat approach was utilized; differences and trends in group HPD use and hearing climate were analyzed using a mixed-effects model to account for repeated measures from individual participants. The HearWell Design Team maintainers reported the highest frequency of HPD use. Hearing climate improved in each group 6 months following intervention implementation, with the largest increase and highest value for the HearWell Design Team workers. The HearWell pilot intervention showed promising results in improving HPD use through a participatory TWH approach to hearing conservation. Furthermore, results suggest that employee participation in hearing conservation programs may be necessary for maximal effectiveness.Our objective was to pilot test HearWell, an intervention created to preserve hearing among highway maintainers, by using a participatory  Despite over 30 years of occupational noise regulation in the United States (US), noise-induced hearing loss (NIHL) remains one of the most common self-reported occupational illnesses or injuries . While iWhile noise exposures were recognized as an occupational hazard for centuries, in 1983 the US—through the Occupational Safety and Health Administration (OSHA) Hearing Conservation Amendment–required hearing conservation programs (HCP) for worksites where noise exposures meet or exceed 85 dBA over an 8-h time-weighted average (TWA) . The OSH®Total Worker Health (TWH) approach, where workers use their expertise to design or change their workplace, work organization and/or jobs to improve physical and psychosocial working conditions [OSHA’s Hearing Conservation amendment is a performance standard, where the content of the HCP is prescribed, and workplaces may use methods of their choosing to implement their HCP. One approach to addressing worker health is through active employee engagement, a cornerstone of participatory ergonomics and the nditions ,10. In fnditions . Furthernditions .The Center for the Promotion of Health in the New England Workplace (CPH-NEW), a NIOSH TWH Center of Excellence, has designed the Healthy Workplace Participatory Program (HWPP) as a TWH approach for addressing worker health, safety and well-being issues and concerns in which employee engagement is a cornerstone. At the core of the HWPP is the active participation of employees through worker teams and a structured root-cause analysis approach using the Intervention Design and Analysis Scorecard (IDEAS) Tool . The IDEOur objective was to design, implement and evaluate elements of an HCP, called “HearWell,” using a participatory TWH approach based on CPH-NEW’s HWPP. While the IDEAS process can be used to address any well-being issue, for the purpose of this study workers were asked to focus exclusively on hearing health. We hypothesized that, compared to a standard HCP, a participatory program would improve hearing-related attitudes and behaviors. Furthermore, we expected that workgroups with a higher level of participation would show the greatest improvements in attitudes and behaviors related to hearing loss prevention which would represent a more lasting solution.8hr over the work shift and 92.1 (7.6) dBA Leq while using the chainsaw [We used a cluster randomized control design  to test chainsaw . MaintaiThe HearWell intervention was developed using the HWPP with a focus on hearing health. While traditional HCPs required by OSHA require several elements, given the limited scope of this project (budget and timeline) and with the direction of the Design Team, HearWell focused on the training and hearing protection components of the HCP. The other components of an HCP including audiometry, noise monitoring and control, and record-keeping, were already being addressed by the DOT’s Health and Safety Department. With respect to policy, at the time of the study, the DOT had a general policy requiring ear protection when working in an environment with sound levels that exceed 85 dB. Ear protection in the form of muffs and earplugs was issued to all maintainers. Yet, clarification on when worker noise exposures exceeded this level as well as the specific hearing protection required was at the discretion of the supervisors. The HearWell study period was from February 2016 through August 2019 . The UCoMaintainers worked out of 48 garage facilities spread evenly across the state. The 48 garages are classified into 8 sections or groupings based on geography. In consultation with management and for the purpose of this study, 24 garages in 4 sections were chosen based on similarity of work tasks after considering the types of roadways and typical weather events within each section . For ranUsing the participatory methodology outlined by CPH-NEW ,17, we iSupervisors at the two HearWell Design Team garages were each asked to recruit five workers to form the worker Design Teams. The Steering Committee and Design Teams worked together through the 7-step IDEAS process. The Design Teams each held 20 1-h meetings, beginning in March 2017 and ending in November 2018 . In meetThe development, selection, implementation and evaluation of interventions occurred in IDEAS Steps 5–7. In collaboration with the Steering Committee, the Design Team and research staff developed interventions across four months and five Design Team meetings. The intervention included multiple components including supervisor training, a noise hazard management scheme, and a HearWell training video and presentation. Design Team members from both garages were actively engaged in drafting each intervention component. The noise hazard scheme was reviewed and adapted based on members’ suggestions. Workers suggested and edited a maintainer-specific scenario within the supervisor safety training materials to emphasize HPD use. To create the HearWell training, Design Team members reviewed numerous industry videos and presentations and assessed which elements and content they found most effective. They also discussed the relative merits of different methods to deliver the training .The supervisor training was implemented in October 2018 at the 6 HearWell garages (those with and without Design Teams). Supervisors in the control garages received no additional training. In January through February of 2019, the HearWell worker training and HearWell noise hazard scheme interventions were both implemented among HearWell garages . WorkersSurvey data collection occurred at four time points across the study period: randomization, pre-intervention, training and post-intervention . SurveysEach survey included items to assess demographics and job history, as well as the frequency of HPD use . WorkersThe Design Team suggested additional survey items for the pre-intervention, training, and post-intervention surveys. A new hearing climate scale was modeled on the concept of safety climate as a way to capture attitudes about noise and hearing prevention within the workgroup. The hearing climate scale was validated prior to its use .In order to address the bias inherent with asking workers to report on their own HPD use frequency, the Design Team included a question on frequency of HPD use by co-workers: “How often do your co-workers wear hearing protectors  when they use noisy tools or are in noisy areas?” This used the same 6–point frequency scale as the self-assessment, from rarely or never (1) to always (6). On the pre- and post-intervention surveys, workers were also asked how often they used HPD during specific home or leisure tasks and activities. Workers used the same 6–point frequency scale or indicated that they did not perform such tasks or activities. Attitudes, beliefs, and behaviors about hearing protection were measured pre- and post-training using the NIOSH Hearing Protection Beliefs, Attitudes and Behaviors Items and Scales (BAPHLS) ,24 with An intent-to-treat approach was used in evaluating differences between control, HearWell, and HearWell-Design Team arms. The following hypotheses were tested:Hypothesis 1 (H1).HearWell and HearWell Design Team garage workers will show changes in HPD beliefs, attitudes and behaviors following the HearWell training.Hypothesis 2 (H2).Compared to the control group at randomization, workers in the HearWell and HearWell Design Team garages will report an increase in HPD use frequency following supervisory training (pre-training) and 6 months following the HearWell training (post-training).Hypothesis 3 (H3).Compared to the control group at pre-training, workers in the HearWell and HearWell Design Team garages will show an increase in hearing climate (attitudes about noise and hearing prevention) 6 months following the HearWell training (post-training).Hypothesis 4 (H4).Compared to the control group at pre-intervention, workers in the HearWell and HearWell Design Team garages will show an increase in at-home HPD use (post-intervention).p-values represent the comparison of the selected survey period and intervention arm to the control group at the earliest survey period. In sensitivity analyses, stratified analyses were performed by the intervention group, with the earliest survey period serving as the reference. In addition to the main outcome variables of interest (HPD use frequency and hearing climate), a sensitivity analysis was performed by examining the difference in reported frequency of HPD use among co-workers. All analyses were conducted in SAS 9.4.We assessed changes in HPD beliefs, attitudes and behaviors following the training by performing paired t-tests on pre- and post- values for each subscale by each independent intervention scenario group. We assessed the impact of the HearWell intervention using mixed linear modeling while accounting for repeated measures among participants. Analyses were conducted in SAS 9.4 using PROC MIXED with a REPEATED statement. A categorical variable for the survey period  was included in the model along with a variable to indicate intervention scenario . For each analysis, the control group at the earliest survey period served as the reference. Reported The two HearWell Design Teams completed the IDEAS process Steps 1 through 5 in parallel through seven meetings each. The major results are presented in In Step 2, Design Team members strategized a full range of solutions without the consideration of feasibility. Solutions fell within the areas of noise reduction, policy, noise awareness, hearing culture, HPD, training, and work practices . ResearcIn IDEAS Step 5, the Steering Committee and Design Team worked together to select, adapt and create three main HearWell intervention components; supervisor training, a noise hazard management scheme, and the HearWell training .The goal of the supervisor training was to increase leadership support of hearing and HPD use and ultimately create a safe and consistent environment supportive of hearing health. The Foundations for Safety Leadership (FSL) Training was identified as a relevant component as its goal is to teach construction supervisors leadership skills to strengthen workplace safety climate and reduce adverse safety outcomes . With peThe goal of the noise hazard management scheme was to easily identify noise levels of individual equipment models and indicate the required HPD for each. The Design Team, Steering Committee and researchers developed a color-coded noise hazard scheme that allows workers to recognize equipment and task noise levels and choose the appropriate HPD . BrieflyThe goal of the HearWell training was to educate workers (maintainers and supervisors) on the noise hazard scheme as well as the content required by OSHA and other information suggested by Design Team members. Topics required by OSHA (CFR 1910.95) were incorporated into the training including: (a) the effects of noise on hearing; (b) the purpose of hearing protectors, the advantages, disadvantages, and attenuation of various types and instructions on hearing protectors selection, fit, use, and care; and (c) the purpose of audiometric testing, and an explanation of the test procedures. In addition to training on the noise hazard scheme, Design Team additions included: (a) ways to reduce noise exposure ; (b) assessing noise levels  ways that co-workers can support HPD use and practices to reduce noise exposures. The Design Teams chose a video format to provide a consistent experience and allow for easier rollout. Following the video, workers suggested a demonstration of proper HPD use including earplug insertion and muff adjustment as well as time for questions and answers.A total of 271, 163, 140 and 95 workers were surveyed at randomization, pre-intervention, pre-training, and post-intervention, respectively. Survey participation at randomization averaged 81% among the 12 garages. Among the randomized control and HearWell garages, high participation was maintained for the pre-intervention, pre-training, and post-intervention surveys . A total of 288 participants were surveyed with 131 (46%) providing one survey, 78 (27%) providing 2 surveys, 52 (18%) providing 3 surveys and 27 (9%) providing 4 surveys. Survey respondents were predominantly male, White, and maintainers, with a mean age of 44 years and a mean of 11 years in the current job . All chan = 72) of HearWell garage workers and 94% (n = 68) of control garage workers. The majority (84%) of workers who received the training were maintainers; three workers did not indicate a job title  using a mixed-effects model to account for repeated measures of participants across surveys. In a sensitivity analysis, HPD use frequency by co-workers was examined as an alternative to self-report (data not shown). Co-worker HPD use frequency was consistently lower than self-reported HPD use frequency, with a mean (SD) of 4.13 (1.19); 4.37 (1.46); and 5.0 (0.94) for control, HearWell and HearWell Design Team garage workers, respectively at post-intervention. Yet, similar trends were observed over time and by the intervention arm. The scale point increase in HPD use frequency by intervention arm from pre-intervention (when the co-worker HPD use frequency variable was first introduced) to 6-months post-intervention was calculated as 0.74 (95% CI: 0.12 to 1.29) for HearWell, 0.75 (95% CI: −0.01 to 1.50) for HearWell Design Team, and 0.55 (95% CI: 0.03 to 1.06) for control garage workers.We also assessed hearing climate at pre-training and post-intervention by intervention arm (Hypothesis 3). Using linear mixed models with the control at pre-training as a reference, we found no meaningful difference in hearing climate by intervention arm at pre-training . HoweverFor Hypothesis 4, with the exception of one activity (snow blowing), there were no meaningful differences in at-home HPD use among study arms, at pre-intervention . The freThe HearWell intervention created by the worker Design Teams and Steering Committee was comprised of multiple components including supervisor leadership training, noise hazard management scheme, and customized hearing prevention training. These intervention components built upon an existing policy that directed workers when to wear HPD, yet offered little guidance on identifying high noise levels or selecting the correct HPD. The goals of the intervention were to increase HPD use; improve the hearing climate in the workplace, including supervisor and co-worker support for HPD use; and reduce ambient noise levels. While all three intervention arms  showed increases in HPD use over the study period, the only statistically significant increase was in the HearWell Design Team garage workers, who also reported the highest HPD use frequency 6 months after the intervention. Both HearWell and HearWell Design Team workers reported statistically significant increases in some beliefs and attitudes about hearing loss and hearing protection following the HearWell training. Interestingly, all three intervention arms showed an improvement in hearing climate as well as increases in at-home HPD use.The training was shown to be an effective means of improving HPD use ,27,28. AIn addition to its ability to improve hearing-related outcomes, the success of HearWell can also be assessed in its ability to achieve a TWH approach. TWH is defined by the NIOSH as “policies, programs and practices that integrate protection from work-related safety and health hazards with promotion of injury and illness prevention efforts to advance worker well-being” . While tA comprehensive TWH approach would prioritize workplace changes to promote well-being and can be expected to be consistent with the industrial hygiene hierarchy of controls with respect to noise exposure. This prioritizes eliminating noise exposure followed by buying quiet equipment  and toolA TWH approach to hearing preservation also considers workplace policies, programs, and work organizations as well. HearWell addressed workplace hearing health and noise culture through the supervisor training in safety leadership, adapted from the FSL training for construction leaders . The FSLAdditional facets of work organization addressed through the HearWell training included co-workers’ support for reducing noise exposures. Design Team member suggestions for increasing co-worker support for HPD use included (a) keeping extra plugs in the truck for co-workers who forget them; (b) reminding and encouraging co-workers to use HPD, especially those new to the job; and (c) before starting up a noisy piece of equipment, warning co-workers to check that they are wearing HPD.Administrative controls to reduce noise exposure were also part of HearWell interventions. Job rotation or switching off on noisy equipment such as the chainsaw was emphasized within the HearWell training. In addition, within Design Team garages, the noise hazard color scheme was used when assigning morning work orders. Supervisors and crew leaders added the color code corresponding to the noise level and required HPD to be added to the work order as a way to emphasize that HPD was required.Overall, HearWell addressed workplace contributors to hearing health, yet the approaches that were adopted could have been further improved by prioritizing the hierarchy of controls with respect to noise exposure; namely noise exposure elimination or reduction at the sources over the use of HPD. Perhaps after a longer period of collaboration, members of the Design Team would no longer rule out the selection of quiet equipment due to feasibility concerns. Nonetheless, the reliance on HPD use to control noise exposure, while less desirable than engineering controls, is relatively commonplace and has been implicated as a driver of the high burden of hearing loss among noise-exposed workers . HPD useA comprehensive TWH approach to promoting hearing health would also consider work and non-work risk factors for hearing loss. In addition to workplace noise exposures, non-work exposure to noise at home and in the community can also put workers at risk for hearing loss. Among maintainers within this study, noisy tasks such as lawn mowing or leaf blowing may occur concurrently at work and home increasing daily noise exposure levels. As part of the HearWell program, workers addressed at-home noise exposure by encouraging protective behavior outside of work and surveying at-home HPD use. Interestingly, we observed an increase in at-home HPD use for the majority of tasks over time regardless of study arms. At-home HPD use for chainsaw use was high at pre-intervention and changed little post-intervention. However, prior to the pre-intervention survey, researchers conducted in-depth noise survey monitoring during tree removal , which iA comprehensive, TWH approach to hearing health considers work and non-work exposure to ototoxic chemicals promotes healthful living and monitoring activities including regular audiometric exams . HearWelParticipatory engagement is the cornerstone of a TWH approach . A partiParticipatory engagement appeared to have played a key role in the success of HearWell. HPD use frequency was highest across time and showed a statistically significant improvement for the HearWell Design teams compared to the control garages. The benefits of employing a participatory process when designing interventions are known to be multifold  and provWhile both HearWell and HearWell Design Team garage members benefited from the HearWell interventions, direct employee engagement in TWH efforts promotes employee self-efficacy  which maA TWH approach involves the coordination of programs and activities that support worker well-being which can occur across a spectrum ranging from parallel programs with cross-promotion of specific activities to programs that are integrated through the common goal of promoting hearing health. Therefore, coordination to support hearing health may encompass a broad range of programs, policies and departments that support the reduction of noise exposure as well as the promotion of behaviors supporting hearing health.Through the Steering Committee, the HearWell program advanced coordination of noise reduction strategies with other ongoing initiatives. The Steering Committee included representatives from finance as well as operations, and meetings focused on topics that included the importance of considering noise levels when buying new equipment, the need for a variety of HPDs for workforce fit and comfort, staffing needs, and best practices for limiting noise exposures. Notably, the HearWell interventions were limited by the small budget provided by the research staff for materials that included worksheets, posters, video production software and sample HPD. Higher expenditures for training and HPD fit-testing have been associated with reduced hearing loss documented through standard threshold shifts  and mighThe HearWell study had a number of noteworthy limitations. Ideally, the goal of an HCP is to preserve hearing health and reduce noise exposures. Yet, for the purpose of the HearWell pilot program, we did not have access to audiometry nor comprehensive noise exposure data for either motivating workers or evaluating HearWell effectiveness. Rather, HearWell relied on self-report measures, namely frequency of HPD use as well as hearing climate, to assess intervention effectiveness. While there is an inherent bias in self-report measures, in a sensitivity analysis we observed similar trends when workers were asked to report on co-workers HPD use frequency. Furthermore, small sample sizes may have limited our ability to detect differences in the groups. While garages were randomized at the study start, small sample sizes may have contributed to the unequal distribution of HPD use frequency, with the HearWell garages with the lowest HPD use at randomization. Some workers also switched between garages over the course of the study. Those transfers might have led to misclassification with regard to the intervention dose actually received. While the intention-to-treat analytic approach is appropriate for control of selection bias, misclassification could have biased these findings towards the null value, further limiting our ability to observe statistically significant associations. Yet despite these limitations, the HearWell pilot intervention showed promising results in improving HPD use through a participatory TWH approach to hearing conservation.The work performed by maintainers has and can be expected to change in the future due to myriad factors linked to climate change. In addition to increased outdoor heat exposures due to climate change-related heat increases, maintainers are also affected by the increasing frequency, duration and severity of extreme weather events caused by climate change . With reConsistent with the future of work trends across the workforce in general, maintainers are a multi-generational and aging workforce. The participatory methods employed in HearWell allowed for a range of worker attitudes, beliefs and needs to be heard and addressed. When the Design Team engaged in the IDEAS processes including root causes analysis, this consensus-building process was able to incorporate the diversity of concerns present across the entire workforce. Importantly, the participatory design process and Design Team experience overall promoted skill development in the areas of interpersonal communication and group problem-solving, both of which are recognized as core competencies required for a successful future workforce .The results of the present study indicate that the well-established occupational safety and health area of noise and hearing conservation can benefit from adopting a TWH approach. Employee engagement in hearing health promotion efforts was found to be an effective way of promoting behaviors that support hearing protection and instituting organizational changes in support of hearing conservation. Although employees benefitted from receiving the same interventions that were developed by employees elsewhere, maximum program impact was found at those sites in which employee design teams actively engaged in intervention design efforts. Thus, the present findings suggest that future hearing conservation programs should leverage employee participation for maximal effectiveness.


OBJECTIVES/GOALS: This study evaluates the utility of self-reported quality of life measure in children with hearing loss. We will compare self-reported HEAR-QL scores with parent-reported HEAR-QL scores. We will then test the relationship between HEAR-QL scores and scores on a standardized assessment of cognition, the NIH Cognition Battery. METHODS/STUDY POPULATION: We will administer the HEAR-QL questionnaire to children with hearing loss and their parents. We will then administer the NIH Cognition Battery to the child. We will include in our population children ages 7 to 14 with hearing loss of any severity or side. We will exclude those with intellectual disability, disorders of speech or language, or those who would be unable to complete the questionnaires for any reason. Children will be recruited from Otolaryngology clinics at St. Louis Children’s Hospital based on ICD diagnosis of sensorineural hearing loss between 01/2015 – 03/2020. RESULTS/ANTICIPATED RESULTS: We will aim to recruit 44 patients in total, which is the sample size needed to detect a moderate correlation (r = 0.4) with a 1-sided α = 0.05 and 1-β = 0.8. HEAR-QL scores and NIH Cognition Battery scores will be reported using descriptive statistics. Linear regression as well as correlation analysis between HEAR-QL scores and cognitive testing scores will be performed using a 1-sided α = 0.05, with 1-β = 0.8. If recruitment is sufficient, we will adjust for demographics that are significantly correlated with the outcome on multivariate analysis. Finally, we will test for agreement between parent report and child report by calculating a Kappa statistic. DISCUSSION/SIGNIFICANCE OF IMPACT: There is little clarity on the necessity of amplification in children with hearing loss, yet the child’s perspective is not routinely assessed in clinical practice. This study employs self-report in a pediatric population with hearing loss to find out if children provide new and reliable information.


Key Points: Question: Can the traditional Chinese version of the hearing handicap inventory for elderly screening (HHIE-S) checklist screen for age-related hearing loss (ARHL) in elderly individuals? Findings: In this cross-sectional study of 1696 Taiwanese patients who underwent annual government-funded geriatric health checkups, the Chinese version of the HHIE-S had a sensitivity of 76.9% and a specificity of 79.8% with a cutoff score greater than 6 for identifying patients with disabled hearing loss (defined as a PTA > 40 dB). Meaning: The traditional Chinese version of the HHIE-S is an effective test to detect ARHL and can improve the feasibility of large-scale hearing screening among elderly individuals. Purpose: The traditional Chinese version of the hearing handicap inventory for elderly screening (TC-HHIE-S) was translated from English and is intended for use with people whose native language is traditional Chinese, but its effectiveness and diagnostic performance are still unclear. The purpose of this study was to evaluate the validity and reliability of the traditional Chinese version of the HHIE-S for screening for age-related hearing loss (ARHL). Methods: A total of 1696 elderly people underwent the government’s annual geriatric medical examination at community hospitals. In this cross-sectional study, we recorded average conducted pure-tone averages (PTA) , age, sex, and HHIE-S data. Receiver operating characteristic (ROC) curve analysis was used to identify the best critical point for detecting hearing impairment, and the validity of the structure was verified by the agreement between the TC-HHIE-S and PTA results. Results: The HHIE-S scores were correlated with the better-ear pure-tone threshold averages (PTAs) at 0.5–4 kHz (correlation coefficient r = 0.45). The internal consistency of the total HHIE-S score was excellent , and the test-retest reliability was also excellent . In detecting disabled hearing loss , the HHIE-S cutoff score of > 6 had a sensitivity of 76.9% and a specificity of 79.8%. Conclusions: The traditional Chinese version of the HHIE-S is a valid, reliable, and efficient tool for large-scale screening for ARHL. Hearing loss is very common among people aged 65 or older worldwide, but it is not fully understood or treated. According to statistics released by the United Nations in 2019, the proportion of the population aged more than 65 years in East Asia and Southeast Asia is expected to increase from 11% in 2019 to 24% in 2050 . TherefoThere is evidence that patients with hearing loss have more tinnitus and balance problems and a worse long-term quality of life ,5. TheseHearing loss is usually defined by the difference in threshold between the two ears. There are many recommended standards for comparative hearing standardization of the test procedures , such asThe hearing handicap inventory for elderly screening (HHIE-S) is an abbreviated version of the elderly hearing impairment inventory (HHIE). It consists of 10 questions that can help clinicians assess the emotional and social aspects of hearing loss. The HHIE-S score has been verified with respect to a hearing test for hearing loss, and the results show that it has sufficient sensitivity and specificity in identifying individuals with hearing loss ,34. Yangp > 0.05). This study was approved by the Joint Institutional Review Board of Taipei City Hospital (TCHIRB-10811011-E).The subjects included in this cross-sectional study were individuals residing in the Zhongzheng and Wanhua districts of Taipei City, which consist of 348,390 residents, 18.5% of whom are older adults aged more than 65 years. Taipei is the most populated city in Taiwan and is comprised of 12 districts with a total population of approximately 2.7 million [t-tests, which corresponds to the small effect size of d = 0.2, and the allocation ratio was 1:2. Therefore, the sample size used in this study had enough power to detect differences between the groups. We recruited 1696 people aged 65 or older who visited an otolaryngology outpatient clinic. Investigators explained the research objectives and process, and written informed consent was obtained from all the patients who were enrolled. Instructions regarding the screening procedures and operations were provided by the trained examiners prior to each hearing screening test.The data used in this community-based study were collected from the Health Promotion Center of the Heping branch of the Taipei City Hospital from 2016 to 2018. The sample size was estimated considering the type I error rate and type II errors using 0.05 (two-tailed test) and 0.2 (power = 80%), respectively. The required sample size was 886 participants, as calculated by two independent The participants met the following requirements: (1) self-suspected hearing loss and (2) able to understand and communicate in Chinese or Taiwanese. Patients were excluded if they had any neurological diseases that might interfere with their decision making. All of the subjects included in the study were randomly recruited. Informed consent was obtained from the participants, and then, demographic information, such as age and sex, was collected via a questionnaire. The TC-HHIE-S was then administered by a licensed interviewer, an audiologist, and a trained undergraduate student in audiology supervised by the audiologist. The order of the questions of the TC-HHIE-S is the same as that of the English version. First, each participant was given general instructions for the TC-HHIE-S by the interviewer. The items were then administered via a face-to-face interview. A score of 0 was assigned for “no” responses, a score of 2 was assigned for “sometimes” responses, and a score of 4 was assigned for “yes” responses. The total score was the sum of all the scores for the responses. The air conduction pure-tone average at hearing thresholds of 0.5, 1, 2, and 4 kHz was then assessed with an MA30 audiometer  using pure-tone stimuli in a sound-treated booth with ambient noise <30 dBA located in a quiet room. The thresholds were measured with standard TDH-39 supra-aural earphones and expressed in dB HL; the thresholds were considered the intensity levels at which the tones were heard in 50% of the trials using the descending technique. If a subject reported asymmetric hearing, the better ear was tested first. Otherwise, the right ear was tested first. Narrow band masking was used as appropriate. An ordinary patient-response button was used by nearly all the subjects. The pure-tone average (PTA) was calculated by averaging the measurements of these four frequencies’ AC thresholds. The PTA of the better-hearing ear was used for the final analysis. Calibration was performed according to the reference equivalent sound pressure levels specified by ISO 389-1 and 389-3. All equipment was calibrated annually.t-test when the data were not normally distributed.IBM ©SPSS © statistics version 25 , R 3.6.1 , and Microsoft Excel 2013  were used for all the statistical analyses in this study. For the descriptive data, we calculated the mean and standard deviation. For the categorical data, we used chi-square tests. For continuous data, we used the Mann–Whitney U test instead of the independent Construct validity was verified by the agreement between the TC-HHIE-S and PTA results, as determined using Spearman’s correlations (Rho); the PTA was used as the gold standard of hearing sensitivity. The reliability of the TC-HHIE-S was estimated in terms of internal consistency with Cronbach’s alpha, with a value of 0.7 being the minimally acceptable level. The test-retest consistency was evaluated with the data from a total of 188 subjects who repeated the audiometry tests and TC-HHIE-S with PTA changes of less than 10 dB HL during the study period. Spearman’s correlation coefficients and intraclass correlation coefficients (ICCs) with corresponding 95% confidence intervals were calculated. Usually, ICCs greater than 0.7 are considered to indicate good repeatability. A receiver operating characteristic (ROC) curve was utilized to find the optimal cutoff point for detecting hearing impairment. The sensitivity and specificity were also calculated.This study included 1696 adults who visited an emergency department or an otolaryngology clinic. The mean age of the study cohort was 75.0 ± 21.0 years, and 53% (899/1696) were females. The responses to the TC-HHIE-S are shown in For construct validity, the Spearman’s correlation coefficient was approximately 0.45 between the total score of the TC-HHIE-S and the audiometry results, which means that they were moderately correlated . HoweverThe ROC curves for the TC-HHIE-S scores and the different definitions of hearing impairment are shown in To the best of our knowledge, this is the first community-based study to evaluate the effectiveness of TC-HHIE-S in the diagnosis of age-related hearing loss among elderly individuals in Taiwanese Mandarin. We aimed to assess the utility of the TC-HHIE-S as a screening tool for identifying Mandarin-speaking elderly individuals with disabled hearing loss/hearing impairment who may need otologic or audiologic referrals because aural rehabilitations are warranted. This study investigated the relationship between audiometric and self-assessed hearing measurements determined by the 10-item Likert-type TC-HHIE-S questionnaire.In this study, we measured the construct validity of the TC-HHIE-S and found a Spearman’s correlation coefficient of 0.45 . This reThe internal consistency of the total score of the TC-HHIE-S was excellent in this study, with a Cronbach’s alpha of 0.901 , despiteWe found that the Spearman’s correlation coefficient (Spearman’s r) was 0.60, and the intraclass correlation coefficient (ICC) was 0.75 (95% CI = 0.67–0.81) when the TC-HHIE-S scores for the first and second administrations were compared to estimate test-retest reliability . In compScreening for any disease typically leads to an increase in the likelihood that individuals with the disease will be identified (sensitivity), and those without the disease (specificity) will be excluded. In practice, however, not all subjects will be identified by screening , and some individuals without the disease may be wrongly classified as having it . Therefore, there is an intrinsic and inevitable trade-off between sensitivity and specificity . AccordiChoosing the optimal cut-off point for large-scale hearing screenings warrants additional studies. The TC-HHIE-S is a cost-effective and easy test to administer in various settings, including senior centers, nursing homes, and primary care practices, where standard audiometry is often not available. This study suggests that the TC-HHIE-S can be important for public health applications because of its ability to detect moderate and severe hearing loss in a large population. To further improve the feasibility and efficiency of the HHIE-S for large-scale screening, future studies that administer the TC-HHIE-S via internet or smartphone-based approaches are needed.The TC-HHIE-S proposed in this study has been shown to be suitable for hearing screening in primary care practices (PCPs) or other busy clinical settings, such as urgent care and emergency departments for individual care. We believe that this TC-HHIE-S can be used as a point-of-care test for PCP-level hearing screening because it is economical and efficient and requires minimal training of case managers in health systems.There are several strengths of our study. The cohort included in this study is a representative sample of noninstitutionalized older adults in Taiwan because they were randomly selected among individuals eligible for the global annual government-funded geriatric health check-up program. The cost of audiometric testing was covered by the research grant that supported this study, and thus, no out-of-pocket expenses were paid by the study participants. As a result, the prevalence of hearing loss was not confounded by socioeconomic factors. The use of standard audiometry equipment in a sound-treated room also reduced the potential measurement errors caused by ambient noise.Nonetheless, the study also has several limitations that need to be addressed. The participants of this study voluntarily agreed to join the annual health check-up program. Selection bias may be present, and the results of our study may not be generalizable to less healthy or hospitalized populations.In this study, the diagnostic reliability and validity of the TC-HHIE-S for identifying individuals with age-related hearing loss were proven to be acceptable. We believe that the TC-HHIE-S is an effective and cost-effective tool for large-scale hearing screenings among older adults. Additional clinic-epidemiological studies of the administration of the TC-HHIE-S via webpages or smartphone apps are thus imperative.