Choosing which ear to implant in adult candidates with functional residual hearing

This study examined whether audiologists consider the potential benefits of contralateral hearing aid use following cochlear implantation when recommending which ear to implant in UK adult candidates with residual hearing. Thirty-four audiologists from providers of adult implantation services completed a decision-choice experiment. Clinicians were willing to consider recommending that the poorer ear be implanted, provided it had been aided continuously, suggesting that their decision making seeks to preserve access to residual hearing in the non-implanted ear where possible. Future approaches to determining candidacy should therefore consider that a sub-set of patients may obtain additional benefit from this residual hearing following implantation

The Cost-Effectiveness of Bimodal Stimulation Compared to Unilateral and Bilateral Cochlear Implant Use in Adults with Bilateral Severe to Profound Deafness

Objectives: An increasing number of severe-profoundly deaf adult unilateral cochlear implant (CI) users receive bimodal stimulation; that is, they use a conventional acoustic hearing aid (HA) in their non-implanted ear. The combination of electric and contralateral acoustic hearing provides additional benefits to hearing and also to general health-related quality of life compared to unilateral CI use. Bilateral CI is a treatment alternative to both unilateral CI and bimodal stimulation in some healthcare systems. The objective of this study was to conduct an economic evaluation of bimodal stimulation compared to other management options for adults with bilateral severe to profound deafness.Design: The economic evaluation took the form of a cost-utility analysis and compared bimodal stimulation (CI+HA) to two treatment alternatives: unilateral and bilateral CI. The analysis used a public healthcare system perspective based on data from the United Kingdom (UK) and the United States (US). Costs and health benefits were identified for both alternatives and estimated across a patient’s lifetime using Markov state transition models. Utilities were based on Health Utilities Index (HUI3) estimates and health outcomes were expressed in Quality Adjusted Life Years (QALYs). The results were presented using the Incremental Cost-Effectiveness Ratio (ICER) and the Net Monetary Benefit approach to determine the cost-effectiveness of bimodal stimulation. Probabilistic sensitivity analyses explored the degree of overall uncertainty using Monte Carlo simulation. Deterministic sensitivity analyses and Analysis of Covariance identified parameters to which the model was most sensitive; i.e. whose values had a strong influence on the intervention that was determined to be most cost-effective. A Value Of Information analysis was performed to determine the potential value to be gained from additional research on bimodal stimulation.Results: The base case model showed that bimodal stimulation was the most cost-effective treatment option with a decision certainty of 72% and 67% in the UK and US, respectively. Despite producing more QALYs than either unilateral CI or bimodal stimulation, bilateral CI was found not to be cost-effective because it was associated with excessive costs. Compared to unilateral CI, the increased costs of bimodal stimulation were outweighed by the gain in quality of life. Bimodal stimulation was found to cost an extra £174 per person in the UK ($937 in the US) and yielded an additional 0.114 QALYs compared to unilateral CI, resulting in an ICER of £1,521 per QALY gained in the UK ($8,192/QALY in the US). The most influential variable was the utility gained from the simultaneous use of both devices (CI+HA) compared to Unilateral CI. The value of further research was £4,383,922 at £20,000/QALY ($86,955,460 at$50,000/QALY in the US).Conclusions: This study provides evidence of the most cost-effective treatment alternative for adults with bilateral severe to profound deafness from publicly-funded healthcare perspectives of the UK and US. Bimodal stimulation was found to be more cost-effective than unilateral and bilateral CI across a wide range of willingness-to-pay thresholds. If there is scope for future research, conducting interventional designs to obtain utilities for bimodal stimulation compared to unilateral CI would reduce decision uncertainty considerably

Contralateral acoustic hearing aid use in adult unilateral cochlear implant recipients: current provision, practice, and clinical experience in the UK

Objectives: The study surveyed practising cochlear implant audiologists with the aim of: (1) characterising UK clinical practice around the management and fitting of a contralateral hearing aid in adult unilateral cochlear implant users (‘bimodal aiding’); (2) identifying factors that may limit the provision of bimodal aiding; and (3) ascertaining the views of audiologists on bimodal aiding. Methods: An online survey was distributed to audiologists working at the 20 centres providing implantation services to adults in the UK. Results: Responses were received from 19 of the 20 centres. The majority of centres reported evaluating hearing aids as part of the candidacy assessment for cochlear implantation. However, a majority also indicated that they do not take responsibility for the contralateral hearing aid following implantation, despite identifying few practical limiting factors. Bimodal aiding was viewed as more beneficial than wearing the implant alone, with most respondents actively encouraging bimodal listening where possible. Respondents reported that fitting bimodal devices to take account of each other’s settings was potentially more beneficial than independently-fit devices, but such sympathetic fitting was not routine practice in any centre. Discussion: The results highlight some potential inconsistencies in the provision of bimodal aiding across the UK as reported by practising audiologists. The views of audiologists about what is best practice appear to be at odds with the nature and structure of the services currently offered. Conclusion: Stronger evidence that bimodal aiding can be beneficial for UK patients would be required in order for service providers to justify the routine provision of bimodal aiding and to inform guidelines to shape routine clinical practice

Access to aidable residual hearing in adult candidates for cochlear implantation in the UK

Guidance from the National Institute for Health and Care Excellence (NICE) permits candidates to receive a cochlear implant provided they only hear sounds louder than 90 dB HL at 2 and 4 kHz. In some patients, their level of residual hearing may be sufficient to warrant the use of a hearing aid in their non-implanted ear. A survey of unilaterally-implanted adults indicated that those implanted since the publication of NICE guidance were almost seven times more likely to use a hearing aid than those implanted prior to this. If contralateral hearing aid use provides additional benefits over implant use alone, it may be appropriate to consider the capacity to use residual hearing following implantation when determining candidacy

Effects of Tinnitus on Cochlear Implant Programming

Clinical observations suggest that tinnitus may interfere with programming cochlear implants (CIs), the process of optimizing the transmission of acoustic information to support speech perception with a CI. Despite tinnitus being highly prevalent among CI users, its effects and impact on CI programming are obscure. This study characterized the nature, time-course, and impact of tinnitus effects encountered by audiologists and patients during programming appointments. Semistructured interviews with six CI audiologists were analyzed thematically to identify tinnitus effects on programming and related coping strategies. Cross-sectional surveys with 67 adult CI patients with tinnitus and 20 CI audiologists in the United Kingdom examined the prevalence and time-course of those effects. Programming parameters established at CI activation appointments of 10 patients with tinnitus were compared with those of 10 patients without tinnitus. On average, 80% of audiologists and 45% of patients reported that tinnitus makes measurements of threshold (T) levels more difficult because patients confuse their tinnitus with CI stimulation. Difficulties appeared most common at CI activation appointments, at which T levels were significantly higher in patients with tinnitus. On average, 26% of patients reported being afraid of “loud” CI stimulation worsening tinnitus, affecting measurements of loudest comfortable (C) stimulation levels, and 34% of audiologists reported observing similar effects. Patients and audiologists reported that tinnitus makes programming appointments more difficult and tiresome for patients. The findings suggest that specific programming strategies may be needed during CI programming with tinnitus, but further research is required to assess the potential impact on outcomes including speech perception

Refugees : The Millenium Development Goals' overlooked priority group

The Millennium Development Goals (MDGs) apply to the world’s 43 million refugees and forcibly displaced. While States have an obligation to meet minimum human rights levels for all persons including 'non-citizens', UNHCR must ensure countries adopting MDG targets report on the progress of their refugee populations. If we are to make significant change within the MDG time-frame, the health and human rights needs of refugees and the displaced must be urgently integrated into the development policy agendas of sovereign States, and be at the fore of the international community’s attention

Chiral Hexanuclear Ferric Wheels

The homochiral iron(III) wheels [Fe(6){(S)-pedea}(6)Cl(6)] and [Fe(6){(R)-pedea)}(6)Cl(6)] [(R)- and (S)-2; pedea = phenylethylaminodiethoxide] exhibit high optical activities and antiferromagnetic exchange. These homochiral products react with each other, producing the centrosymmetric, crystallographically characterized [Fe(6){(S)-pedea}(3){(R)-pedea}(3)Cl(6)] diastereomer [(RSRSRS)-2]. (1)H NMR and UV-vis studies indicate that exchange processes are slow in both homo- and heterochiral systems but that, upon combination, the reaction between (R)- and (S)-2 occurs quickly