Electroconvulsive Therapy in Cochlear Implant Users.

To evaluate the listening conditions of bilateral cochlear implant (CI) users in their daily living environment. Retrospective study. University hospital. Thirty-one adult CI users 16 years or older; 18 underwent sequential surgery, and 13 underwent simultaneous surgery. Inclusion criteria included the availability of CI data logging features and a minimum duration of binaural use of 6 months. Retrospective analysis of data obtained from the automatic scene classifier data logging system. Comparison of data logging and maximum speech discrimination scores of the two surgery groups (sequential vs. simultaneous) to investigate the potential influence of these factors on the listening conditions of CI users. The maximum speech discrimination score of the second CI in the sequential group was significantly worse than that of any other CI in the sequential and simultaneous CI groups. Additionally, the longer the interval between surgeries, the more significant the difference in "time on air" between the first and the second CIs. The second CI in sequential CI surgery had a shorter "time on air" than the first or the bilateral simultaneous CIs; the second CI was also used more frequently in noisy and speech with background noise environments. A second CI may be more frequently used in challenging listening environments because of its binaural auditory effect, despite its lower speech discrimination performance. The timing of sequential implantation and the potential impact of binaural hearing should be considered when developing rehabilitation strategies for individuals with bilateral CIs.

This study aimed to characterize horizontal plane sound localization in interfering noise at different signal-to-noise ratios (SNRs) and to compare performance across normal-hearing listeners and users of unilateral and bilateral cochlear implants (CIs). CI users report difficulties with listening in noisy environments. Although their difficulties with speech understanding have been investigated in several studies, the ability to localize sounds in background noise has not extensively been examined, despite the benefits of binaural hearing being greatest in noisy situations. Sound localization is a measure of binaural processing and is thus well suited to assessing the benefit of bilateral implantation. The results will inform clinicians and implant manufacturers how to focus their efforts to improve localization with CIs in noisy situations. Six normal-hearing listeners, four unilateral, and 10 bilateral CI users indicated the perceived location of sound sources using a light pointer method. Target sounds were noise pulses played from one of 11 loudspeakers placed between -80 and +80 degrees in the frontal horizontal plane in the free field. Localization was assessed in quiet and in diffuse background noise at SNRs between +10 and -7 dB. Speech reception thresholds were measured and their relation to the localization results examined. Localization performance declined with decreasing SNR: target sounds were perceived closer to the median plane and the standard deviation of responses increased. Localization performance across groups was compared using a measure of "Spatial Resolvability" (SR). This measure gives the angular separation between two sound sources that would enable an ideal observer to correctly distinguish them 69.1% of the time. For all participants SR increased with decreasing SNR, that is, at low SNRs the spatial separation between sound sources remained distinguishable only when it was larger. Normal-hearing participants performed best, with SR between 1.4 and 5.1 degrees in quiet. Bilateral CI users showed SR between 8.3 and 43.6 degrees in quiet, corresponding approximately to the spatial resolution of normal-hearing listeners at an SNR of -5 dB. Most bilateral CI users had lost the ability to correctly determine which side the sound came from at an SNR of -3 dB. Overall, the SNR had to be at least +7 dB to achieve localization performance near to that in quiet for all bilateral CI users. No significant correlation was found between spatial resolution and speech reception thresholds, but the speech processor sensitivity setting did significantly affect performance. Unilateral CI users showed the most severe localization problems, with only two of four participants being able to correctly determine which side sounds came from in quiet. This study is the first to examine sound localization with CIs at various SNRs and to compare it with normal hearing. The results confirm that localization with CIs is strongly disrupted in noisy situations. Bilateral CIs were shown to be clearly superior over unilateral CIs for localization in quiet and in noisy situations. With bilateral CIs, localization declined at moderately high absolute noise levels (>63 dB SPL), suggesting that an extension of the acoustic-dynamic range to higher levels would be beneficial. The absence of a relation between speech reception thresholds and spatial resolution highlights the need for additional clinical tests to assess the binaural benefit of a second implant.

Music plays an important role in the daily life of cochlear implant (CI) users, but electrical hearing and speech processing pose challenges for enjoying music. Studies of unilateral CI (UCI) users’ music perception have found that these subjects have little difficulty recognizing tempo and rhythm but great difficulty with pitch, interval and melody. The present study is an initial step towards understanding music perception in bilateral CI (BCI) users. The Munich Music Questionnaire was used to investigate music listening habits and enjoyment in 23 BCI users compared to 2 control groups: 23 UCI users and 23 normal-hearing (NH) listeners. Bilateral users appeared to have a number of advantages over unilateral users, though their enjoyment of music did not reach the level of NH listeners.

School closures and other COVID-19-related restrictions could decrease children's exposure to speech during important stages of development. To assess whether significant decreases in exposure to spoken communication found during the initial phase of the COVID-19 pandemic among children using cochlear implants are confirmed for a larger cohort of children and were sustained over the first years of the COVID-19 pandemic. This cohort study used datalogs collected from children with cochlear implants during clinical visits to a tertiary pediatric hospital in Toronto, Ontario, Canada, from January 1, 2018, to November 11, 2021. Children with severe to profound hearing loss using cochlear implants were studied because their devices monitored and cataloged levels and types of sounds during hourly use per day (datalogs) and because their hearing and spoken language development was particularly vulnerable to reduced sound exposure. Statistical analyses were conducted between January 2022 and August 2023. Daily hours of sound were captured by the cochlear implant datalogging system and categorized into 6 auditory scene categories, including speech and speech-in-noise. Time exposed to speech was calculated as the sum of daily hours in speech and daily hours in speech-in-noise. Residual hearing in the ear without an implant of children with unilateral cochlear implants was measured by pure tone audiometry. Mixed-model regression analyses revealed main effects with post hoc adjustment of 95% CIs using the Satterthwaite method. Datalogs (n = 2746) from 262 children (137 with simultaneous bilateral cochlear implants [74 boys (54.0%); mean (SD) age, 5.8 (3.5 years)], 38 with sequential bilateral cochlear implants [24 boys (63.2%); mean (SD) age, 9.1 (4.2) years], and 87 with unilateral cochlear implants [40 boys (46.0%); mean (SD) age, 7.9 (4.6) years]) who were preschool aged (n = 103) and school aged (n = 159) before the COVID-19 pandemic were included in analyses. There was a slight increase in use among preschool-aged bilateral cochlear implant users through the pandemic (early pandemic, 1.4 h/d [95% CI, 0.3-2.5 h/d]; late pandemic, 2.3 h/d [95% CI, 0.6-4.0 h/d]) and little change in use among school-aged bilateral cochlear implant users (early pandemic, -0.6 h/d [95% CI, -1.1 to -0.05 h/d]; late pandemic, -0.3 h/d [95% CI, -0.9 to 0.4 h/d]). However, use decreased during the late pandemic period among school-aged children with unilateral cochlear implants (-1.8 h/d [95% CI,-3.0 to -0.6 h/d]), particularly among children with good residual hearing in the ear without an implant. Prior to the pandemic, children were exposed to speech for approximately 50% of the time they used their cochlear implants (preschool-aged children: bilateral cochlear implants, 46.6% [95% CI, 46.5%-47.2%] and unilateral cochlear implants, 52.1% [95% CI, 50.7%-53.5%]; school-aged children: bilateral cochlear implants, 47.6% [95% CI, 46.8%-48.4%] and unilateral cochlear implants, 51.0% [95% CI, 49.4%-52.6%]). School-aged children in both groups experienced significantly decreased speech exposure in the early pandemic period (bilateral cochlear implants, -12.1% [-14.6% to -9.4%]; unilateral cochlear implants, -15.5% [-20.4% to -10.7%]) and late pandemic periods (bilateral cochlear implants, -5.3% [-8.0% to -2.6%]; unilateral cochlear implants, -11.2% [-15.3% to -7.1%]) compared with the prepandemic baseline. This cohort study using datalogs from children using cochlear implants suggests that a sustained reduction in children's access to spoken communication was found during more than 2 years of COVID-19 pandemic-related lockdowns and school closures.

Electroconvulsive Therapy and Cochlear Implantation

Objectives To perform a systematic literature review (SLR) on hearing and quality-of-life (QoL) benefits of bilateral versus unilateral cochlear implants (CIs) in adults with sensorineural hearing loss (SNHL), and to quantify benefits through a meta-analysis when feasible. Methods Embase, MEDLINE, and Cochrane were searched from January 2005–June 2022. Eligible studies presented effectiveness of CIs and/or QoL of adult CI users. Articles that presented numerical point estimates for, or numerical difference between, bilateral and unilateral CI, and measures of uncertainty were considered for meta-analysis, with data analyzed using fixed- and random-effects models. Results Thirty-five articles were included. There was a trend of significant improvement with bilateral CIs in sound localization and binaural redundancy. A meta-analysis confirmed statistically significant benefits in speech perception (in quiet, 12.6 percentage point [95% confidence interval: 7.1, 18.1] improvement; in noise, improvement in speech reception threshold of 1.5 dB signal-to-noise ratio [–1.5 dB; 95% confidence interval: −2.5, −0.4]). There were beneficial trends of bilateral CIs regarding head-shadow effect and binaural release from masking. Significant improvements in hearing-specific QoL were observed; generic QoL was mostly unchanged. Discussion Bilateral CIs provide audiological benefit over unilateral CI, resulting in hearing-specific QoL improvements. Lack of changes in generic QoL may reflect that instrument domains are insensitive to hearing-related changes when going from unilateral to bilateral CIs. Meta-analyses could not be performed for all hearing and QoL outcomes owing to variability in methodologies across studies. Conclusions These findings should be used to inform clinical decision-making to ensure the best outcomes for adults with bilateral SNHL.

The aim of our study is to compare the outcomes in unilateral and bilateral cochlear implants in pediatric age and also between simultaneous and sequential cochlear implant surgery. This retrospective study was carried out with 83 children aged between 12months to 2.5years which included 41 children with bilateral Cochlear implants and 42 with unilateral implants. Out of these 41 children, 21 were simultaneous and 20 were sequential cochlear implant. All the children were operated at civil hospital Gandhinagar, Gujarat, India. CAP, SIR, localization, traffic noise and speech in noise scores were assessed at regular intervals over the period of 4years. Also the drug administration time, surgical time, operating room time were assessed for simultaneous and sequential cochlear implant surgery. Children with bilateral simultaneous implants fared significantly better with CAP, SIR, localization, speech noise and traffic noise scores than sequential bilateral implants and unilateral implants with a significant difference of means t tests between the two groups. Simultaneous cochlear implant surgery is associated with reduced surgical time, operating room time, it shortens the total in patient stay. There is less of drug administration and bilateral ones are stimulated simultaneously. Bilateral cochlear implants perform better with respect to auditory perception skills and spontaneous speech when compared with unilateral implants, but simultaneous surgery is better and safe option for pediatric cochlear implantation.

Byline: B. Gangadhar In the recently introduced Mental Health Care bill, electroconvulsive therapy (ECT) practice figures with a caution. The bill allows the use of ECT only under anesthesia (modification). In other words, if the bill is passed and implemented, the unmodified (direct) ECT cannot be practiced. Concerns have been raised by some well-meaning psychiatrist colleagues. The cost of ECT would increase, thus taxing the poor patients. Anesthesiologists to provide modification are fewer. In emergency ECT situations, depending on anesthesiologists would pose challenges in that crucial eleventh hour. The position in the bill and the arguments for or against the unmodified ECT are examples of the issues to be faced by psychiatrists in the days to come. How are we prepared? In its first move, the Indian Psychiatric Society produced the position paper on unmodified ECT. [sup][1] It did endorse the benefits of modification in ECT and also conceded that such a procedure should be the contemporary standard. At the same time, the group recorded the concerns of denying ECT on the grounds of unavailability of resources to support modification. The position of the society is to allow use of unmodified ECT only in exceptional circumstances. Unmodified ECT has been a matter of concern and debate since many years. As early as in 1980, Lancet published several views for and against following a report of use of unmodified ECT in Broadmoor (UK). Arguing for unmodified ECT, Crammer [sup][2] also stated that some patients actually preferred ECT without injections (unmodified). Another supporter of this procedure stated that withholding ECT when modification is not possible amounts to unethical practice. Situations of failing to get a vein for intravenous injections (repeated injections in previous ECT sessions can result in such a difficulty) is one such circumstance when unmodified ECT may be the option. [sup][3] On the other hand, nearly 40 other psychiatrists wrote against unmodified ECT, terming it as anachronistic and indefensible. [sup][4] They also opined that unavailability of anesthesiologist does not condone use of unmodified ECT. It may be noted that some psychiatry textbooks from the West have altogether dropped information on unmodified ECT in their recent editions. There is no doubt that modified ECT should remain the current standard of ECT practice. In reality, however, unmodified ECT is in vogue in many parts of the world, [sup][5] China, [sup][6] Pakistan, [sup][7] and India. [sup][8] Together, this would account for the largest ECT population in the world. In our country itself, a recent survey indicated that over 50% of ECTs are unmodified. [sup][9] Clearly, the bill would affect the majority in this regard. This majority would, therefore, not get the benefits of ECT as unmodified ECT would be disallowed. Even if supported by the position adopted by the Indian Psychiatric Society, most, barring the exceptional ones, would be denied ECT. Psychiatrists may also be tempted to adopt different definitions of this exceptional indication. For example, a social reason was an urgent indication for ECT. [sup][10] It is true that earlier users of unmodified ECT had recognized adverse events such as fractures and even rupture of bladder, [sup][11] apart from others, that discouraged them from using unmodified ECT. In this context, Indian reports have reassured, though not convincingly, that unmodified ECT is not as unsafe as has been projected. [sup][12],[13] Benzodiazepine as a muscle relaxant has been suggested as an alternative to modification. [sup][14],[15] It is arguable, however, as an anticonvulsant this drug may interfere with seizure induction. Suggestions have also been advanced if psychiatrists can be trained in ECT-related anesthesia procedures. [sup][16] This issue surely deserves consideration for debate and consensus. In this background, we need to be also alert to the concerns of patients and their kin. …

Background: The COVID-19 pandemic rapidly spread through Europe in the first months of 2020. On the 9th of March 2020, the Italian government ordered a national lock-down. The study’s objectives were: to investigate the effect of lockdown on CI users; and to detect the difference in the perception of discomfort existing between unilateral cochlear implant (UCI) users and bilateral cochlear implant (BCI) users, due to the lockdown experience. Methods: A 17-item, web-based, anonymous online survey was administered to 57 CI users, exploring hearing performance, emotions, practical issues, behavior, and tinnitus. Participation in the study was voluntary. Results: all CI users obtained an abnormal score in all questionnaire themes. For the emotion theme and the practical issue theme, the age range 61–90 showed a significant difference between UCI and BCI users in favor of BCI users (emotion theme: UCI mean = 3.9, BCI mean = 2.3, p = 0.0138; practical issues: UCI mean = 4, BCI mean = 3, p = 0.0031). Conclusions: CI users experienced the lockdown negatively as regards behavior, emotions, hearing performance, and in practical issues. CI subjects with UCI in old age suffered more from the experience of lockdown than subjects with BCI in the same age, with regards to emotions and practical issues.

Factors affecting binaural fusion in cochlear implant users.

This study aimed to investigate whether unilateral cochlear implant (CI) users benefit from the addition of a contralateral microphone (CI-CROS) for spatial speech recognition. Tertiary referral otology and cochlear implant center. The digits-in-noise test was used to measure speech in noise recognition abilities. Evaluations were made in 3 conditions: speech and noise presented from the front of the listener (S0N0) and with spatial separation of speech and noise (S90N-90 and S-90N90). The performance of CI patients using CI-CROS was compared with their unilateral CI condition (n = 10), normal-hearing subjects (n = 12), and bilateral CI users (n = 5). The presence and extent of several binaural phenomena (binaural summation, binaural squelch, and the better-ear effect) were evaluated. CI-CROS only provided a benefit in the listening situation wherein speech originates from the side of the CROS microphone; however, this benefit was repealed by disadvantages in other listening conditions. With CI-CROS, the hearing of patient is essentially monaural, albeit with bilateral input; therefore, patients were not able to benefit from the same binaural advantages as normal-hearing subjects and bilateral CI users. Moreover, patients using CI-CROS lost the ability to choose the optimal listening condition to perform as well as unilateral CI users. We conclude that CI-CROS is not advisable for unilateral CI users. Bilateral cochlear implantation would be a better alternative for the rehabilitation of patients with unaidable hearing on the contralateral side.

ELECTROCONVULSIVE THERAPY (ECT) IS ONE OF THE most controversial treatments in all of medicine. There are a number of reasons for this. The discovery in the 1930s that inducing a series of generalized seizures, initially with chemicals, later with electric current, could cause the recovery of patients with severe and previously untreatable mental disorders produced a wave of enthusiasm that eventually led to a period of indiscriminate use and misuse in the middle decades of the 20th century. This period of abuse created, perhaps deservedly at that time, a bad reputation for an effective treatment modality. That reputation was enhanced by the immediate adverse effects of bitten tongues and even fractured bones and teeth caused by the induction of generalized seizures, and the painful effects of electroshocks administered without anesthesia when they did not successfully induce a seizure with loss of consciousness. The 1975 movie One Flew Over the Cuckoo’s Nest contributed to an erroneous view of ECT as a punitive, painful, and assaultive procedure used by authorities to control inconvenient creativity. That view has been associated with attempts to regulate, or even eliminate, the use of ECT through legislation in a number of jurisdictions, and public fears and distrust about the use of ECT have persisted. The best response to such concerns on the part of physicians is to be aware of the facts about current use of ECT, including its efficacy and possible adverse effects, so they can respond to questions from patients, families, and the public. The indications, possible adverse effects, and current recommendations for treatment procedures have been summarized in a task force report just published by the American Psychiatric Association Committee on Electroconvulsive Therapy. An effective and safe treatment for severe major depression, ECT has had response rates reported in the range of 80% to 90% as a first-line treatment, and in the range of 50% to 60% for patients who have not responded to 1 or more trials of treatment with antidepressant drugs. Electroconvulsive therapy may also be seriously considered as treatment for patients with acute mania, and for patients with schizophrenia who have not responded to adequate trials of antipsychotic medications. As currently practiced, ECT involves the use of informed consent, ultra-brief general anesthesia and muscle relaxants (thus attenuating motor seizure activity) with appropriate airway management, and use of ECT devices to provide adequate ictal responses. Most patients in the United States receive 3 treatments per week, and a course of ECT for major depression generally consists of 6 to 12 treatments, with the course ended or tapered as soon as maximum response has been reached. This usually occurs more quickly than the 4 to 6 weeks required for an adequate trial of an antidepressant drug. There continues to be some controversy about the use of right unilateral or bilateral electrode placement, with right unilateral ECT causing less cognitive adverse effects, but bilateral ECT often viewed as being more effective. A recent randomized controlled trial showed that right unilateral ECT at high dosage was as effective as bilateral ECT in many patients and caused less impairment on several measures of anterograde and retrograde memory. The issue of cognitive adverse effects from ECT is central to its reputation for harm and requires careful consideration to separate facts from myths. Studies of this issue have been reviewed and summarized by the American Psychiatric Association Committee on Electroconvulsive Therapy. Patients experience a variable but usually brief period of disorientation (postictal confusion) immediately after seizure induction. Electroconvulsive therapy also typically results in retrograde amnesia, greatest immediately after the course of treatment and for events that occurred temporally close to the treatment. The extent of the retrograde amnesia usually decreases substantially with time, but many patients have persistent loss of memory for some events that occurred in the interval starting several months before and extending to several weeks after their ECT course. Anterograde amnesia, characterized by rapid forgetting of learned information, also may occur during and immediately following ECT but resolves within a few weeks. Importantly, there is no objective evidence that ECT has any long-term effect on the capacity to learn and retain new information. Assessment of cognitive effects from ECT is complicated by the cognitive impairments associated with the mental disorders being treated. For example, patients with severe depression may have substantial impairments in cognitive function, and patients with schizophrenia or other psychotic

Bilateral cochlear implants (BI-CIs) or a CI for single-sided deafness (SSD-CI; one normally functioning acoustic ear) can partially restore spatial-hearing abilities, including sound localization and speech understanding in noise. For these populations, however, interaural place-of-stimulation mismatch can occur and thus diminish binaural sensitivity that relies on interaurally frequency-matched neurons. This study examined whether plasticity-reorganization of central neural pathways over time-can compensate for peripheral interaural place mismatch. We hypothesized differential plasticity across two systems: none for binaural processing but adaptation for pitch perception toward frequencies delivered by the specific electrodes. Interaural place mismatch was evaluated in 19 BI-CI and 23 SSD-CI human subjects (both sexes) using binaural processing (interaural-time-difference discrimination with simultaneous bilateral stimulation), pitch perception (pitch ranking for single electrodes or acoustic tones with sequential bilateral stimulation), and physical electrode-location estimates from computed-tomography (CT) scans. On average, CT scans revealed relatively little BI-CI interaural place mismatch (26° insertion-angle mismatch) but a relatively large SSD-CI mismatch, particularly at low frequencies (166° for an electrode tuned to 300 Hz, decreasing to 14° at 7000 Hz). For BI-CI subjects, the three metrics were in agreement because there was little mismatch. For SSD-CI subjects, binaural and CT measurements were in agreement, suggesting little binaural-system plasticity induced by mismatch. The pitch measurements disagreed with binaural and CT measurements, suggesting place-pitch plasticity or a procedural bias. These results suggest that reducing interaural place mismatch and potentially improving binaural processing by reprogramming the CI frequency allocation would be better done using CT-scan than pitch information.SIGNIFICANCE STATEMENT Electrode-array placement for cochlear implants (bionic prostheses that partially restore hearing) does not explicitly align neural representations of frequency information. The resulting interaural place-of-stimulation mismatch can diminish spatial-hearing abilities. In this study, adults with two cochlear implants showed reasonable interaural alignment, whereas those with one cochlear implant but normal hearing in the other ear often showed mismatch. In cases of mismatch, binaural sensitivity was best when the same cochlear locations were stimulated in both ears, suggesting that binaural brainstem pathways do not experience plasticity to compensate for mismatch. In contrast, interaurally pitch-matched electrodes deviated from cochlear-location estimates and did not optimize binaural sensitivity. Clinical correction of interaural place mismatch using binaural or computed-tomography (but not pitch) information may improve spatial-hearing benefits.

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The aim of the study was to develop a Markov model and apply it for the evaluation of three different treatment scenarios for adult patients with severe to profound bilateral sensorineural hearing loss. Prospective Observational Study. Hospital. A clinical group of 22 adult patients (59.1% men, 40.9% women) aged from 59.13 ± 8.9 years were included in the study. The study comprised two arms: patients in group 1 received the second cochlear implant one to three months after the first implant; while patients in group 2 got the second cochlear implant approximately one year after the first implant. All participants were first asked to complete an AQoL-8D questionnaire. For the cost-effectiveness analyses, a Markov model analyzed as microsimulation was developed to compare the different treatment options. The analyses show that bilateral cochlear implantation strategies are cost-effective compared to the 'no treatment' alternative when having a 10-year model time horizon. When all three model scenarios are compared, the bilateral simultaneous cochlear implantation strategy (Scenario 3) compared to the 'no treatment' option is even more cost-effective than the Scenarios 1 and 2, compared with the 'no treatment' alternative. The model results summarize that bilateral (sequential and simultaneous) cochlear implantation that are represented in the model scenarios, are cost-effective strategies for Polish adult patients with bilateral severe to profound sensorineural hearing loss.