 don't know me. And I'm the president of the Hearing Loss Association of America, the Diablo Valley chapter, which is in Walnut Creek, California. Before we start, we'd like to ask that everybody who's from a different state than California, rename yourself. And after your name, just go ahead and put what state you're from. And so if you don't know how to rename yourself, if you drag your cursor over your thumbnail in the upper right hand corner, a little, I think it's lines come up, just click on that and it says rename, and you can add your state. So I'll give everybody a few minutes to take care of that. And while you're doing that, I'm going to let you know that prior to our presentation about cochlear implants today from Kurt Kramer, we give directions on how to use Zoom. So video conferencing has been, in my opinion, the best things in sliced bread for all of us with hearing loss. We're able to read everybody's lips. We have captions. We can see the captions for what we're missing. And so we want to make sure that everybody gets up to speed on how to use Zoom. Some of us are old pros by this point, but others are just really kind of getting into the swing of things. And Zoom also keeps changing its functions, adding new things and removing them. So I'm going to go ahead and start sharing my screen. Oh, excuse me, before I do that, we have board members here who work behind the scenes on all of our meetings to ensure that they run smoothly. And I'd like to acknowledge them. So, Zoher Chiba, I saw that you joined us. And Zoher is our vice president. Can you just say hello? Sorry, I was on mute. Hello. Hi there. Welcome. Thanks, Zoher. Alan Kutzer is our secretary. Alan, can you say, and tech guy behind the scenes all around my right hand person? Good morning, everyone. And as well here, I know I haven't seen him. Okay, so our treasurer isn't here, so I can't introduce him. So now I'm going to go ahead and start our directions for Zoom. So before Kurt goes ahead and gets started, is everybody have their captions turned on? And is everybody able to hear and comfortable? Because this is really a very important presentation for all of us who are here. So everybody's good. Okay, before I introduce Kurt, I'd like to let everybody know that I'm a UCSF patient. I have two cochlear implant, do a very successful cochlear implants that I had done at UCSF. And there are two CI audiologists. Kurt doesn't happen to be my audiologist, but I am acquainted with him. So, Kurt, I'm going to go ahead and turn this over to you. And do you want to share a presentation or did you want to just talk? I have a presentation to share. I will go through it mostly, but, you know, if we questions get off the presentation, we can answer the question. So feel free to answer questions whenever. So, Kurt, we need to go ahead and make you a co-host so you can share. Okay, you can go ahead and share your screen. And could you share your video so that we can lip read you? Yes. Thank you. Can you hear me okay? Oh, I can hear you fine. Okay, all right. And you don't see me yet? No, I don't see you. Oh, let's see here. Ah, there we go. You're coming down. Thank you. Hello, everyone. Good morning and thank you for having me to your meeting. I see some familiar faces. I see a few people that are a little overdue to come see me as well. Donna and Susan for sure. Thank you for the introduction. And let me pull up my screen here. There's this. All right. Can everyone see my screen? Yes. Okay. So once again, my name is Kurt Kramer. I work at UCSF cochlear implant center in San Francisco. I've been at UCSF for about 13 years. On out of those 13 years, I've been doing cochlear implants solely full time for the 12 years. And like Ann said, I do know her. She's come with a couple of our recipients in the past. And then more recently, she got implanted herself. And today I'm just going to talk to you about hearing loss, audiology and the treatment for it. And like I said, I'm going to go through the slide. I'm not committed to it. So if you have questions, just feel free to ask. Okay. Okay. Here we go. Sorry. I'm a little rusty with PowerPoint. Okay. So let's talk about hearing loss. As you know, I, you know, there's a large group here in the meeting and about 15% of the American population over 18 has some difficulty with hearing. And then as people age, the hearing loss becomes a little bit more disabling. And you can see here about 2% of adults between before you go on. Can I ask you to start the slide show? So we only see the slides you're talking about? If you hit the F five key, it should go to slide show. Yeah, it's not working. See in your menu bar, it says slide show. So file home insert draw design transition animation slide show. I don't see that. It's so bizarre. Are you showing yours full screen? Yeah. Okay, so take it out of full screen. Start the slide show and then come back. So quit sharing. Put it in a show slide show, then share it. There we go. I apologize for this. There you go. All right. Are we back in business? Yeah. And on your side, Kurt, I think you should see in the bottom left hand corner, you can advance the slides there or just use your arrows or mouse or your glide path. I've never seen it do this before. Okay. So when you share that screen, sometimes you need to click on the screen to make sure it knows the screen is active. See now we're into the sorter or out of the slide show. There we go. Perfect. Okay. Thank you for that. Sorry about the technical difficulties. So as I was saying, as people get older, there's this more and more disabling hearing loss, which it can be costly on many levels, opportunity cost, psychological cost of this, and it's something that really needs to be addressed. And to be honest with you, in my last decade plus of working with hearing aids and cochlear implants especially, it's been really great to see how much more people do know about cochlear implants coming into the clinic. When I first was starting out in this, a lot of my recipients or candidates would come in, not even knowing that it required a surgery. So it can be, as these coming to these meetings and these hearing loss groups, it's just been really nice. The recipients and candidates are coming to the clinic with more knowledge based on certain treatments, hearing aids, and when to get out of hearing aids and start looking into the cochlear implant space. So I want to talk about types of hearing loss first. I'm going to kind of just breeze through this because two of them don't really apply to the cochlear implant scene, but there's one type of hearing loss is conductive hearing loss. And then the most common one, and what we're going to be focusing on today is the sensory neural hearing loss. And then lastly, there's a combination of both of them. Sometimes you can have a problem getting the sound to the cochlea and then a problem with the cochlea itself, which causes a mixed hearing loss between the two. And there's different treatments for all of these kinds of hearing losses. So a conductive hearing loss is when the problem is conducting the sound waves anywhere through the route of the ear from the pinna all the way through the eardrum and the middle ear bones, which are called the ossicles. And the most common causes of conductive hearing loss is earwax impaction, where the ear canals get full of wax and can actually become solid and block any sound from passing through. Another one, especially in children, is middle ear infections. And then people who have these middle ear infections with fluid and that are chronic over time, a lot of those ears can then develop what is called the Cholestia Toma, which is like a benign mass or tumor in the ear that is behind the eardrum and it can erode the middle ear bones. Then you got sensory neural hearing loss. And that is more of what a permanent hearing loss. And that is the cause of the hearing losses somewhere in the cochlea in the inner ear or in the cochlear nerve. And sometimes it's hard to tell exactly where that hearing loss is. So that's why it's called sensory neural, sensory being the cochlea, neural being the nerve. And so there's certain hearing losses that we can kind of tell where they are located and where the pathology is, but a lot of times we don't really know. And as you can see, sensory neural hearing loss accounts for about 90% of all that hearing loss that I talked about earlier. And then you have some common causes of the hearing losses, genetics, familial trends. I see some people who they start losing their hearing in their 20s and 30s. And then they get their hearing aids and cochlear implants. And as their kids age around the same time in the 20s, they start having hearing loss too. And another one that you guys are all probably familiar with is Maneers. And then something a little bit more severe is the acoustic neuroma, which is actually another benign tumor, but instead of in the middle ear space, like a Colestia Toma, it occurs on the auditory nerve coming out of the, from the cochlea. And then the most common kind of hearing loss is related to aging, and that's called the Presbycusis. And then lastly, ototoxic drugs. So some drugs that people need for treatments of cancers or really severe infections, and they need to have a lot of antibiotics that are very strong to treat these things and the chemotherapy drugs, they can actually wipe out your hearing in the cause sensory neural hearing loss. And then lastly, this mixed hearing loss. And this is the combination of both the permanent sensory neural hearing loss and then the conduction. And some of the causes of this, the very common one is otosclerosis. That's actually bony growth on the middle ear bones. So what happens is with that bony growth, it doesn't, when the sound wave hits the eardrum, and it tries to send the motion through the bones, because the ear bones are surrounded in extra bone, they don't move and you can't get the sound to the cochlea. And then another thing that some people get for mixed hearing losses is the balance organ is comprised of the hearing organs comprised of two things, the hearing and the balance. And in some of those balance organs, you can have like an opening in it and it's called a semicircular canal to hiscence, which is a little hole, which can cause a mixed hearing loss. So before we go into treatment and where these hearing losses occur, I just want to just do a brief overview of the ear on the outer ear, the pinna, and then it goes down through the ear canal and eardrum. And then those are the three little bones there in the middle that I was speaking of. And then the blue organ there is the cochlea. And you can see the cochlea looks like the snail shape. And the three circular canals are the balance organ. So the cochlea is comprised, like I said, of the hearing and balance. And then you have the auditory nerve that supplies both of the hearing and balance organs. So when we're talking about a conductive hearing loss, the conductive pathology is somewhere in that ear canal, outer ear or the middle ear. That's where the pathology lies. And then we're talking about a sensory neural hearing loss. It's here in the cochlea or the auditory nerve. So I just want to review audiograms. I'm sure you're all pretty familiar with audiograms. I'm sure you all have had multiple hearing tests before, but the audiogram is measuring pitch frequencies and soft and loud sounds. So if you start in the upper left, that is very soft and in a very low pitch. And as you go to the right, the frequencies increase and you get more higher pitches that we're testing. And then as you go down, it's the louder the sound. So in an audiogram, we're measuring from negative 10 decibels to 120 decibels. And you can kind of see the categories of hearing loss here. Anything above 20 decibels is considered normal hearing. The further you go down on the audiogram, the worse the hearing loss is. And then here, something you're probably familiar with, the red circles and blue Xs. That's for red circles is for the right ear. We always remember red right. It's the easiest thing. And in my profession, we do switch ears a lot. It's one of the common mistakes that we make, even though we've been doing it every day for many years. But the blue Xs are the left and the red circles are the right ear. And as you can see, this is a normal hearing audiogram. And when we test hearing, we mostly test between 125 Hertz and 8000 Hertz because that is the most important frequencies for speech. And for humans, it's communication. And that's why we are looking at those frequencies. Now, when some people go through cancer treatments and they get on those ototoxic drugs, we can test up to 20,000 Hertz, which is the highest the human ear can hear. When people start these ototoxic drugs, the ultra high frequencies tend to go away first. So that's something we do monitor when people are on those ototoxic drugs. But for cochlear implants, we're looking at this 125 Hertz to 8000 Hertz range. And then here's a typical mild flat hearing loss. And then conversely, all the way down here at the bottom, this is definitely cochlear implant, candidacy range, a profound hearing loss in both ears. And then I want to show you this is probably a more common type of hearing loss, especially as people age. And in the low frequencies, they have pretty good hearing. And then as the high frequencies go on, you have more and more hearing loss. This is most likely related to how the cochlea is set up. Your cochlea is organized by pitch. So at the entrance of the cochlea, you hear 20,000 Hertz. And as it curls around two and a half times, you go all the way down to 20 Hertz. And so every sound wave that comes in, whether it's a low frequency or high frequency is passing the entrance to the cochlea. So that's why you see a lot of high frequency hearing losses. And this is something a lot of people say, I can hear, but I can't understand. And I'm going to show you why. So this is a familiar sounds. And the pink line here is called the speech banana. And I don't know if you can see it too well, but you see all of the English letters and phonemes that is in the English language. And you can see where they lie based on the frequencies they have and how loud they are. So one thing I always tell my recipients and candidates in the cochlear implant clinic is like, for instance, in English, the consonants are very important for speech understanding. They give a lot of meaning to words. So F, S, T, H, S, H, T, K, these are all high frequency sounds that give a lot of meaning to words. And then you go down to the lower and you have your vowels, A, E, I, O, and U. The vowels in the English language carry the volume of speech. Whereas conversely, like French speaking, the vowels are much more important in French than the consonants are. So then this is a sloping hearing loss. The circles are the right ear that, once again, the X's are the left. And as the hearing loss slopes, you can kind of track this. And you can do this with your own audiogram if you have a copy. As anything above the hearing loss, X's and O's, the person would not be able to hear without intervention. So you can kind of see what you're missing when you have a certain kind of hearing loss. And this is another version of that. So like, you can see here, the T, F, T, H, S, and K, they are not heard by this person with this hearing loss without any intervention or increasing the volume. And so when we're looking at pitch and frequencies, that's one component of what we're testing. The other component that is important here is the word recognition score, if you see up top. And so you see this person here has what I would say a mild to moderately severe hearing loss. But when we turn the volume up to 70 decibels, so make it loud enough for this person to hear, their word recognition scores isn't too bad. So they have a significant hearing loss here, but with audibility, they do pretty well in understanding speech. So this is a very important thing when it comes to cochlear implant. When we, when we review cases coming in, what I look at is not only the detection thresholds of the X's and O's of where they fall on the audiogram, but it's the word understanding. And so if you have a good word understanding, word recognition score, it is a good indication that hearing aids will be very successful for you. Get some hearing aids on, provide some audibility, and you should be able to do pretty well. Then conversely, is if the word recognition, recognition score is poor, hearing aids probably won't work or aren't really indicated. But we would try them to see if they do help. But then we have to look at something else to help the hearing loss, because that's probably more of a distortion in the nerve than anything that we can take care of just by increasing audibility of the sound. Okay. So there's different treatments for the different kinds of hearing losses. For conductive hearing loss treatment, it's typically done with medical intervention. Some of these hearing losses are temporary. Some of them can be chronic. But for instance, I mentioned having middle ear fluid or an ear infection. A lot of times what doctors will do, and this can be done in the clinic, in the doctor's office, they'll just cut a little hole in your eardrum and they'll put a little tube to help aerate the middle ear space and let that fluid drain out. And a lot of times that relieves that hearing loss right away. And then when it comes to that cholesterol or the masses in the middle ear, what they do is go in and they can remove that surgically. And then lastly, some people are born without an ear. Some people just have chronic conductive hearing loss that can't be managed surgically. So there's a device called a Baja hearing device. It's another type of ear implant. It is not a cochlear implant. It actually is embedded in the skull and it vibrates the skull with the sound processor connected. And what it's doing is bypassing that outer ear and the middle ear and it's stimulating the cochlea directly. And then let's talk about some basic sensory neural hearing loss treatments. So some people come in with fluctuating hearing loss or a sudden sensory neural hearing loss where they wake up one day and they had no hearing. In those cases, it's usually treated with steroid. Either orally or through injections into the eardrum. And then in those cases of the acoustic neuromas, they can have to cut the nerve or remove the tumor off the auditory nerve. And sometimes you just have to sacrifice the ear when you're doing that based on how big that neuroma is. And a lot of times people do that because the acoustic neuroma is causing them constant dizziness. And it's very debilitating. So they have to go through an extreme case of going through surgery and getting that removed. But what do you think is the most common form of treatment for sensory neural hearing loss? Let's see if anyone's hearing the chat. Nothing. Nothing. Okay. Okay. It's hearing aids. And it looks like I see some hearing aids in this group. I know some of my, I see some of my recipients have cochlear implants, but hearing aids is the most common. And we definitely encourage trying hearing aids before moving into the cochlear implant space. Hearing aids work by picking up sound through a microphone. The signal is passed on to the amplifier and then the receiver sends the signal to the ear. So as you can see here, the hearing aid is in the ear. This is in the canal hearing aid. And it goes through the ear canal and it hits the eardrum and it sends the sound away through the cochlea up to the nerve. And here's some different styles of hearing aids that you're all probably pretty familiar with. You got in the ear, you got CIC in the canal ones, you got the behind the ear. And more common these days is what the receiver in the canal, it's called a RIC. Those are what usually I'm seeing most often these days. So for hearing aids, they have channels or frequency bands to individually fine-tuned where your hearing loss is and address the hearing loss at certain frequencies. So we have handles on the hearing aid programming software to adjust accordingly. And then also has algorithms in there for noise reduction and directional microphones for helping hearing and noise. But there's some limitations to hearing aids. Some people have problems with sensitive skin or sensitive ears or they have a hole in their eardrum that hasn't closed and they can get wet and they can get infected and they are allergic to hearing aids. So some people just can't even wear them. And then once you get to a certain level of hearing loss, hearing aids become non-functional for you because you are only working with the system you have with hearing aids. So if your system is beyond damage, you've got a lot of neural hearing loss or the lot of hair cell hearing loss in the cochlea, the hearing aids won't work for you. So that's when we go into cochlear implants. So essentially it's when hearing aids aren't cutting in anymore. And this is when you come into our clinic, this is what we're assessing. We test your hearing and then we'll check your hearing aids to see if they fit appropriately for your hearing loss. And if it's not, then we have our clinic aids that will fit for you and just make sure that you're getting the audibility out of the hearing aids. And then we do the speech testing and that kind of helps us determine if we're going to move forward with the cochlear implant. Cochlear implants are indicated for people who have poor word recognition ability when the sound is loud enough for them to hear. And what's different about cochlear implants than hearing aids is it's hearing aids is acoustic sound. It's how we hear through our ear without any hearing aids. Hearing aids is pick up the sound acoustically and go through the microphones and then you get a lot of amplification. Whereas a cochlear implant, it's actually bypassing the ear and it's actually sending electrical pulses to the auditory nerve. So there's two main components to a cochlear implant. On the left here is the external sound processor. As you can see, it's a little bit larger than a typical behind-the-ear hearing aid. It comprises of all the things that hearing aids have, directional microphones, frequency channels in there. And the one big difference of a speech processor compared to a hearing aid is the coil, which you can see is connected to a wire to the sound processor. And that coil has a magnet in it, then it connects to the implant, which is on the right. That's the piece that is embedded under the skin on top of the skull. It's not brain surgery, but the surgeon will place this implant. And in the center of that circle of the implant is a magnet, and that's how the processor connects to the implant. And the processor tells the implant what to do via a radio frequency signal. And then the implant will fire. So as before with the hearing aid, the hearing aids sat in the ear canal, but now with the cochlear implant, you can see the coil up there in the top left connected to the implant on the inside. And then that wire goes through the bone behind your ear. If you touch that bone, all of you right now, that's actually the hardest bone in your body. And that's because it's protecting your cochlea. So when the surgeon goes in, they drill the little hole in that bone, and then they put the wire in behind the eardrum. And you can see the wire then is inserted into the cochlea. About two and a half turns. So I want to talk about candidacy, because I know that was kind of important. And what I'm showing you here is what is called, I would say, traditional cochlear implant candidacy. So people, most insurances, now including Medicare, they've all aligned. Medicare used to have separate rules for candidacy than private insurances. But all of the insurances now say that you need to have moderate to profound hearing loss in both ears. And so if you have your audiogram, you can kind of track where your symbols fall to see if you qualify for a cochlear implant using this basic graph. Now, there's a lot of exceptions to this rule. Some people have hearing loss in one ear only that's profoundly deaf and have a normal hearing ear. And we started implanting those ears probably about, I think it was in 2015. So it's technically not approved for cochlear implants aren't approved technically up until last year, I think, for single sided hearing loss. But that's just another kind of candidacy. So just because you don't necessarily have a moderate to profound hearing loss doesn't mean you won't qualify for a cochlear implant. Because there's a lot of off label things that we can do to get a cochlear implant for certain types of hearing losses. So when you come into our clinic, we do some testing and to qualify you for a cochlear implant, see if you can receive one. And the main thing is insurances state that you have to have less than 60% sentence score. So we present sentences in quiet and noise sometimes, and to get people to qualify they have to do less than 60%. Medicare up until I believe four or five months ago, they required less than 40%. So that was a very limiting factor for the biggest group of people, most of them who most of our population are on Medicare. And so for them to qualify for a cochlear implant, they need to have a score 40% or less. And that's really bad hearing. So there's a big chunk of those people who couldn't qualify for a cochlear implant. But we're struggling a lot and hearing aids weren't cutting it for them. But a few months ago, Medicare caught up to private insurances. And now it's less than 60%. So it's kind of opened up the candidacy. And now more people can get access to a cochlear implant. Another criteria that you need is you have to have an auditory nerve. I know that sounds a little strange, but some people are born without a nerve. And you have to have a nerve to stimulate for a cochlear implant. And if you don't have a nerve, there's nothing to stimulate so you can't get a cochlear implant. And you can't have any active ear infections. You're not having brain surgery when it comes to cochlear implant, but there is a lot of cranial fluid in there. And so we have to have free of infection before we go and put an implant. So some people who have those chronic holes in their eardrum, they have constant infections, and then it's affected their hearing to the point where they do need a cochlear implant. Oftentimes, the surgeons will do a two-step process. They will go into the ear, they will clean up the infection, and then they actually close off the ear, removed like the eardrum. And what happens with that is then it frees up the ear from infection. And then after they heal from that first surgery, they go in a few months later and they get their cochlear implant. And now, as of last year or a year before, it used to be 12 months or older to get a cochlear implant. Now they've reduced that to nine months. So a lot of these babies who are born with significant profound hearing loss have access to cochlear implants at an earlier age. And the earlier you get implanted for children, the better your language development will occur. And then lastly, a lot of times people have other medical conditions. And so a lot of times we have to get authorization from the primary care physician or a cardiologist to make sure that they can undergo surgery and withstand anesthesia. So if you come into the clinic for our testing, there's what is called the minimum speech test battery. Now you go to Stanford, you go to UCSF or Kaiser, wherever across the country, people should be using these basic tests because our field came together about, I think it was revised last time in 2011. And there's two types of testing, CNC testing, which is one syllable words. It's two consonants and one vowel. And then we do AZ biosentences. It's four speakers, two male and two female speakers. And when we do that testing, it's completed at 60 dB decibels. A lot of times people are like, can you turn it up? I just need it a little bit louder. But we cannot do that when we're testing because we're using a standardized platform to determine candidacy. So we can't make things louder. So preoperatively, we test at 60 dB, postoperatively for outcomes, we also test at 60 dB. So why cochlear implant over a hearing aid? By the time people get to me and are looking for a cochlear implant, it's that they've usually tried hearing aids and it's just not cutting it. The distortion, the hearing aid just causes more distortion that's louder. So with cochlear implants, it provides clearer sound quality, improved speech understanding, and less listening effort, and overall just better access to sound. But there's some things to consider. We're putting a wire down in your ear when you get a cochlear implant. So in doing that, it's a foreign object in your body. So what happens is your body sends the immune system to your ear and it tries to seal off the cochlear implant from the body because it thinks it's under attack. And in doing that, you get scar tissue after surgery. And as a result, if you had any residual hearing, it's usually significantly lowered or completely gone after surgery. Cochlear implants are also not normal hearing. It's a great tool, but the average performance with on the single words for the cochlear implant is 50%. And that has kind of been the standard since probably the late 90s to early 2000s. And then what our clinic did at UCSF, we did because you don't see much data in the research about performance anymore. And so what our clinic did, just to check in to see what is the current state of cochlear implants. And we assessed all of our clinic data and all of our patients who got implanted from 2015 to the first part of 2020. So many, many years of data and we found the same thing. No matter the company, the device of cochlear implant, the average score on single words is about 50%. So it's an average, meaning some people do a lot better, some people do a lot worse. But it's not normal hearing. And then another thing for cochlear implants is having a magnet in your head and that can be limiting for MRIs. Now, as of a few years ago, all three of the cochlear implant companies have a cochlear implant that is capable to get an undergoing MRI. There's some conditions based on the device you have to be able to do so. But up until 2015, it wasn't really possible to get an MRI, which is important for, as people age, there's a lot of conditions that diagnostic MRIs are a very beneficial tool. And a lot of times if it was serious enough, people would have to go in and get the magnet removed from their cochlear implant before getting the MRI. And then another limitation and a barrier, and it's a big one, is just cochlear implant programs, they usually run at a loss. And so small practices can't do cochlear implants. And so all the centers tend to be in big medical centers, which happen to be in urban areas. And UCSF, we serve all the way up from the Oregon border, all the way down to Fresno, essentially. So that's a wide range. But that's very hard for people to get to from those areas. So let's talk about the three companies of cochlear implants. There was a fourth, but cochlear bought it out. Oticon, I don't know if any of you have an Oticon hearing aid. Oticon was going to come to market with the cochlear implant, but then cochlear bought them last July, I believe. So there's three companies, Advanced Bionics. It's located just down Interstate 5, just north of Los Angeles, right across the street from Magic Mountain Theme Park. Then you've got Cochlear Corporation. They're based out of Sydney, Australia. Their U.S. office is in Denver, Colorado. And then lastly, Meadow. Meadow is based off of Innsbruck, Austria. And their U.S. base is in North Carolina. So here is Advanced Bionics. And the upper left here is the NAIDA M90. It was released, I believe, in the spring of 2021. And you see their implant there. And then a Roger disc and a mini mic accessory to help hear noisy situations, to help hear at church. If you go to a lecture, these are just some accessories you can use with the Advanced Bionics system to help hear better. And then we got Cochlear. And there's something different here with Cochlear. They have two type of processors. They have the standard behind the ear processor with the coil up to the head, as you can see on the left. But then they have what's called an off-the-ear processor. And that's in the middle there. It's called the Canso II. That piece actually just sits on top of your head here with nothing on your ear. And with the pandemic happening and all the masking that's been going on, people have been really liking these off-the-ear options because a lot of times you have glasses, you have other things behind your ear, then you have to put a mask on. And people take those masks off and they lose their Cochlear implant processor. These off-the-ear processors have been really beneficial for some of these people during the pandemic phase. And then similar to Cochlear, Metell has the behind-the-ear processor and a button processor off-the-ear. So these are your basic components of Cochlear implant system across the three companies. So how do you know if you're a Cochlear implant candidate? So think to yourself, even with hearing aids, do people say you're talking too loud? Is your TV really loud? Does it take multiple attempts to get your attention? Do you have to actually someone come and touch you to get your attention? And the biggest one here, and it's actually one of the saddest things I see, and then it's also one of the most rewarding things I see on the back end of a Cochlear implant, is I see people starting to regress from social situations. I have people who like to volunteer and they stop volunteering and they all of a sudden become reclusive over a course of years and then depression sets in. And I've actually seen people come get a Cochlear implant and that has allowed them to get back engaged in the activities they like to do. And I can see the turnaround and it's like one of the most rewarding parts of my job actually is to see how these Cochlear implants can really benefit and get people back out to doing meaningful things and establishing meaningful relationships. So if you think you're a candidate, you can come see me or my colleague Dr. Colleen Polite. There's two of us audiologists at UCSF that do Cochlear implants strictly and we currently have two adult surgeons. We're located in the middle of San Francisco on Sutter Street. You can see our email there and our phone number and I can get this information to Anne. I think Anne already has it and she can disseminate it to you if you would like, if you're interested or you think you qualify for a Cochlear implant, we can start that evaluation. That's all I have for my slideshow. I can have some time for questions. Okay everybody, click on the smiley face with reactions for your questions. Diane Bishop from Pennsylvania, make sure to mute yourself. Okay, I mean unmute yourself. Hello everybody. Can you hear me? Are you familiar with auditory hallucinations or musical ear syndrome? And do you know if getting a Cochlear implant helps that situation? I'm vaguely familiar with it. I have a few patients that have various songs on loop in their ear, like it's a form of tinnitus, but they do have a Cochlear implant and that still exists for them when they're not wearing their Cochlear implant. So usually with these cases like the auditory hallucinations or that musical ear or just general tinnitus of itself, when they put the Cochlear implant on, it's providing the ear with some stimulation, which then will suppress those hallucinations or the music or the tinnitus, but when they take it off, it returns sometimes. Okay, thank you. Mark Goldenberg. Yes, the implant that's implanted under the skull behind the ear, how is that device powered? Is it powered by the body or is it powered by way of the transmitter from the processor? Good question. So all the power is done externally through a rechargeable battery on the external processor. So there's no power supply internally on the Cochlear implant. It's all done on that behind the ear or the button processor off the ear. The power supply is a rechargeable battery typically. Okay, so it's essentially wireless charging by way of the transmitter? Yes. Okay, that's what I suspected, but I in all of my research, I hadn't found anything that explained how the internal device was powered, because obviously it's got to have power if it's going to transmit electrical impulses to the nerve. Exactly. And so that's why Cochlear implants are larger than hearing aids, because the demands of a Cochlear implant, it's doing so much more, you're actually driving current. And that was one of the limitations. When Cochlear implants first came out when they were under development, like in the 60s and 70s, the first Cochlear implants, the processor was actually in a box that the people had to carry around because of the power supply was so immense, you needed a big battery. So over the years, it wasn't until like 2000. So just about two decades ago, where these processors got small enough to be put on your ear, because the battery improvement got to the point where the processors would get smaller. And that's always a limiting factor. Like right now, Cochlear is brand is the smallest processor on the market. And it's because they found a battery that's small enough to power their system. So as the battery technology improves, the processors will continue to get smaller. Jonathan Patton. Yes, thank you. Kind of, I've got a few questions. Just going off of that last one though. How are they replaceable batteries? Sounds like they're rechargeable batteries that are used. Yep. So most of the systems with the three companies, you'll get at least two rechargeable batteries and a charger. And then all of them do come with disposable batteries that you can use in the event that you're in a place without electricity. So there is an option to use disposable batteries. But versus like a hearing aid, people use one battery in their hearing aid. These Cochlear implants require two large 675 batteries to power the system. And how long does it last between charges? So a standard rechargeable battery should get you through one day of use, which is typically anywhere between 12 and 16 hours, because people don't wear it while they sleep. So assuming you're sleeping for about eight hours, a full day is about 16 hours. And that would be really good battery life. Now some people's ear anatomy and their cochlear implant have such high power demands that they don't get a full day of batteries. And they have to switch their battery in the evening. But generally speaking, one battery should get you through a day and then you put it on the charger overnight. I see. Oh, it's interesting that they have rechargeable batteries that you can take out and regular hearing aids don't or not that I know of anyway. Yes. So actually hearing aids are, they're more and more companies are getting rechargeable hearing aids where it comes with like a little case or a stand that you put the hearing aids in. So it is getting away from the zinc air disposable batteries, which is good for the environment and a lot more cost effective over time. Right. But I was just thinking you have to send it in to get the battery replaced instead of you changing it yourselves. And two other questions. I know cost is probably variable with your insurance, but typically if you have regular commercial insurance, do you know, can you say, is there like an average of what it would cost out of pocket? It's so variable depending on the insurance. There's so many insurances. I can tell you right now, the whole surgery and the implant and the external processor, you'll get, people get two processors when they first have surgery, one primary and then one for backup in the event their primary breaks. Surgery and all of that is billed at $180,000. And most people, I would say most people don't pay much more than $1,000 or so, generally speaking. But this is very dependent on what kind of insurance you have and what kind of deductibles you have in premiums and things like that. When it comes to Medicare, Medicare will cover 80% of the cochlear implant. And then a lot of people have a secondary insurance that will cover the last 20%. So some people paid no money at all. Jonathan, I have Medicare and I have a Medicare Advantage plan, and I paid $200 for the outpatient surgery just to use the surgery as a deductible. And for each one of the appointments with the audiologist, it was $15 per appointment. So very minimal. Yeah, that's good. And then it's considered a different kind of medical device. And I don't know if you've been reading about the news, but Medicare doesn't cover ears, eyes or teeth, right? And so they're trying to work and change that because it's such a huge need in the hearing loss. It's such an impactful disorder that many people who are on Medicare have. But as it stands now, Medicare doesn't cover hearing aids. But when you get to this point of needing a cochlear implant, Medicare will cover that. And then another question. I've heard conflicting comments about how they work so well in noisy environments. And other people saying they're kind of like hearing aids, they help, but they don't work that well. Is there? I would say generally that I see them help more in noise than hearing aids do. Hearing a noise is challenging for everyone. And then it gets more difficult as hearing loss increases. But with cochlear implants, and now the algorithms and the processing that they have, I'm finding, especially with the new advanced Bionics One, and now cochlear has a new one coming out, these directional microphones on the cochlear implants have progressed to a point where it is very beneficial in hearing a noise. But like so, for instance, the word scores, and I see down here in chat, someone mentioned this. So the outcome of a cochlear implant, when we test those individual words that I mentioned, and when we test the sentences, the average score with a cochlear implant is that 50% on the individual words. And then the average score on the sentences is about 60%. And then what we do after that is we test you in quiet, say you do average 60%, we'll put in some noise, which is about five decibels lower than the speech. So the speech is still a little bit louder, but there's a lot of background noise. When you put in the next level of noise, you usually see a 20% drop from your score in quiet. So you do get degraded performance, but at the same time, you still can hear a noise. Okay. And then last, I can think of more, but I know a lot of people are asked, or other hands up, so I'll make this my last question. I was listening to something a couple of days ago about how they're putting something on the wire that can stimulate hair growth. I don't know if that's experimental or that's, or what? Yeah. So that's in the hair growth regeneration studies. It's not currently commercially available. That's just in the research phase right now. And that's what they're trying to do, is get to the point where, when you get to these damaged hair cells in your cochlea, and that's where it's causing your hearing loss, a cochlear implant bypasses that, but what the research is really working on right now is delivering these treatments and medicines into the cochlea to regrow those hair cells. So in the future, hopefully we won't need cochlear implants because they can regrow the hair cells, but that is very much in the research phase. I think they're just starting human trials at a couple of centers in the US, but we're really far off from that being a possibility. Okay. Thank you. Great questions. Thank you. Okay. Brian, Fikima, is that how you pronounce your last name? Fikima. Thank you. And I, you know, I think you just answered a couple of my questions. So it's about 60 and 40% on average on word, 60% not noise, 40% in noise. So like for sentence testing with the two male and two female speaker tests that we use, the average score in quiet is about 60% and then we do the first level of noise and we typically see about a 20 to 25% drop from the score in quiet. And then as you put more and more noise in, I mean, we can put more and more noise and it gets you to perform at zero, but there's no point in testing that. But yes, you usually see about 25% drop per round of noise. And I usually test in two different noise levels. Okay. Because I mean, I'm still trying to figure out if I'm, I mean, I've been told I'm a candidate, but I'm so right on the line that nobody can tell me if it's going to actually make anything better. See, that's when they, you know, like what I tell people, if they look at their audiogram and their word score on their audiogram, if your score is somewhere around 60, 70, like you're probably going to be not a candidate, but it's worth coming in to go through the initial part of the evaluation to see where you're at if you are that borderline. Now, I can tell you the borderline recipients of cochlear implants, they don't have as much of a wow factor as someone who is completely deaf before they get implanted, right? Because they have some functional hearing. And so a lot of times we're taking a look at how much natural hearing do you have and how well are you doing on these speech tests, because we want to maintain our natural hearing as long as possible. So if you are that borderline would like we take a look at your scores and how much residual hearing you do have, you know, if we don't want to risk that, we'd probably hold off and like reevaluate in like a year or so. Okay. And that was my second question, because I've gotten so much conflicting things on this, on how much of your sound or how much do you actually keep. And I mean, I noticed like Medell even now has a cochlear implant hearing aid in one device. So is that just if you're, if you happen to be lucky enough or yeah, you know, as kind of what I was talking about earlier, by putting that implant down in your ear, you're doing damage to your ear. But some people have that really good low frequency hearing. And the low frequencies are deep into your ear. And as your cochlea curls around in those turns, it actually is getting narrower. So cochlear implants don't actually go to the end of the cochlea. They can't get down in there. So when you get a cochlear implant, it's inserted. And where it stops, you still, it doesn't hit those low frequencies. So a lot of times people can maintain their low frequency hearing, but their high frequency hearing disappears. And in that case, like you said, Medell, well, all three of the companies now have a device where you stimulate the high frequencies electrically with a cochlear implant. And then it has a receiver and the canal wire attached to it, where you can acoustically amplify the low frequencies. And that's called hybrid hearing. Okay. And is that, I mean, because I have moderate severe to one kill heart dropping sharply to profound. But when I went into my surgeon, he basically said, I'd lose it all anyways, and it wouldn't be worth. Yeah. So if you're at moderately severe to profound hearing loss, you're consider your lowest frequencies, we considered preserved hearing 25 dB hearing loss. So if you even lose 25 decibels of your hearing, that's considered preserved hearing. But for you in the moderately severe range, if you lost 20 decibels, it would put you in the profound range. So we would just electrically stimulate and you wouldn't really qualify for that acoustic hybrid hearing. Okay. Thank you. Thanks, Brian. Okay, Jack London. Thank you. That was a good presentation. I learned quite a bit. My question is, is overall success? What are what percentages are you seeing of people who come away, not necessarily with that aha moment, but just much improved and people who are kind of disappointed and aren't getting the results that you'd hoped for? So that's a good question. It's always a challenging one. A lot of times we can parse out expectations of what we expect someone to do with a cochlear implant before they get implanted. So we kind of hedge that. People who have significant hearing loss for a long period of time, say you've had hearing loss for once you get to 15 years of a completely deaf and dear without wearing a hearing aid, outcomes for cochlear implant become very poor. And just because it's that adage of if you don't use it, you lose it. So we know these people who come to us and like, oh, I want a cochlear implant now, but they've been deaf for 20, 30 years. We counsel them, yes, you'll get sound, but will you get meaningful speech understanding? More than likely not. But in terms of people who have hearing loss, they wear their hearing aids, the hearing aids aren't cutting it for me anymore and get implanted with cochlear implants. I would say about 90% of the people that I work with see a pretty big benefit. It's a lot of people that find benefit from their cochlear implants and about 10% of people for various reasons. Sometimes it's just cosmetic and they don't like it on their ear. Some people they don't because it's not like a hearing if you put it in and you can hear you're really retraining your brain. It's a totally new way of hearing. So in the beginning, it's noisy and it's mechanical and robotic and some people can't tolerate that. So what they do is stop wearing it. By doing that, they never get adjusted to the cochlear implant. The first month of a cochlear implant after activation is very, very challenging. It's exciting, but it's also frustrating. Some people who can't get past that then they don't wear it and then they're frustrated with their experience. Thank you. Thank you. Jack, even though I'm really involved in the hearing loss community and I knew probably everything anybody could know about implants and everything else as a lay person, I was not prepared for what the sound was when I was activated. It felt like there were aliens talking to me that first month. So I'm just confirming what Kurt's saying. Jim Schroeder. Yeah. I just had a couple of comments about some of the other questions. First about costs. I was first implanted in 2016. And what I found in terms of out-of-pocket costs, there are a lot of things you have to do to prepare for implant. You have to get at least back then. I know things may have changed. I had to get an MRI and then I had to have some immunizations for, I think it was pneumonia. And some of those things, I actually had copays that were substantial. And so that's where most of the out-of-pocket cost was. The ligand, just the surgery and all of that was mostly covered by insurance. I had Medicare at the time and I still do. So I just wanted to point out that there's a number of hoops you have to jump through. Once you've been said, yeah, we're going to give you a cochlear implant, you have to go through to medically make sure that everything inside your ear is what's expected and preparing for the surgery. Yeah. And I guess that's all I had to say. Anyway. John Gallagher. Okay. Hi. Thanks for the discussion. And you touched on it a little bit. Would you please touch a little bit more on the post-stop learning and adjustment that people have to do, number one? And number two, can you discuss what music is like to people who have had implants? Yes, I can. So like I said, the first month is very frustrating. Before technology gave us access to a lot of rehabilitation tools, we would send people after we activate them to a speech therapist actually to do auditory verbal therapy with their cochlear implant. Now there's so many tools available through each manufacturer. There's apps on your phone and your iPads. There's free programs online that we have people do for at least 30 minutes a day in that first month. I always say at least 30 minutes, but the more you do, the better it will be, especially in the beginning parts. But there's a really good tool called Angel Sound. It's a free program on the computer. It's a free app on iPhones or iPads. Cochlear has a program called Telephone with Confidence. In each day, you just go to the website, you call a number, and every day there's a new list of words. There's new passages. Each week is like one week it's sports related and every day you call in a number and it's all very different passages that you can follow along for auditory training using your phone. And then we always encourage people to listen to music for at least 10 minutes a day with cochlear implants. But if someone were to come to me saying they wanted a cochlear implant so they could hear and appreciate music, I would send them out the door because cochlear implants are just not known for music appreciation. Now what I find like anecdotally clinically with my recipients is that it's kind of like this bell curve. On one end is some people who love music and they appreciate it. They can hear the melody. They really enjoy it. On the very other end, people hate music. It's actually just noise to them. It doesn't make sense. It's not enjoyable and in fact it bothers them because it impacts their ability to understand speech. And then the most majority of people I would say have some ability to appreciate music that they are very familiar with from their past. Songs that they love, songs that are imprinted on you. So I always encourage people when they get their cochlear implant to start listening to songs they know by heart. So it's going to sound so weird through the cochlear implant, but the brain's a wonderful tool. It has an auditory memory and it can fill in the gaps and can help the music appreciation. But when it comes to new music, most people don't like with their cochlear implants. When people go to a concert or something like that, do they choose to turn off their cochlear implant while they're trying to listen to the well-said concert? Most often than not, people do not. They wear their cochlear implant. There's program settings that we can have to help music appreciation by making, when we're processing music, we don't want to limit the sound and we don't want lots of processing on it. So there are music programs that we can put on the cochlear implant to make the sound more linear and have music be more robust. But ultimately, cochlear implants can hear the beat or the rhythm of music very well, and then the cochlear implants allow them to hear the lyrics better. Thank you. Thanks, John. Oh, hi, Julius, and thanks for joining us. You're next. There are so many questions and thoughts I've had during this. Thank you very much. It's been really interesting. First of all, I'm a bimodal user. I have hearing aid and a cochlear implant. And I use the mini mic from Cochlear a lot. I refuse to give up my social life. We go out a lot. We have a lot of fun. We do things. And I have found that the telecoil and the mini mic have really, really made a big difference in my ability to enjoy things. So I want to just mention that telecoil thing because I know Cochlear left that out with their off-the-ear second generation. And that's really a shame. It's nice that the mini mic has it. But you've got to charge that too. And all of a sudden, you're traveling and you've got so many chargers that sometimes it's nice to be able to use regular batteries. But anyhow, that's been my experience. I was diagnosed with progressive sensorineural bilateral hearing loss when I was 22. And that was a long time ago. 1960, you bore. And so I lived with that for a long time because I was told hearing aids wouldn't make a difference, wouldn't help me. I was just going to go deaf and I needed to learn to live with it. That was a long time ago. So I feel very blessed to have had the opportunity to have high quality hearing aids and the implant. But I was fit with only one hearing aid when I was in my mid 30s. That's when I finally said I'm getting a hearing aid. And I went for all those years until 2015 and did not have a hearing aid in my right ear. It was just in my left ear. And I was struggling with it, but I was using a neck loop and a pocket talker and I was doing everything I could. I opted to let them do the CI on my unaided ear. But I was told, and I listened, to wear a hearing aid on that unaided ear for two years and listen to audiobooks with a neck loop and a telecoil and everything. So I did that for two years. And then they did the CI on that ear that had been unaided. And it's been just absolutely fabulous. I just, I can't say enough about it. I am so glad I did it. And I appreciate music. I have a granddaughter who is a vocalist. But you are right. If the music is familiar, it's much easier to enjoy it. And if it's not, you have to listen to it several times, but it does come. So I wouldn't ever feel that that was that awful, you know, unless music is your profession and that's your life. I do have one question that I wanted to ask. We have an HLAA chapter member who had serious profound Meniere's disease. And he was losing his hearing along with that. And he got a single-sided implant and got the cochlear implant. And it helped him tremendously. But he still struggled because he couldn't use, he didn't have the ability to put a hearing aid in the other ear that was compatible. And all of a sudden, he decided that he would try a hearing aid. And he, this is after five years or six years of having the implant. And it's working miraculously for him. He's flabbergasted. Does Meniere's burnout, does it eventually stop? Or what happens? Because he's mystified and he's got us all mystified along with him. Yeah, I do see a lot of times that Meniere's can go on for years, but I do see most of my patients that have cochlear implants and as a result of severe Meniere's disease, the flares kind of flame out at a certain point. But that can be anywhere from, you know, five years to 20 years. Meniere's is very debilitating and very, with that vertigo, it affects everyone differently in terms of severity. But yes, I do see a point where a lot of these patients, essentially the Meniere's symptoms go away after some time. It's just fascinating to watch what happens to different people within different situations and being involved in HLA is really, it's really an educational opportunity. That's enough, I've said enough. Julie, thank you so much for reminding people about the value of telecoils. I basically, generally in my life, haven't even needed to use any other devices with my CIs, but I've had two very disturbing funerals that I needed to attend this year. And both of them were so upsetting, even though all of you know me to be a died-in-the-wool advocate, I just really couldn't cause any more disturbance, couldn't do one more thing about these and had not used my telecoil in my CI. But since I know about them, I made sure that my telecoil was activated in my CIs. And in both circumstances, walked into the church, and one was this huge church in North Carolina with tall ceilings, carved wood and all this stuff. And there was a hearing loop symbol at the front door of the church. And the minister started talking and the reverberation in that church was so profound because of the acoustics and the shape. I went, oh, no. And then I thought, oh, okay, so I pressed the telecoil in the program and I'm telling you clear as a bell. Even when I had hearing aids, the telecoil program was not so not as good as that. And the second such time it was the same thing. So please, if all of you are approaching CIs, make sure to have your CI audiologist activate your telecoil. And if you have hearing aids, make sure that you have gone to your audiologist to make sure that you have a telecoil in them or activated if you can have that. Kathy Rothschild, welcome. Hi. Thank you for your wonderful presentation, Kurt. Thank you. I got one cochlear implant. Both ears needed in November and had an activated end of November. And from the beginning I could understand and comprehend right away. I was very lucky. But I've had like a transistor radio screeching in the ear. And my audiologist has programmed it and programmed it and reprogrammed it and programmed it and can't figure it out. And she said, well, you know, just you're hearing things, sounds you didn't hear before. But it's like all the time, even when I'm alone and nobody's talking. Have you ever heard of that? And I have a cochlear America's. Yeah. I mean, a lot of times that can be addressed with advanced programming techniques. Sometimes it's just in the settings. There's various settings with cochlear implant. We can control how fast the cochlear implant fires and stimulates the ear. We can control how big the pulses are when we are stimulating. We can set the loud levels and the soft levels. And so these are something like what you're experiencing is very common in like the first month or two months after surgery. But these things, that shouldn't be happening all the time now that it's been, you know, you're coming up on two, just over two months, like in the next month or so that should go away on its own. Otherwise, if it doesn't, that's probably some programming that needs to be completed. If we, if we didn't have the procedure done at UCSF, can we still go to and all? Could I go see you at UCSF? So it's a tricky. Ultimately, yes, we don't encourage people switching between the centers, especially the Bay Area has a lot of cochlear implant centers. And so the general rule amongst the cochlear implant communities, if you're within 90 miles of your cochlear implant center, we prefer that you return to them. But, you know, on a case by case basis, if you want to request a transfer, you can email that email that I had on the slide earlier and you can request to transfer to UCSF. But what we try to avoid is having people bouncing between the clinics. So are there any more questions? Last call. Thank you. Thank you. Thank you. Thank you. I just want to say, can I say one thing? Because I know that you're such a huge fan of the T-Coil and I think there's something exciting coming out. And the cochlear, the new processor, the N8 processor, which was just released in December, they actually have a new, there's a new Bluetooth coming to the world. It's not out there yet, but it's coming, I think, that's starting slowly this summer. But essentially, it's kind of like T-Coil-esque, but it's wireless Bluetooth. It's going to be, I'd say you go to a theater or to airport. You can go on your wireless device, your phone, and it's like, you know, when you go to places and you want to get on the Wi-Fi with your phone, this is what the new Bluetooth is going to be. You can select, say you're at San Francisco International Airport, you're at Gate B-17. You can go onto your phone and select Gate B-17 when this is available. And what will happen, anytime any announcement is coming from that gate, it will go right into your hearing devices. And this is going to be accessible in public and public transit. It's going to be accessible in theaters and at airports. So I think it's going to be something to look forward to in the future. And Cochlear Cooperation already has it embedded in their new processor, and I'm sure the other companies will catch up soon. Yeah. So Kurt, I sit on the Bluetooth SIG group as an HLA representative, and what you're talking about is called AuraCast. And to have the infrastructure be in place, it's anticipated that it's going to be at least 10 years for us to benefit from that. So I just wanted to let you know if you didn't know that, and I'll send you a link about that. Please do, because yeah, I heard that it was coming soon. Yeah. Yeah. So if you think of all of the people, so hearing loops, telequills and hearing loops and AuraCast will coexist for a whole long time here. And I know a lot of my patients, I don't know if anyone likes to go to the theater, but the Golden Gate Theater here in San Francisco, their tea coil is wonderful. And like he said, they went to Hamilton, and Hamilton's a very hard show to hear for people with hearing loss, right? And a lot of times people will study the lyrics and the plays before they go see them, but he said he could hear everything with his Cochlear implants with the tea coil. So Bob always brings us a muffin, and I have to speed up here. So here's your muffin, and these are Cochlear Implant Resources, and we have a YouTube channel, so you can see them later on the channel. And if you'd like a copy of this slide, I'd be happy to do that. I'd like to remind everybody to communication access, we need to ask for what you need. And UC, I am on the UCSF Patient Family Advocacy Committee to improve accommodations for all of us at UCSF. And this is who you would contact if you would go there, if you needed accommodations and you were having a difficulty. We have some announcements. Next month, we have a very interesting presentation. It's a social science research coming from Stanford, Bryn Griswold. In April, we're going to have lessons from Lane County in Oregon on how they are getting hearing loops throughout their city. And advocating for hearing loops in March, they walk for hearing in June, and the convention in July. We'd like to make sure everybody knows that we have a YouTube channel with most of our presentations. Unfortunately, last month, the Know Your Rights ask for what you need presentation, which is going viral. I'm being asked all by chapters and organizations all over the country to give that presentation. We forgot to record it. We are looking for people on our programs committee. And you know, I'm always looking for some help on the advocacy committee. We're a member organization. Please renew your membership. You can do so online. And here we are. And we have two minutes to spare. We'd like to thank our captioner today for these absolutely fabulous captions. And I'd like to let everybody know that the state of California now makes captions available to us through our relay service. And this is the first time that we contacted them to do that. And they are free of charge for any event. So I'd like to let everybody know about that in case you didn't know about it. And the captions have been over the top. Wonderful. We have one minute left. Does anybody have anything, any last thing to say? Kurt, I'd like to really thank you. This is, for me, the best presentation, overall presentation I have ever experienced on having an overview of hearing, having an overview of the implants, just the whole general educational format. I really appreciate it. And thank you very much. Thank you for having me. I really appreciate it. And I love seeing all these faces in the crowd. And I hope to see them in clinic. I actually like seeing, without being in clinic, it's nice to actually see people's faces because we've been masked up for now two or three years. So been really nice. And I really appreciate you inviting me to come speak. Thank you very much.