Talk:Cochlear implant/Archive 2

Archive 1

Archive 2

Hearing Voices.

La percepccion en partes diferentes del cerebro en distancias difrentes, intensidad en los niveles de las voces, pareciese de igual manera que cada una de las difehtes voces de cuatro a cinco en total diferentes unas de otras, al sentir la distancia en el cerebro se mueven espacialmente a otra ubicacion en fraccines de segundos, pareciendo que de una posicion exterior a una interior or de estar muy serca a una mas aljqda en, sin enbargo frecuentemente las voces sse hacen acompanar ce pisadas que marcan el movimiento ligeramente de las vofes, mayormente solo el sonido d la voces sin la mescla d los sndos exernos normales. Juanjosedp (talk) 07:01, 7 November 2014 (UTC)

WP:OR - overall rewrite needed

In general, this article is WP:OR, almost completely sourced from WP:PRIMARY sources. The pulling-together of the story, based on primary sources, by one or more editors is what makes this OR. I have gathered a bunch of reviews and intend to do an overhaul based on WP:SECONDARY sources - in other words, what the review literature says about the history. That literature tells us what events or innovations are important and what WP:WEIGHT they deserve. Jytdog (talk) 14:29, 3 February 2015 (UTC)

specific section

I cut the following from the article. The OR problems are really clear here, and the content and sources added today don't fit, grammatically.

In 1988, B. Wilson (USA) developed a device directly inspired from the French patent, which he never mentioned in his subsequent publications. He modified the frequency of stimulation, by means of continuous interleaved stimulation (CIS). Curiously however, subsequent descriptions, notably in Nature in 1991 and at a recent media event, although astonishing with respect to the electrophysiology of the cochlear nerve, have never been discussed up to 3 recent technical papers.

needs to be reworked based on WP:SECONDARY sources and made sense of... Jytdog (talk) 14:31, 3 February 2015 (UTC)

edits by IP on goettingen study

64.53.165.92 added content about work done in Germany in this dif, which I reverted since the content is promotional and is based on a WP:PRIMARY source. We don't use primary sources for health related content in wikipedia, per the guideline, WP:MEDRS. The IP edit warred the content back in. I've opened this discussion to see if the IP has any justification for the edit. Jytdog (talk) 15:45, 9 February 2015 (UTC)

I thought you wanted me to change from a primary source to a secondary source. I did that. scientfica.co.uk is a secondary source, correct?

My intention was not promotional. Northwestern University is mentioned in that same paragraph -- isn't that promotional as well?

I think that the optogenetics research should be mentioned. My justification is that it builds upon the research done by Northwestern University, and I think that this research is advancing the science of optical cochlear implants. I have no connection to the university mentioned, or the researchers. Just wanted to add something I thought was notable to wikipedia on a subject that interests me.

I'm new to this though -- I thought I was doing the right thing. What would be a better way of citing it, if at all, jytdog? 64.53.165.92 (talk) 22:08, 9 February 2015 (UTC)

Please read WP:MEDRS. If people talking with you take the time to provide a link to a policy or guideline, please read it. I'll respond after you write back, after you have read it and considered your edit in light of it. And please don't wikilawyer this. Don't read the guideline looking for justification for what you did - read it and try to understand the heart of it. Please also read my comment in the section directly above. This article needs a complete rewrite. Thanks Jytdog (talk) 01:29, 10 February 2015 (UTC)

Alright, I read it. I think I understand what it is getting at. Citing secondary sources is important not only because there is a possible conflict-of-interest in citing the primary source, but also because citing a single research study does not necessarily indicate a breakthrough or have the weight of scientific consensus. Based on that, it is probably better to wait until more research in this area is done, and more thorough review is done by other sources. Thanks 64.53.165.92 (talk) 02:00, 10 February 2015 (UTC)

You the man!  :) hooray! I hope you stick around. (that is 100% genuine. just realized you might take that as sarcastic and it was not) Jytdog (talk) 02:03, 10 February 2015 (UTC)

SPA/COI note

This article has been subject to some SPA and possibly COI editing per tags in yellow box at the top of the page. Jytdog (talk) 11:06, 31 March 2015 (UTC)

Rehabilitation resources link

correct link for rehabilitation resources. no account here so someone please edit? http://www.cochlear.com/wps/wcm/connect/in/home/support/rehabilitation-resources 87.113.92.59 (talk) 17:53, 1 April 2015 (UTC)

Proposed edit to 'Scientific and Technical advances'

I have a disagreement with the laser stimulation research presented in Scientific and Technical advances. Since it was added to the wiki article, additional research has been performed which questions the mechanisms of this technique and suggests that it does not work in deaf cochleae and will therefore not be useful in cochlear implants (eg dx.doi.org/10.1016/j.heares.2015.03.005 and dx.doi.org/10.1117/12.2039256). These are both WP:PRIMARY and therefore not ideal for health related articles WP:MEDRS, I am also an author on one of these articles and have a conflict of interest and shouldn't directly edit this part of the article. Any suggestions for changing this text or adding some skepticism to the claims? Paging user Jytdog for comment. Talexbikes (talk) 13:28, 22 October 2015 (UTC)

cleanup part 1 History section - unsourced, OR, essay

I cut this from the article and put it here. This section has bothered me for a long time. It is full of unsourced content, and it is also the WP:OR of some editor who strung together a bunch of primary sources to create a secondary source, here in WP. This needs to be rewiritten based on secondary or tertiary sources. The primary sources can stay of course, for their historical interest. I have changed all the section headers to bold.

History==

Any history of the cochlear implant must start with an overview of non-surgical treatments proposed in the eighteenth century to overcome the social and psychological consequences of total neonatal deafness. The story begins in the early eighteenth century. Although the Frenchman Abbé de l’Épée (1712-1759) did not actually invent sign language, he did at least bring together the results of various experiences, notably those in Spain, before standardizing and teaching this method with the aim of facilitating communication among all those who practise it, whether deaf or not. Abbé de l’Épée was the first to use sign language to promote the mental development and education of deaf children. In the middle of the eighteenth century he created a free public school, which survived the French Revolution and was perpetuated by the nascent Republic in the form of the National Institute for Deaf-Mutes (Institution nationale des sourds-muets). This institute, now called the National Institute for Young Deaf People (Institution Nationale des Jeunes Sourds), has always been located in rue St Jacques, Paris. For many years it was recognized internationally as a leader in the education of deaf children, but its teachers and physicians disagreed on certain teaching methods: the teachers tended to prefer oralisation (difficult, owing to the lack of sensory feedback), while the physicians (notably Prosper Menière and Edouard Fournié) opted for sign language. In fact, this disagreement concerned not only communication itself but also the very place of deaf people in society: sign language favored the teaching and development of deaf people within their own community, while oralisation sought to integrate deaf people into the rest of society. Towards the end of the 19th century the development of international transport and the ENT (ear, nose and throat) medical discipline internationalized the debate.

Early cochlear implants in adolescents and adults who had been deaf since birth met with failure, often abandoned by their users. These failures largely accounted for the widespread opposition of the deaf community to this new therapeutic approach. Animal experiments subsequently showed that the auditory system could mature with chronic cochlear implant stimulation, but only if they started to be stimulated within an early period after birth. Early cochlear implantation in children and the corresponding maturational processes ignited in their brains support such concept.

Electrical stimulation of afferent auditory pathways became feasible in the last half of the twentieth century. Chronologically, its development can be divided into three periods:

• Basic research and early human trials (1957-1975)
• Development of multichannel implants in four countries (France, Austria, Australia and the United States), ending in a consensus on the best approach (1976-1997)
• The modern era

Basic research

In 1961, G von Bekesy (1899-1972) received the Nobel Prize for demonstrating that sounds trigger vibrations of the basilar membrane which spread from the base to the apex of the cochlea in the form of longitudinal waves; peaks occur at various points depending on the frequency, resembling the keys of a piano, with low frequencies towards the apex and high frequencies towards the oval window. The terms "cochlear keyboard" and “cochlear tonotopy” are often used to describe these phenomena.

In 1968, H. Davis described the physiology of auditory receptors.

In 1972, NY Kiang unraveled the physiology of electrical stimulation of the inner ear.

In 1975, EF Evans showed that each sensory afferent fiber of the cochlear nerve handles a specific frequency, making it electively sensitive to a very narrow frequency band.

First human trials

grandeur and limitations of the single-channel implant

In 1957, A. Djourno, a Parisian professor of medical physics, and C. Eyries, a Parisian otologist, restored hearing to a deaf patient with total bilateral cholesteatomas by electrically stimulating acoustic nerve fibers still present in the inner ear. This result was fortuitous, however: Djourno and Eyries had in fact been seeking to remobilize the frozen facial traits of a patient with cholesteatomas in both ears, which had been complicated, probably many years previously, by bilateral facial paralysis. They failed in their primary goal but had the wherewithal to record their electro-acoustic observations over several weeks and to publish them in the French journal Presse Médicale. They stopped their experiment when the apparatus broke down after less than a month.

If these French researchers had not noted their unexpected findings, William House might never have dared try to compensate total deafness, which is all the more severe when bilateral.

In 1961, a patient gave William House, a Californian otologist, a copy of a Los Angeles Times article describing the work of the Paris researchers. House had already transformed the functional outcome of cerebellopontine angle surgery by making use of the first surgical microscopes developed in the late 1950s, and was familiar with total deafness. He resumed his research, basing his indications on what was known at the time about the physiology of hearing, a rapidly progressing field, at least in animals. House standardized the surgical procedure and stably positioned the stimulatory electrode by threading it through the round window in the cochlear channel. He encountered a number of difficulties, especially in sealing the implant. Solutions emerged with the advent of pacemakers, but it took House almost ten years to develop a single-channel cochlear implant. This ultimately robust and simple device stimulated the whole set of the auditory nerve fibers simultaneously, meaning that the recipient was able to recognize only the rhythms of the speech.

House marketed his device jointly with J. Urban and continued to implant it until at least 1965. The system was sufficiently reliable for researchers and otologists to overlook its mediocre functional performance.

In 1966 B. Simmons (Palo Alto, CA) performed the first temporary human implantation of a multichannel system in the trunk of the auditory nerve itself, in a deaf volunteer. This experimental work showed that stimulation of limited quotas of the auditory nerve fibers generated sensations of different frequencies depending on the origin of the stimulated fibers on the cochlear keyboard. Shortly afterwards, Mr. Merzenich (UCSF - San Francisco) confirmed these findings in macaques, using a different approach.

In 1967, G. Clark in Melbourne created a team to conduct basic research on the pathophysiology of profound deafness in animals and on the tolerability of implanted materials.

In 1973, R. Michelson (UCSF - San Francisco) chronically implanted a deaf man with an experimental multichannel implant: this device used pairs of antennas for each channel, one transmitting and one receiving. It was possible to measure several parameters and to test various types of stimulation, including both bipolar and unipolar.

In 1973, CH Chouard had extensive personal experience of petrous bone surgery involving the vestibular and facial nerves. Together with P. MacLeod, a close friend specializing in sensory physiology, Chouard decided to create a multidisciplinary team at the ENT Research Laboratory of St-Antoine teaching hospital in Paris. In 1975 the two men showed, in several patients with total unilateral traumatic deafness and facial paralysis, that electrical stimulation of 8 to 12 electrodes, isolated from one another and placed in different parts of the scala tympani, allowed the recipients to perceive different frequencies.

Then, having developed a test to ensure that auditory fibers were still present and functional (based on electrical stimulation of the round window), the Paris team implanted their electrodes in patients with long-standing total bilateral deafness. After a relatively brief period of postoperative speech therapy, all the patients were able to recognize a variable percentage of words without lip-reading. Under the scientific direction of P. Mac Leod, industrial production of an implantable functional device was entrusted to the Bertin, a French company. A table-top prototype was quickly built, but the untimely death of Jean Bertin in late 1975 led to restructuring of the company, and it was only in the summer of 1976 that the French researchers finally received the first 6 devices.

In the meantime, other French teams launched their own research programs, particularly in the area of the electrodes bearer, but they were forced to abandon their efforts.

In 1975, K. Burian in Vienna, building on the long tradition of the Viennese ENT school, launched the development of the first Austrian implant. His work on single-channel intra- and extra-cochlear stimulation, and then on multichannel stimulation, was pursued by his pupil I. Hochmair-Desoyer and her husband Professor Hochmair of Innsbruck. Their work culminated in 1982 with the Austrian Med-el implant.

Technological evolution and competition leading to a consensus on the best approach (1976-1997)

The first implant took place at Saint-Antoine hospital, Paris, on Wednesday 22 September 1976. It was performed by CH Chouard, assisted by Bernard Meyer. The patient recovered his hearing the following day, and another 5 patients were quickly implanted despite the bulky nature of the transmitter. On 16 March 1977, Bertin filed Patent No. 77/07824, based on the physiological criteria of MacLeod and making two simultaneous claims: 1) sequential transmission to the cochlea of an indeterminate number of frequency bands, and 2) transmission of all the sound information. The first results were presented at the XIth World ENT Conference in Buenos Aires, and were quickly published.

For nearly twenty years, this document influenced all the procedures and approaches used by other international teams, who were obliged to find ways around the patent claims, usually by opting to transmit only a portion of the speech information, until the patent fell into the public domain in 1997.

On 3 November 1977, the team of G. Clark (Australia) filed a patent for a system with three functional electrodes but using only a limited part of the speech information (voicing and one of the two formants of the vowels).

In 1975, Ingeborg and Erwin Hochmair started cochlear implant development at the Technical University of Vienna. 1977 the world’s first microelectronic multi-channel cochlear implant developed by Ingeborg and Erwin Hochmair was implanted in Vienna by Prof. Kurt Burian (1924 – 1996). The implant had 8 channels, a stimulation rate of 10.000 pulses per second per channel and 8 independent current sources and flexible electrode for 22–25 mm insertion into the cochlea. Prof. Kurt Burian inserted the flexible electrode through the round window into the scala tympani.

In December 1977, the Austrian team implanted a multichannel system with sufficient flexibility to study responses to various manipulations of the sound signal.

September 1978 saw the first International Teaching Seminar on Cochlear Implants held in Paris and attended by representatives of the other three involved countries, namely I. Hochmair-Desoyer and E. Hochmair (Austria), J. Patrick (Australia), R. Michelson and R. Schindler (USA).

In 1978, Graeme Clark (Australia) implanted his first patient.

In fall of 1979 a patient implanted in August 1979 with a device by Ingeborg and Erwin Hochmair, received a small body worn speech processor. It was modified in March 1980 at which time the patient became the first person to show open set speech understanding without lip-reading using a portable processor.

In 1982, CH Chouard, employing the Born reconstruction technique which he had previously used in his neuroanatomical research together with C. Eyries, was the first to demonstrate in animals the need for early implantation to avoid the atrophy of the central auditory structures that occurs very rapidly in case of persistent neonatal deafness.

In 1982 the new Bertin device, Chorimac 12, was presented. It had 12 electrodes and a smaller transmitter but was still much larger than the Australian and Austrian devices. A few years later, after announcing the arrival of the all-digital device that Chouard and MacLeod had been demanding since 1980, Bertin abandoned the field and sold its license to another French Company, MXM-Neurelec, in 1987. Bertin filed for bankruptcy in 1998.

In 1983, the 2nd international conference on cochlear implants was held in the former Paris Faculty of Medicine, just before the annual meeting of the international ENT collegium (ORLAS).

In 1984, the U.S. Food and Drug Administration approved the Australian implant for use in adults.

In 1985, the Australians improved on their original device35, which now transmitted all the vowel information.

In 1990, the U.S. Food and Drug Administration approved the Australian implant for young children.

In 1990, Ingeborg and Erwin Hochmair started their company Med-el based in Innsbruck, Austria and hired their first employees. One year later the company presented the world’s first behind-the-ear audio processor.

In 1991, MXM-Neurelec presented their first multichannel implant based on the Bertin license. It was fully digitized and could be adapted to an ossified cochlea.

From 1992 onwards, the multichannel cochlear implant gradually gained acceptance in France. Other teams, first in Montpellier and Toulouse, begin to implant it. At the same time, the sound processing strategy used by the different cochlear implants gradually adopted technology resembling that described in the Bertin patent, delivering all the sound information in a sequential manner. The American implant too provided the entire information in this way, while avoiding falling foul of the French patent by employing a few clever tricks and restrictions. The Australian device was also improved, providing all the sound information but retaining only the channels containing the maximum energy. This restriction also avoided the Bertin patent claims.

In 1994, Med-el presented the world’s first electrode array capable of stimulating the entire length of the cochlea to allow a more natural hearing.

In 1995, Paris organized the 3rd International Conference on Cochlear Implants.

1996, Med-el presented the world’s first miniaturised multichannel implant (4 mm thin) and also had the first bilateral implantation for the purpose of binaural hearing.

In 1997, the French license was blatantly copied, leading to Bertin to bring a lawsuit with seizure of the apparatus in question. This was just before the patent fell into the public domain. However, the charges were quickly dropped following protests in some surgical centers. In addition, the cost of the legal proceedings far exceeded any financial retribution the company could expect to obtain.

All manufacturers have since applied the principles of the Bertin patent defined by P. Mac Leod and CH Chouard.

Present

Following the French National Ethics Committee's approval of screening in the early neonatal period, and the tercentenary of the work of Abbe de l'Épée, celebrated in 2012 at the initiative of Legent, the positions of the deaf and hearing communities in France have started to be reconciled. In a cordial and respectful dialogue, avoiding proselytism, the two communities are striving to refine the criteria of choice between the cochlear implant and the use of sign language. Both options are sometimes valid.

References

- Jytdog (talk) 19:40, 23 February 2016 (UTC)

Cleanup part 2 - More WP:OR

The following sections are almost entirely unsourced WP:OR and have been for too long. I have again changed section headers to bold.

Candidates

A number of factors determine the degree of success to expect from the operation and the device itself. Cochlear implant centers determine implant candidacy on an individual basis and take into account a person's hearing history, cause of hearing loss, amount of residual hearing, speech recognition ability, health status, and family commitment to aural habilitation/rehabilitation.

A prime candidate is described as:

• having severe to profound sensorineural hearing loss in both ears.
• having a functioning auditory nerve
• having lived at least a short amount of time without hearing (approximately 70+ decibel hearing loss, on average)
• having good speech, language, and communication skills, or in the case of infants and young children, having a family willing to work toward speech and language skills with therapy
• not benefiting enough from other kinds of hearing aids, including latest models of high-power hearing instruments and FM systems
• having no medical reason to avoid surgery
• having appropriate services set up for post-cochlear implant aural rehabilitation (through a speech language pathologist, a deaf educator, or an auditory verbal therapist).

Type of hearing loss

People with mild or moderate sensorineural hearing loss are generally not candidates for cochlear implantation. Their needs can often be met with hearing aids alone or hearing aids with an FM system. After the implant is put into place, sound no longer travels via the ear canal and middle ear but is picked up by a microphone and sent through the device's speech processor to the implant's electrodes inside the cochlea. Thus, most candidates have been diagnosed with a severe or profound sensorineural hearing loss.

The presence of auditory nerve fibers is essential to the functioning of the device: if these are damaged to such an extent that they cannot receive electrical stimuli, the implant will not work. Some individuals with severe auditory neuropathy may also benefit from cochlear implants.

Age of recipient

Post-lingually deaf adults, pre-lingually deaf children and post-lingually hard of hearing people (usually children) who have lost hearing due to diseases such as CMV and meningitis, form three distinct groups of potential users of cochlear implants with different needs and outcomes. Those who have lost their hearing as adults were the first group to find cochlear implants useful in regaining some comprehension of speech and other sounds. The outcomes of individuals that have been deaf for a long period of time before implantation are sometimes astonishing, although more variable.

The risk of surgery in the older patient must be weighed against the improvement in quality of life. As the devices improve, particularly the sound processor hardware and software, the benefit is often judged to be worth the surgical risk, particularly for the newly deaf elderly patient.

Infant with cochlear implant

Another group of customers is parents of children born deaf who want to ensure that their children grow up with good spoken language skills. The brain develops after birth and adapts its function to the sensory input; absence of this has functional consequences for the brain, and consequently congenitally deaf children who receive cochlear implants at a young age (less than 2 years) have better success with them than congenitally deaf children who first receive the implants at a later age, though the critical period for utilizing auditory information does not close completely until adolescence. One doctor has said, "There is a time window during which they can get an implant and learn to speak. From the ages of two to four, that ability diminishes a little bit. And by age nine, there is zero chance that they will learn to speak properly. So it’s really important that they get recognized and evaluated early." Additionally, there is another sensitive period for strong asymmetry in hearing that closes earlier in life. In cases of early single-sided deafness or unilateral cochlear implantation, the brain reorganizes towards the hearing ear and that puts the deaf ear into a disadvantage. Consequently, the benefit of a sequential second implantation (on the deaf ear) is critically dependent on the delay between implantations. Periods of asymmetric hearing during early childhood should be avoided, and therapy of deafness should be binaural.

The third group who will benefit substantially from cochlear implantation are post-lingual subjects who have lost hearing: a common cause is childhood meningitis. Young children (under five years) in these cases often make excellent progress after implantation because they have learned how to form sounds and only need to learn how to interpret the new information in their brains.

Number of users

By the end of 2008, the total number of cochlear implant recipients had grown to an estimated 150,000 worldwide. A story in 2000 stated that one in ten deaf children in the United States had a cochlear implant, and the projection was that the ratio would rise to one in three in ten years.

Mexico had performed 55 cochlear implant operations by the year 2000 (Berruecos 2000). Taiwan and China announced an approximately $270 million order for cochlear implant devices for children in 2006, which are being paid for by major healthcare organization based in Taipei. These cochlear implants are a donation by the Taiwanese organization

In India, there are an estimated 1 million profoundly deaf children, and about 5,000 have cochlear implants. This minuscule number is due to the high costs for the implant, as well as subsequent therapy.

The operation, post-implantation therapy and ongoing effects

Cochlear implant as worn by user

The device is surgically implanted under a general anesthetic or local anesthetic without or with sedation, and the operation usually takes from 1½ to 5 hours. First a small area of the scalp directly behind the ear may be shaved and cleaned. Then an incision is made in the skin behind the ear and the surgeon drills into the mastoid bone, creating a pocket for the receiver/stimulator, and then into the inner ear where the electrode array is inserted into the cochlea. The patient normally goes home the same day or the day after the surgery, although some cochlear implant recipients stay in the hospital for 1 to 2 days. As with every medical procedure, the surgery involves a certain amount of risk; in this case, the risks include skin infection, onset of (or change in) tinnitus, damage to the vestibular system, and damage to facial nerves that can cause muscle weakness, impaired facial sensation, or, in the worst cases, facial paralysis. There is also the risk of device failure, usually where the incision does not heal properly. This occurs in 2% of cases and the device must be removed.

There is also a potential risk to lose the residual hearing the patient may have in the implanted ear because of the shaving of hair cells in the cochlea but the chances have decreased over time; as a result, some doctors advise single-ear implantation, saving the other ear in case a biological treatment becomes available in the future. However, with a careful surgical technique and a flexible electrode the residual hearing of the patient can be preserved. Ever since Ingeborg Hochmair and her husband Erwin Hochmair started their work this aspect has been one of the priorities.

After 1–4 weeks of healing (the wait is usually longer for children than adults), the implant is "activated" by connecting an external sound processor to the internal device via a magnet. Initial results vary widely, and post-implantation therapy is required as well as time for the brain to adapt to hearing new sounds. In the case of congenitally deaf children, audiological training and speech therapy typically continue for years, though infants can become age appropriate—able to speak and understand at the same level as a hearing child of the same age. The participation of the child's family in working on spoken language development is considered to be even more important than therapy, because the family can aid development by participating actively—and continually—in the child's therapy, making hearing and listening interesting, talking about objects and actions, and encouraging the child to make sounds and form words. Professionals trained to work with children who have received cochlear implants are a major part of the parent-professional team when addressing the task of teaching children to use their hearing to develop speech and spoken language. These professionals include, but are not limited to:

• Speech-Language Pathologists (SLP)
• Certified Auditory-Verbal Therapists (LSLS Cert. AVT)
• Pediatric Audiologist (AuD)
• Teacher of the Deaf (ToD) with a specialization in Oral Deaf Education

Some users, audiologists, and surgeons also report that when there is an ear infection causing fluid in the middle ear, it can affect the cochlear implant, leading to temporarily reduced hearing.

The implant has a few effects unrelated to hearing. Manufacturers have cautioned against scuba diving due to the pressures involved, but the depths found in normal recreational diving appear to be safe. The external components generally need to be turned off and removed prior to swimming or showering, unless manufacturers specified that the external components are water proof. In most cases, certain diagnostic tests such as magnetic resonance imaging (MRI) cannot be used on patients with cochlear implants without first removing the small internal magnet (an outpatient procedure usually performed with a local anesthetic), but some implants are now FDA approved for use with certain strengths of MRI machine.

File:The SYNCHRONY Implant.png

Implant SYNCHRONY (PIN) MRI Safe at 3.0 Tesla

The company Med-el has tackled this issue and has launched in 2014, the implant SYNCHRONY (PIN). Users with this implant do not have to undergo multiple surgeries to remove and reinsert the magnet and consequently lose their hearing while the magnet is out to undergo a MRI of up to 3.0 Tesla (common strength of MRI nowadays).

Large amounts of static electricity can cause the device's memory to reset. For this reason, children with cochlear implants are also advised to avoid plastic playground slides. The electronic stimulation the implant creates appears to have a positive effect on the nerve tissue that surrounds it.

References

- Jytdog (talk) 19:43, 23 February 2016 (UTC)

Cleanup part 3 - functionality

More unsourced WP:OR

Functionality

A man running the New York Marathon wearing an Advanced Bionics waterproof model

The implant works by using the tonotopic organization of the basilar membrane of the inner ear. "Tonotopic organization", also referred to as a "frequency-to-place" mapping, is the way the ear sorts out different frequencies so that our brain can process that information. In a normal ear, sound vibrations in the air lead to resonant vibrations of the basilar membrane inside the cochlea. High-frequency sounds (i.e. high pitched sounds) do not pass very far along the membrane, but low frequency sounds pass farther in. The movement of hair cells, located all along the basilar membrane, creates an electrical disturbance that can be picked up by the surrounding nerve cells. The brain is able to interpret the nerve activity to determine which area of the basilar membrane is resonating, and therefore what sound frequency is being heard.

In individuals with sensorineural hearing loss, hair cells are often fewer in number and/or damaged. Hair cell loss or absence may be caused by a genetic mutation or an illness such as meningitis. Hair cells may also be destroyed chemically by an ototoxic medication, or simply damaged over time by excessively loud noises. The cochlear implant bypasses the hair cells and stimulates the cochlear nerves directly using electrical impulses. This allows the brain to interpret the frequency of sound as it would if the hair cells of the basilar membrane were functioning properly (see above).

Processing

Sound received by the microphone must next be processed to determine how the electrodes should be activated.

Filterbank strategies use fast Fourier transforms (FFTs) to divide the signal into different frequency bands. The algorithm chooses a number of the strongest outputs from the filters, the exact number depending on the number of implanted electrodes and other factors. These strategies emphasize transmission of the spectral aspects of speech. Although coarse temporal information is presented, the fine timing aspects are as yet poorly perceived, and this is the focus of much current research.

Feature extraction strategies use features which are common to all vowels. Each vowel has a fundamental frequency (the lowest frequency peak) and formants (peaks with higher frequencies). The pattern of the fundamental and formant frequencies is specific for different vowel sounds. These algorithms try to recognize the vowel and then emphasize its features. These strategies emphasize the transmission of spectral aspects of speech. Feature extraction strategies are no longer widely used. Cochlear implant manufacturer use various coding strategies. Cochlear Americas, for example, uses the Speak-ACE strategy. ACE is mainly used, in which number of maxima (n) from the available maxima in sound are selected. Advanced Bionics uses other techniques like CIS, SAS, HiRes, and Fidelity 120, which stimulate the full spectrum. The processing strategy is a main block upon which one has to choose the implant manufacturer. Research shows that patients can understand speech with at least 4 electrodes, but a greater obstacle is in music perception, where it returns that fine structure stimulation is an important issue. Some strategies used in Advanced Bionics and Med-el devices make use of fine structure presentation by implementing the Hilbert transform in the signal processing path, while ACE strategies depends mainly on the short time Fourier transform.

Transmitter

This is used to transmit the processed sound information over a radio frequency link to the internal portion of the device. Radio frequency is used so that no physical connection is needed, which reduces the chance of infection and pain. The transmitter attaches to the receiver using a magnet that holds through the skin.

Receiver

This component receives directions from the speech processor by way of magnetic induction sent from the transmitter. (The receiver also receives its power through the transmission.) The receiver is also a sophisticated computer that translates the processed sound information and controls the electric current sent to the electrodes in the cochlea. It is embedded in the skull behind the ear.

Electrode array

The electrode array is made from a type of silicone rubber, while the electrodes are platinum or a similar highly conductive material. It is connected to the internal receiver on one end and inserted into the cochlea deeper in the skull. (The cochlea winds its way around the auditory nerve, which is tonotopically organized as is the basilar membrane). When an electric current is routed to an intracochlear electrode, an electrical field is generated and auditory nerve fibers are stimulated.

In the devices manufactured by Cochlear Ltd two electrodes sit outside the cochlea and act as grounds—one is a ball electrode that sits beneath the skin, while the other is a plate on the device. This equates to 24 electrodes in the Cochlear-brand 'nucleus' device: 22 array electrodes within the cochlea and 2 extra-cochlear electrodes.

Insertion depth is another important consideration. The mean length of the human cochlea is 33–36 millimetres (1.3–1.4 in), due to some physical limitation, the implants do not reach to the apical tip when inserted but it may reach up to 25 millimetres (0.98 in) which corresponds to a tonotopical frequency of 400–6000 Hz. Med-el produces long electrode arrays that can be inserted up to a tonotopical frequency of 100 Hz (according to Greenwood frequency to position formula in normal hearing), but the distance between the electrodes is about 2.5 millimetres (0.098 in), while in the Nucleus Freedom from Cochlear Ltd it is about 0.7 millimetres (0.028 in). There is strong research in this direction and the best sounding implant can be subjective from patient to patient.

Speech processors

Speech processors are the components of the cochlear implant that transforms the sounds picked up by the microphone into electronic signals capable of being transmitted to the internal receiver. The coding strategies programmed by the user's audiologist are stored in the processor, where it codes the sound accordingly. The signal produced by the speech processor is sent through the coil to the internal receiver, where it is picked up by radio signal and sent along the electrode array in the cochlea.

There are primarily two forms of speech processors available. The most common kind is called the "behind-the-ear" processor, or BTE. It is a small processor that is worn on the ear, typically together with the microphone. This is the kind of processor used by most adults and older children. Babies and small children wear either a "baby" BTE (pinned or clipped to the collar) or the body-worn processor, which was more common in previous years. Today's tiny processors can often take the place of bulky body-worn processors. Med-el and Cochlear brands both carry a "baby BTE" configurations. Med-el launched in 2013 the world’s first single unit processor, which is attached through magnet to the implant and leaves the ear completely free.

Programming the speech processor

The audiologist sets the minimum and maximum current level outputs for each electrode in the array based on the user's reports of loudness. The audiologist also selects the appropriate speech processing strategy and program parameters for the user.

References

- Jytdog (talk) 19:45, 23 February 2016 (UTC)

cleanup part 4 - further reading list

This is way too long - it looks like someone copy pasted the reference section out of a book or something. Moving here.

Further reading

• A wide range of information and activities designed to help recipients and the professionals they work with develop or re-learn listening and language skills - http://www.cochlear.com/wps/wcm/connect/in/home/connect/rehabilitation-resources/rehabilitation-resources
• Berruecos, Pedro. (2000). Cochlear implants: An international perspective - Latin American countries and Spain. Audiology. Hamilton: Jul/Aug 2000. Vol. 39, 4:221-225
• House, W. F., Cochlear Implants. Ann Otol Rhinol Larynogol 1976; 85 (suppl 27): 1 – 93.
• Simmons, F. B., Electrical Stimulation of the Auditory Nerve in Man, Arch Otolaryng, Vol 84, July 1966
• Pialoux, P., Chouard, C. H. and MacLeod, P. 1976. Physiological and clinical aspects of the rehabilitation of total deafness by implantation of multiple intracochlear electrodes. Acta Oto-Laryngologica 81: 436-441
• Chorost, Michael. (2005). Rebuilt: How Becoming Part Computer Made Me More Human. Boston: Houghton Mifflin.
• Christiansen, John B. (2010) Reflections: My Life in the Deaf and Hearing Worlds. Washington, DC: Gallaudet University Press.
• Christiansen, John B., and Irene W. Leigh (2002,2005). Cochlear Implants in Children: Ethics and Choices. Washington, DC: Gallaudet University Press.
• Cooper, Huw R. and Craddock, Louise C. (2006)Cochlear Implants A Practical Guide. London and Philadelphia: Whurr Publishers.
• Djourno A, Eyriès C (1957). "Prothèse auditive par excitation électrique à distance du nerf sensoriel à l'aide d'un bobinage inclus à demeure". La Presse Médicale. 65 (63).
• Djourno A, Eyriès C, (1957) 'Vallencien B. De l'excitation électrique du nerf cochléaire chez l'homme, par induction à distance, à l'aide d'un micro-bobinage inclus à demeure.' CR de la société.de biologie. 423-4. March 9, 1957.
• Eisen MD (May 2003). "Djourno, Eyries, and the first implanted electrical neural stimulator to restore hearing". Otology and Neurotology. 24 (3): 500–6. doi:10.1097/00129492-200305000-00025.
• Grodin, M. (1997). Ethical Issues in Cochlear Implant Surgery: An Exploration into Disease, Disability, and the Best Interests of the Child. Kennedy Institute of Ethics Journal 7:231-251.
• Johnston, Trevor. (2004). W(h)ither the deaf Community? In 'American Annals of the deaf' (volume 148 no. 5),
• Kral A, Sharma A (2012). "Developmental Neuroplasticity after Cochlear Implantation". Trends Neurosci. 35 (2): 111–122. doi:10.1016/j.tins.2011.09.004. PMC 3561718. PMID 22104561.
• Kral A, Eggermont JJ (2007): What's to lose and what's to learn: Development under auditory deprivation, cochlear implants and limits of cortical plasticity. Brain Res Rev 56: 259-269.
• Lane, H. and Bahan, B. (1998). Effects of Cochlear Implantation in Young Children: A Review and a Reply from a DEAF-WORLD Perspective. Otolaryngology: Head and Neck Surgery 119:297-308.
• Lane, Harlan (1993), Cochlear Implants:Their Cultural and Historical Meaning. In 'deaf History Unveiled', ed. J.Van Cleve, 272-291. Washington, D.C. Gallaudet University Press.
• Lane, Harlan (1994), The Cochlear Implant Controversy. World Federation of the deaf News 2 (3):22-28.
• Litovsky, Ruth Y., et al. (2006). "Bilateral Cochlear Implants in Children: Localization Acuity Measured with Minimum Audible Angle." Ear & Hearing, 2006; 27; 43-59.
• Miyamoto, R.T.,K.I.Kirk, S.L.Todd, A.M.Robbins, and M.J.Osberger. (1995). Speech Perception Skills of Children with Multichannel Cochlear Implants or Hearing Aids. Annals of Otology, Rhinology, and Laryngology 105 (Suppl.):334-337
• Officiers, P.E., et. a. (2005). "International Consensus on bilateral cochlear implants and bimodal stimulation." Acta Oto-Laryngologica, 2005; 125; 918-919.
• Osberger M.J. and Kessler, D. (1995). Issues in Protocol Design for Cochlear Implant Trials in Children: The Clarion Pediatric Study. Annals of Otology, Rhinology, and Laryngology 9 (Suppl.):337-339.
• Reefhuis J; et al. (2003). "Risk of Bacterial Meningitis in Children with Cochlear Implants, USA 1997-2002". New England Journal of Medicine. 349 (5): 435–445. doi:10.1056/nejmoa031101.
• Spencer, Patricia Elizabeth and Marc Marschark. (2003). Cochlear Implants: Issues and Implications. In 'Oxford Handbook of deaf Studies, Language and Education', ed. Marc Marschark and Patricia Elizabeth Spencer, 434-450. Oxford: Oxford University Press, 2003.
• 3M Power Point Presentation on the Cochlear Implant.
• Barton G. Kids Hear Now Cochlear Implant Family Resource Center, University of Miami School of Medicine

- Jytdog (talk) 08:13, 24 February 2016 (UTC)

update

i rewrote the medically relevant parts of this article and that seems OK to me now. 2 sources I used, PMID 26443490 and PMID 26097718 had very good history sections; the first one there is mostly focused on ongoing research so could be used to build that section. Done for now though. Jytdog (talk) 08:15, 24 February 2016 (UTC)

In regards to "in both ears" - there is much information about implants being used for individuals with single sided deafness 1. As such, I believe the phrase is misleading and inaccurate. Additionally, it seems only appropriate to lead the portion about risks with a statement about the overall occurrence of risk from the entire pool of implant recipients, thus presenting an accurate picture of risk occurrence. To do otherwise is to distort the real risk. I will suggest a more precise lead in (with figures and citations) asap. — Preceding unsigned comment added by Kokorobike (talk • contribs) 01:25, 8 October 2016 (UTC)

the WP:LEAD summarizes the body. If you are going to make changes please make them in the body first. Please do not make changes without citing a source. Please make sure any sources you bring for WP:Biomedical information comply with WP:MEDRS. Thanks. Jytdog (talk) 01:27, 8 October 2016 (UTC)

That was a good ref; I updated the body then updated the lead with content sourced from it in these diffs. Jytdog (talk) 01:46, 8 October 2016 (UTC)

Thanks Jytdog - A quick question about language use (sorry it's my profession) - I think changing the first "had" to "have" and removing the second "had" in the following sentence is more appropriate - "as of 2014 they had been used in some people who had acquired deafness in one ear after learning how to speak". What do you think? Kokorobike (talk) 02:27, 8 October 2016 (UTC)

The present perfect is not appropriate as anything after 2014 is not supported by the source. Content has to actually be supported by the source; hence the past perfect. Jytdog (talk) 02:36, 8 October 2016 (UTC)

Jytdog - thanks again - but I'm a bit confused about policies governing language use here (I am, admittedly, a novice WP editor). Should we assume that because the most recent study, in the link I provided, was from 2014, that cochlear implantation for SSD ceased at that point as is implied by use of the past perfect? Given the evidence of efficacy found in those studies it seems fair to assume (and of course continue to provide evidence of) continued use for SSD. Additional evidence does, needless to say, exist.1 Kokorobike (talk) 03:03, 8 October 2016 (UTC)

The underlying principles here are simple. We use good sources, and content is based on them and nothing else. Wikipedia communicates what sources say and nothing more. Somebody reading this might ask, "OK, what about since then?" And when there is a review that discusses more, we can say more. The key thing is that this is clearly experimental - I've added that word to clarify. We don't do cutting edge so much here in WP and that is by design; the new ref you bring is a case study (a primary source), not a review. Jytdog (talk) 03:07, 8 October 2016 (UTC)

Jytdog - I'm afraid I cannot agree with "Wikipedia communicates what sources say and nothing more." in this case - By writing "as of 2014 they had been used experimentally in some people who had acquired deafness in one ear after learning how to speak." you are communicating that cochlear implants are no longer used (experimentally or otherwise) for SSD which is NOT accurate as evidenced by the case study as well as other sources that clearly show cochlear implants being used for patients with SSD. [1] Given the fact that you have included the word "experimentally" there is really no justification for using the past perfect and thus inaccurately implying that the practice is no longer taking place. Additionally, you are also communicating a message that cochlear implants are only used for SSD patients who have already acquired language, which is also incorrect. While arguably experimental, use for pre lingual SSD patients is occurring[2]. I too am primarily interested in communicating an accurate account of current practices and nothing more. Kokorobike (talk) 06:25, 8 October 2016 (UTC)

Don't personalize this - cool down. We can write what we have sources for. Please keep in mind that Wikipedia is not a newspaper. I will look at your refs tomorrow. Jytdog (talk) 06:54, 8 October 2016 (UTC)

Jytdog - Sorry, it was not my intention to come off as angry. :-) I was simply attempting to respond to your comments using some of the language you used....admittedly in an aggressive fashion. Thanks, I appreciate your time and consideration. Also, I do understand that Wikipedia is not a newspaper...and am glad it's not. I just want to update it, in this case, with more recent information and, with your agreement, contribute some additional information (source based, of course) to add to the depth of the entry. Peace! Kokorobike (talk) 07:01, 8 October 2016 (UTC)

I do have a question for you I just thought of - you are doing great at finding sources. The ones you have brought so far for single side use are reviews of clinical trials and case studies... do know of any refs that discuss how much this is being routinely? Jytdog (talk) 07:16, 8 October 2016 (UTC)

To be honest, my current research is in efficacy for pre lingual deaf children so I don't have as much experience with researching outcomes for SSD patients. Within that cohort, I would be personally be most interested in pre lingual recipients but, of course, any valid information available would, I hope, be a candidate for inclusion here. For now, here is another 'summary' resource. [1] Also, just to be safe and clear, I am not the author of any of the studies cited thus far. :-) Kokorobike (talk) 12:35, 8 October 2016 (UTC)

content about kid born without ears

We are having a little edit war about the following: In addition, successful surgeries have existed to develop an ear canal from rib grafts to eliminate the need for external hearing devices entirely.

References

here is what the source says:

Dr. Robert Jahrsdoerfer is trying to correct the effects of Goldenhar's Syndrome, a rare birth defect. Kenny was born without ear canals, without eardrums and without an external ear on the left side. But his inner ear bones are well-developed. Dr. Jahrsdoerfer started on the right ear. In a four and a half hour operation at the University of Virginia,he drilled an ear canal..lining it with skin from Kenny's arm. He built an eardrum with muscle tissue. Cleaning the ear, he sees how it's healing....

• First, there is nothing about "rib grafts" in the source - the operation was about skin and cartilage stuff, not bone.
• second, besides being inaccurate, this has nothing to do with the topic of this article as far as I can see. Why does anybody think it does?
• Third, this is in the medical section, and the source fails MEDRS.

-- Jytdog (talk) 21:56, 21 October 2016 (UTC)

History

User:Edwtie as I noted on your talk page, the content you have added here and here and here and here contains unsourced content as well as content based on unreliable sources. This content violates policy. If you don't understand WP:OR, WP:V, and WP:RS please ask. Thanks. Jytdog (talk) 19:36, 3 January 2017 (UTC)

We have checked this comments. but We will added this cites soon! Please wait Edwtie (talk) 19:38, 3 January 2017 (UTC)

What do you mean by "we"? Jytdog (talk) 19:40, 3 January 2017 (UTC)

Deaf community, many experts of cochlear implants and I aren't agreed with you because many subarticles are deteled. But I saw that sources must be verficerd. I will added this sources. History is almost good but it will rewrite. we have many books. We will added this sources. you must know that this cochlear implants are not always suitable for all kind of deafness. Edwtie (talk) 19:45, 3 January 2017 (UTC)

I do always checked cites. WE = is not wikipedia users. I do only ONE account. but my opinion is almost same with deaf communities but you must learn deaf communcities. I will try added more sources, Edwtie (talk) 20:03, 3 January 2017 (UTC)

Criticism and Controversy section

I changed the first sentence which read: "Much of the strongest objection to cochlear implants has come from the Deaf community" to "Much of the strongest objection to cochlear implants has come from within the Deaf community". The first paragraph of the quoted reference states " For some in the deaf community, CIs are an affront to their culture...". I think including the word "within" more accurately reflects the statement of the source. Jameywiki (talk) 20:28, 28 December 2016 (UTC)

This may be the dumbest article I've ever read on Wikipedia. "An affront to their culture"? Really? So we should just quote ANY article written by an insane person and assume it reflects the majority of deaf people?

Can you imagine if we did the same thing to other topics or medical devices? "There is a significant group of people who find artificial hearts an affront to their culture."

Should we pepper every article of Wikipedia with a "controversy" section for the 20 people who hate that topic? And even worse, should we put their claims in the *introductory paragraphs?*

All of the disagreement text should be moved to the controversy section, and trimmed to the best, sourced, details. Because right now, the article violates NPOV by clearly establishing a bias against Cochlear Implants, and falsely portraying (without citation) that a large population of people are against medical devices designed to treat a known condition. Novous (talk) 20:16, 13 February 2017 (UTC)

NPOV tag

User:Edwtie, please read template:NPOV. You need to discuss here why you believe the article fails the WP:NPOV policy. Just tagging does nobody any good. Please describe why you believe that this article fails NPOV. Thanks. Jytdog (talk) 20:08, 3 January 2017 (UTC)

Clearly, the bias against the medical device showing up in the **introduction** violates NPOV. It makes it look like the majority is *against* using the devices Novous (talk) 20:21, 13 February 2017 (UTC)

I imagine you are talking about the last bit, which summarizes this section: Cochlear_implant#Criticism_and_controversy. How would you summarize that section? Jytdog (talk) 20:28, 13 February 2017 (UTC)

you need rewrite this section because your section seems that cochlear implants are only a solution for deafness. it means for ALL deaf people. it's big wrong. Because prelinqually deaf adults will not profits from cochlear implants. Cultural deaf poeple are against that young children became cochlear implants. you must expain WHY?! you haven't made CLEAR why do parents give cochlear implants to young children. you have deleted many important sentence that a critical period is very important for young children. Because brain development of young children will boost when they are using cochlear implants. Edwtie (talk) 10:04, 6 April 2017 (UTC)

How about you fix those things you don't like? Why should anyone else do it for you?★Trekker (talk) 10:10, 6 April 2017 (UTC)

"A cochlear implant (CI) is a surgically implanted electronic device that provides a sense of sound to a person who is profoundly deaf or severely hard of hearing in both ears"

it must be changed: a person who became profoundly deaf and aren't grown in deaf community and young children who became deaf after illness it means post lingually deaf people and deaf people who have only oralisme. The cochlear implants will supports lipreading and talking (talk) 10:15, 6 April 2017 (UTC)

I have no idea what your issue is but how about if you think something in the article is inaccurate you add a source and fix it?★Trekker (talk) 16:37, 6 April 2017 (UTC)

JOytdoy have big delted big article. When I try to change this then joytdoy will undone this . I hate it. but it take much time,because it must added more source. but article from antoher version is very correct. but he think that it has copyright . but it has no copyright. becuase many editors have added many articles but they have forget sources. but I need more help from another editiors .but joytdoy have big detaled and asked to delete in stead of support to fix source.. he look only to rules of wikipedia but it has NO heart to support editors. Edwtie (talk) 22:13, 13 April 2017 (UTC)

Credibility of Sources

1. The reference to CI's lessening tinnitus is not objectively accurate. If this outcome occurs some of the time, it cannot be used as a sweeping conclusion of having a cochlear implant implanted. This may show bias as personal accounts of CI users have experienced worsened tinnitus.

2. The article cited from the New York times after the sentence claiming resistance from the Deaf Community does not support the claim as it was written by one person and cannot accurately represent an entire community. If the generalization about a communities ideology cannot be back up with a credible, reliable source, it should be omitted. Jpeliz (talk) 01:20, 6 February 2018 (UTC)

That shit was added but some spamming IP editor. i have removed it. Jytdog (talk) 01:36, 6 February 2018 (UTC)

Critique

In the third paragraph of the introduction, the sentence, "There is some evidence that implanting CIs to improve hearing may also improve tinnitus but there is some risk that it may cause people who never had tinnitus to get it." needs a citation. — Preceding unsigned comment added by Jaxanderson (talk • contribs) 02:29, 6 February 2018 (UTC)

The lead summarizes the body of the article per WP:LEAD. Read the body of the article. If the content is supported there it doesn't need to be sourced in the lead. Jytdog (talk) 02:44, 6 February 2018 (UTC)

First cochlear implant

There is not mention of Claude-Henri Chouard in this article. He implanted the first CI in 1976. See this article for more information, especially table 1 — Preceding unsigned comment added by 83.205.6.160 (talk) 15:25, 19 November 2018 (UTC)

Details about different CI models

Greetings, I am not certain where would be place to list detailed information and photos of different cochlear implant models. My first thought is to create a new section here titled 'Devices' starting with Advance Bionics and then slowly add Med-El and Cochlear devices. This could eventually be expanded into an independent article, something like Cochlear implant devices, similar to iPhone and List_of_iOS_devices Shushugah (talk) 10:42, 12 June 2020 (UTC)

Looking for sourcing

User:Kelly222 Can you clarify where the 30%/one-third finding is supported? That is a big claim that I'm having hard time finding support for. Thank you. DLM84 (talk) 19:12, 22 November 2021 (UTC)

..Thank you for leaving it. It's in the footnote Kelly222 (talk) 00:25, 23 November 2021 (UTC)

User:Kelly222 Would you mind copying and pasting the exact line here? I wasn't able to find it in the footnotes - thank you!DLM84 (talk) 17:40, 23 November 2021 (UTC)

 It was footnote 4 which you managed to remove in your last edit. I've used "Undo" to return it. I wasn't sure what your last edit was doing to the article. Can you tell me the purpose of your last edit. I'm did a "diff" but nothing was highlighted. Kelly222 (talk) 20:32, 23 November 2021 (UTC)

User:Kelly222 Apologies for the confusion, but the information (30% and one-third) needs be verified in the article that is linked in footnote 4 (which is now reference 10). Reference 10 is a research article and nowhere in that article does it mention the claim that "...for pre-lingually deaf children the risk of not acquiring spoken language even with an implant may be as high as 30%." Thank you. DLM84 (talk) 19:56, 24 November 2021 (UTC)