Wisconsin Public Television University Place Waisman Center Day  Samuel Gubbles Medical Aspects of Cochlear Implantation  June 23, 2012 UP733 cc >> I'm new to UW-Madison. I've been here for about four years. I'm a cochlear implant surgeon. I do implants in both adults and children. I wanted to first take a minute to thank Ruth, and Theresa --, and Carrie -- who just stepped out for a minute. It's a joint effort in organizing this amongst us. January was our first meeting to think about this meeting and it's a pleasure to see the great turnout we have today. And after so many months of thinking about it, I think we're all very pleased. So thank you all for showing up today. I hope it's useful in all regards. 

I'm going talk a little bit about the medical aspects of cochlear implantation. I hope to have some time at the end to speak a little bit about novel therapies for hearing loss. And no financial relationships. I will be talking about the different implants, and I have no relationships to disclose with any of the manufacturers, while review the devices in brief. Diane talked, and I'll have a little bit more than she covered. This is the outline. I was unaware of how much history and depth Diane would go in her talk about the history which was wonderful, and so we can save time by going through the history quickly. The cochlear implant evaluation. There was a question about the evaluation itself. What are the facets of the evaluation process. 

I'll cover those in detail. And we'll go over the surgery briefly. And we'll talk about life after a cochlear implantation. Briefly some of the nuts and bolts and implications medically for decisions down the road and talk a little bit about novel therapies for hearing loss. So I think we can move through this slide given the crowd and your interests and being here some of the numbers probably familiar to all of you about how hearing loss is a global health problem and both in adults and children. And in general, as Dr. Heatley covered, if we can use hearing aids, we want to use hearing aids. It avoids surgery, and uses normal acoustic hearing than electric hearing that is provided with cochlear implants. Essentially, the fundamentals of cochlear implant candidacy for all age ranges are, are they receiving limited benefit from a hearing aid. If we can use hearing aids, we should use hearing aids. Cochlear implants as we've discussed already, and we've already covered so much in the first few hours of this and there's going to be large holes in my talk that we've already gone over. 

I'll try to move through those. It's an electrical stimulation of the auditory nerve. We talked about different manufacturers and the multiple channels each manufacturer produces. It's not great evidence that we are able to actually harness the extra information provided by additional channels from some of the cochlear implants, and there is, at least in quiet, a ceiling effect in about 6 to 8 channels I think, with speech. Essentially beyond six or eight channels, you can't get additional benefit, at least in quiet conditions, when we are testing speech. Again, it's stimulation directly of the auditory nerve. And I think Diane mentioned, that in 2010 the latest numbers we have, it's about 219,000 people worldwide who have been implanted. Here's a typical -- internal device. We'll go over some of the components of the internal device in a minute. This is a schematic of what the electrode going into the cochlea looks like. 

So again, I'm going to move right through the couple history slides. I think this one's interesting, just because it shows the first device Diane mentioned, which was really this first cochlear implant, is the house 3M device. It was single channel cochlear implant. It's remarkable the benefit that patients got from only one channel. And especially some patients had a remarkable benefit from only one channel. There was a question earlier about the need to re-implant. If you implant a child early in life and the need to re-implant later. Certainly, the thought is that, with a modern cochlear implant, it can last a lifetime. There's a technological risk, if you will, that at some point there's bound be some improvement that you want to take advantage of going from a single channel to multiple channels, or in the future there's investigations going on to look for totally implantable cochlear implants. At some point will we look at doing that, and might one consider the risks of additional surgery to take advantage of those, of the developments in the future, that may be possible. 

But again, this is of historical interest again, being the original cochlear implants. It's also worth the mention I think that cochlear implants are fascinating on many levels but one of the levels is that it's amazing that they work as well as they do. You think the architecture of the inner ear and how delicate it is, that we can put in an electrode and have it function as well in the inner ear it has is really remarkable, and it's actually telling, when the cochlear implants first were introduced, there were many very prominent cochlear implant surgeons world wide who, I remember one of the famous quotations, "there will be a lot of advancements in our ability to improve people's hearing but cochlear implants is not the one." There were implant surgeons who almost got burned a little bit because they made an early judgment. They were surprised at how well the cochlear implants ended up functioning down the road. Here are the current devices in use. Again, there are three manufacturers and they're very similar essentially. Here's the external device for the Nucleus, or the cochlear device, the Advanced Bionics, and Med-El. This is their modern internal implant, with Med-El, and here's the external for the Advanced Bionics, and again, the Cochlear Corporation has the most market share world wide and this is the currently used implant. We'll talk a little bit about the evaluation process. There's three important components, three essential components in the evaluation process. 

One really stands out as the most important. We've touched on it multiple times this morning. That's the audiological evaluation done by the audiologists in determining what level of hearing loss we have. This determination is different for different ages. Young children, as you might imagine, there are more challenges in determining exactly is there is any residual hearing there, and if so, are we better off with hearing AIDS. Whereas in adults it's a little more straightforward on some levels, although always changing. The medical evaluation by the otologist, or cochlear implant surgeon. Radiological evaluation as well, involving a CAT scan or MRI scan, some cases a psychological evaluation. In children, there's other evaluations that are important to consider when we're evaluating a patient for their candidacy and how well they'll do in the future. The audiological evaluation, again, I think Diane touched on one thought that I think is important to say here. 

Really the advantage we get with cochlear implants and really the magic of a cochlear implant is not really what's done surgically. The implant procedure is relatively scripted on some levels. You need flexibility with young children and for different anatomical variance, but on the whole, thankfully for us, the anatomy is pretty constant. Most of the procedures, again, you know what to expect throughout the procedure. Really the advantages and advancements and the benefit that patients receive with cochlear implants is due to what's done with our audiologists, both evaluating patients preoperatively and probably more important after surgery with the multiple visits that they'll have with our audiologist to optimize the device and it's function. Again, the candidacy we've already gone over this, so I'll move through it. We'll have more on this a little bit later today. Severe profound, sensorineural hearing loss in both ears. This can be from before or after the on set of language. This is a determination we're using less these days, pre- or post-lingual, and limited benefit from amplification. 

Again, these are the two most important considerations. It's just really from there a question of how do we demonstrate that audiologically in different age ranges. Another important thing to highlight is there has to be realistic expectations for the device. In the family that Ruth presented, with the parents having 30 years without hearing loss the expectations for what they might achieve from their cochlear implants are going to be very different from their children when they were implanted, that you can expect they're going to perform at a much higher level than a person who's had a prolonged period of hearing loss. Also, we need to speak to the motivation and commitment of the patient and the family. This is a critical factor for getting the best outcomes. Assessing this is hard, but again, there's a lot left in the hands of the patients and we help guide things as far as the leap of faith not using their hearing aid in the other ear anymore. Just focusing on using the cochlear implant, at least for a period of time, to get their brain, essentially, used to using the cochlear implant and going away from auditory hearing, and maybe re-integrating that that down the road. There's really a commitment and motivation requirement that we need to at least mention in the process that's very important. During the medical evaluation, there are really three major things that we look at, the cause of the hearing loss, the duration of the hearing loss, and then hearing aid usage. 

You see on the right, a number of the more common causes of hearing loss. For most of them it doesn't actually effect necessarily the candidacy of a patient. There are some that really will, for example, a history of meningitis will significantly affect what we might expect after cochlear implant, and certainly if they have gone on to develop some -- that some patients will after meningitis. Thankfully this is infrequent. The bottom line is that most of time the etiology is not necessarily why they lost hearing, doesn't affect the ability to implant. Duration of hearing loss helps to predict what the realistic expectations might be. And hearing aid usage is very important. For a patient who hasn't had hearing for ten years but continued to do what they can with a hearing aid as opposed to a parent who just abandoned hearing aids for the last ten years after losing hearing. We might have different expectations after their cochlear implant. Any history of infections, be that acute infections or recurrent infections, perhaps more severe infections that we'll see the of temporal bone, and middle ear infections. 

They'll certainly affect some of the planning we'll do surgically and how we manage the situation. Thankfully, it's an infrequent consideration. Any history of surgery, tubes in the ear, fore-infection, and surgeries for more significant problems, like cholesteatomas, as I mentioned, or skill-based tumors, will certainly factor into our decision-making technically, how we do the surgery. Then, neuro-surgical procedures that may have been be needed. Patients who have with syndromic conditions, like neurofibromatosis, or have had previous surgery in the area, or shunts for hydrocephalis. These are conditions that we certainly want to factor in as we're doing the cochlear implant surgery. None of them would tell us we couldn't do it but would require some additional planning. And then general medical clearance for cochlear implantation. A patient's cardio-pulmonary profile, their heart, lungs, what state they're in, if they had a previous heart attack or any other, maybe congenital, heart abnormalities, bleeding risk, anesthetic risk. And really important is wound healing. 

One of the complications that we can see with cochlear implants are wound related problems. As with any implant, as Diane mentioned, with a hip or an implant anywhere implanted in a human body, there are always risks of infection and other risks that go along with it. We must really focus on wound healing problems so patients who are heavy smokers, uncontrolled diabetes, patients on steroids for autoimmune disease. These are things we'll need to factor this in and they might change plan our surgery a bit as far as what we do planning our incision and some other maneuvers during surgery to help give us the best chance of wound healing without problems. So that's the medical evaluation. Again, we mentioned audiological evaluation, and then last is an evaluation radio graphically to look either with a CAT scan or MRI scan and determine if the inner ear looks implantable. Generally we do a CAT scan and that tells us that the cochlea is open and looks normal otherwise. In patients who've never had hearing in an ear, we'll do an MRI scan. The reason we do that, most important thing we need to identify with a screening evaluation is there an auditory nerve present. Here we see an MRI scan, and a certain technique of doing an MRI scan that can highlight the nerves. 

You'll see this darkened area here is the hearing nerve as it's traversing from the brain stem and out to the inner ear. This is the cochlea right here. And clearly we can tell in this patient there is an auditory nerve present. We'll use this type of evaluation in some patients, particularly young children who have never had hearing to determine if there's an auditory nerve present and determine therefore if an implant seems a reasonable thing to do. Most of the time we use a CAT scan in the majority of patients though, which is a more limited study but still gives us the information that we need. We also want to account for inner ear malformations, or other disease in the middle ear or mastoid bone that may complicate the implantation process as part of the pre-operative evaluation. The next step, essentially at this point we've evaluated and determined that a patient is a candidate, audiologically, the most important part of the process, and that there are no contrary indications medically or on their CAT scan to indicate that we're going to have problems surgically. From there then, we submit to insurance. The question came up on who pays for cochlear implants. That's an important issue. 

Our criteria for cochlear implant candidacy on many levels is based upon insurers. Most of the private insurers base their determination on who's a candidate based on CMS criteria, you can think of as Medicare and Medicaid who set standards for the medical industry as far as when something is paid for and when it's not. That's very true for cochlear implants. It's an expensive venture, so they have strict criteria that we must meet. When we write the letter for prior authorization we have to show that they've demonstrated all these certain prerequisite criteria in order to be implanted. This process, unfortunately, sometimes is only a few weeks to hear back from an insurer, sometimes it's longer. Sometimes there's an appeal involved. It depends. As Diane mentioned earlier, we're fortunate in Wisconsin, I think overall we have very good healthcare coverage and we're more fortunate than many other communities as far as how much we have to fight in these sort of battles to get covered for a cochlear implant. We still have our troubles here and there. 

That consideration aside, we have to decide then which ear to implant, or are we going to pursue implants on both sides. We also have to decide which device to implant. Here at UW we carry the Med-El and the Cochlear devices. Different centers may cover all three, some carry just one device. But that discussion is ultimately made, that decision is ultimately made, by the patient, primarily in discussion with our audiologists about the different pros and cons of each device. Many of them are very similar. It does come down on some level to some bells and whistles, as far as maybe even how the device appears, the external processors, sometimes guarantees on the device or a warranty for a period of five years. One of the companies offers that currently. Sometimes it endings up being small things which determine that. Similarly, when choosing which side, in some patients, it's very clear. 

They haven't had hearing in one ear for 20 years, whereas the other ear they've heard well from and it's slowly progressed and now they're a candidate. We're going to obviously want to do the ear that's their better hearing ear because we can predict they'll do better with a cochlear implant as that nerve is healthier. In other patients, it's a wash. Both ears have had a vary similar history and the decision will be made by their handedness sometimes, are they right or left handed, and sometimes other small factors which will make this decision. Again, the pre-surgical evaluation, we covered most of the main elements, a visit with the primary care physician often is involved for preoperative clearance. Diane mentioned that, as with any surgical procedure, there are risks involved with cochlear implantation. Device failure is probably one of the bigger ones we see. It can come in the form of the device just stopping working all together. That's what we call a hard failure, where it's just no longer working at all, or what's classified as a soft failure. Slowly the device may start malfunctioning on certain levels. 

We think there are different things happening with the device with these two different types of failures. If you look across the board, what's the chance you might have a failure with the cochlear implant? I think reasonable estimates are somewhere between 1 and 4%. Infection is a risk. It's probably 1 to 2% at some point in somebody's life that they could have an infection. Thankfully, most of the time if there's an infection, it can be treated with antibiotics. There are some cases where it's severe enough that the device would have to be removed. We'd wait for the infection to clear and we'd have to replace the device. If that occurs, most of the time we can get a successful re-implantation with a good outcome, but obviously there's two surgeries involved and antibiotics and so-forth. That is a risk, as with any device. Facial nerve stimulation or facial nerve weakness, an inherent part of placing a cochlear implant is that we have to be comfortable around, and very close to, the facial nerve. 

You may have seen a patient with a stroke and a Bell's palsy where there's a facial droop. That's the facial nerve. In cochlear implantation we have to be very close to that nerve. It's an inherent part of the surgery, so there is risk to it. Thankfully, it's very uncommon that we have problems with that nerve, but, again, it's a part of the surgery. A risk of dizziness is possible, and more common if a patient has had dizziness before implantation. And as I spoke to earlier, there's a technical kind of risk involved. The patients who got the original house 3M device, when the multi-channel device became available, they wanted to have that, so that was a number of re-implants that occurred. The same thing might happen in the future. The surgery itself is done under a general anesthetic. 

It's an overnight stay in the hospital. Sometimes, it's done as an outpatient procedure. It depends patients to patient. It can be about two hours on average. There's really minimal hair shaving for the incision that's involved. It's all done under a operating microscope that looks like this. This is one of the monitors, a facial nerve monitor, that I just mentioned that we use during the surgery. There are multiple different types of incisions we use, but I would say this is probably the most common one. This the patient and their nose is up here, the top of the head, the feet up this way here's the back of the head. This is with the ear folded forward and there's an incision like this, what we call a lazy-S incision, behind the ear. 

It's probably the most common. Here's what the device looks like and the essential components of a cochlear implant. This is the brains of the internal-- this is the part that's completely implanted underneath the scalp. This is the receiver stimulator where most the important processing of the device goes on. This coil right here is the cochlear electrode that gets inserted into the cochlea. You can see this particular device coils upon itself. Doesn't come like that, it comes straight when we take it out of the box but when we put it in the cochlea, it coils upon itself. Here's another electrode we have to put under some of the muscle here. There's a magnet here in the middle of this part of the device, and that's to help hold on the external portion of the device which I'll get to that in a minute. And this is an antenna, which you can think of as essentially receiving the power and sound signals from the external device that are transmitted through the skin. 

The surgery itself, I'm not going to spend a lot of time on, but essentially after the incision, if you feel behind your ear the lump of bone right behind your ear, we have to remove a bit. That's called the mastoid process. We have to get though that to get deeper down to where we're at the opening of the cochlea and we can make what's called a cochleostomy. This is a critical part of this surgery, what's called a facial recess, where we're closest to that facial nerve. Again, it's key that, for a successful outcome, that we're very close to it and also respect it, obviously. The facial nerve runs right in there and we're within fractions of a millimeter of it during surgery. Here's the view we have when we're about to make-- This is the innermost of the three hearing bones, the stapes, here's what's called the round window, and we make a hole into the cochlea right here, what's called a cochleostomy, and then insert the electrode. Here's a picture of a small burr, small drill that we use to make the hole prior to implanting an electrode into the ear. After surgery, there's a number of important things involved. There's a dressing that's on for a day or two. 

Immunization Diane covered. The CDC has recommendations that change periodically. The last revision was in 2010 with new recommendations for vaccination for patients with cochlear implants. Essentially there's one bacteria that we're most concerned about with cochlear implants and most people now are immunized for this particular bacteria, but there are new vaccines coming available. It's important part of what we do to search people's vaccination records and make sure that we're adhering to the standards set forth by the CDC for cochlear implantees. As there is a higher risk of meningitis in somebody who has a cochlear implant than somebody who doesn't. Although, it's certainly much, much lower than it once was even about 10 or 15 years ago. After surgery there's minimal restrictions as far as the kind of standard things as far as an incision would go. There's a one month period where we're allowing the wounds to heal up after surgery, and then there's multiple visits with our audiologist over the next 6 or 12 month period. After that there's annual electrode checks and re-mapping visits with our audiologist. 

Should there be any problems with the device or the wound obviously, there's medical attention that we re-connect and address any issues that may come about. Here's the external device, here's the magnet on the outside as I spoke of earlier helps to hold this part of the device directly opposed underneath the implanted portion of the device. Here's the coil or external antenna. The microphone of this device is right up here and this is the speech processor. This is the part of the device that Diane was showing. Initially it was a box this size with the giant microphone and now it's been miniaturized to this. In the next five to ten years, it's likely we have a completely implantable device. That's probably, to one question that came up, and that's possible in the next five or ten years. There's significant challenges to overcome with regard to the microphone that we need to address, but that's an on horizon and an active area of interest as well. What is it like? This is most appropriately covered by the panel that we're lucky enough to have this afternoon. 

But number one, the sound quality is different with a cochlear implant than it is with acoustic hearing. As with a hearing aid, there's challenges with batteries and recharging the device and changing batteries, and that's part of having a cochlear implant. Most patients who have a cochlear implant will use it most of the time. That's not true for everyone. Most of the studies generally show that patients who get a cochlear implant use it. There are occasional problems with externals. They can be damaged or if they happen to drop into the sink or something like that they need to be replaced. That we'll have to help patients work through. There are some implications after a cochlear implant, for you and your healthcare, essentially. Number one is if somebody needs an MRI scan, they have to have the magnet part of the device removed and that requires a separate incision. 

One of the devices is MRI approved. Unfortunately the MRI scanner that we use is really not a modern MRI scanner. For all intents and purposes, if you have to have a MRI scan after a cochlear implant, a surgery will need to be required to remove the battery, have the MRI scan, and replace battery-- I'm sorry, not the battery, the magnet. I apologize. Have your MRI scan and then replace the magnet afterwards. It can be done very safely, but obviously there's an additional infection risk with each surgery. There's also an implication for other procedures you might have. One of the tools we use enterontively, surgically, can damage a cochlear implant. So any surgeries that one may have after a cochlear implant, the surgeon needs to know that there's one present. What's that? One minute, okay. 

I'm running out of time here. Well, I think-- I did want to get to a couple of things and I may run over. Five more minutes, great. We were going to talk a minute about predicting cochlear implant outcomes. I think we're going to cover this later in some of the talks so I'm going to skip through a couple of these. I wanted to show here briefly the hybrid cochlear implant. Moving on a little bit to novel therapies in the future. Ruth talked about the hybrid cochlear implant, which combines a hearing aid in a cochlear implant. It's an electrode to stimulate the high frequencies and then one continues to use hearing aid for the middle and low frequencies. Diane mentioned there's not a lot that has changed for cochlear implant surgery through the years, but one of the big pushes surgically in one of the finesse part of cochlear implants is trying to preserve any residual acoustic hearing that's present. 

If there's a little bit of residual low frequency hearing, and certainly essential to this strategy of a hybrid cochlear implant is how atraumatic, or how delicately, we can do the surgery and place the implant so as not to destroy any residual hearing that may be there. I'd say that's one of the biggest developments surgically, is trying to prefect our techniques into preserving hearing. This is a picture of the hybrid device. Here is the external device for it, which looks just like a cochlear implant otherwise, but here is the hearing aid component of it. We were involved in a clinical trial, not as involved as we had hoped to be as we were a little late to join it, with the hybrid cochlear implant, but the advantages of this strategy are improvements in speech, noise, and also music appreciation. If I had to predict, I think in the next ten years, this is a device we're going to be hearing a lot of. There are so many patients that have a high frequency hearing loss that this applies to. When it is approved by the FDA, there's going to be a large number of people that potentially might be candidates for this. So I'll move kind of through these other areas as Ruth covered most of them. I want to speak just for a few minutes about regenerative therapies for hearing loss, or hair cell regeneration. 

Most people here are probably familiar with-- In the majority of cases, 80% of the time when we lose hearing, it's the hair cells of the inner ear that we lose. This is what they look like. There's three rows of outer hair cells and one row of inner, and these are within the cochlea, not hair cells like otherwise. When a chicken loses hearing, their hair cells are lost. This is what their inner ear looks like. But with time they're regenerated. However, in higher vertebrates, mammals, when we lose our hearing, this is the normal cochlea, this is after loosing our hearing from too much noise for example, there won't be any regeneration. That's why hearing loss is permanent in humans. For many decades there's been a push for hair cell regeneration and progress is being made. There are three approaches that have been taken. 

One is the thought that can we deliver genes that we know are important to the development of hair cells into the inner ear and make new hair cells, once they've been lost. We'll call that gene transfer. Another approach is, there are is population of stem cells that lives in the inner ear, at least in young mice and other rodents. Can we harness the stem cells that are already present in an inner ear in some way to repopulate the inner ear with hair cells once they've been lost. And the third approach, can we take stem cells, if you will, off a shelf, some type of stem cell that we have access to, that can make any cell in the body, and turn them into hair cells and transplant them and have them ingraphed into the inner ear, into the cochlea, and function. Those are three approaches being taken. We'll move a little, with time limits here, through this. The initial approach, the gene transfer approach I was involved in research with previously. The approach has shown promise in that we know of some of the most important genes to regenerate hair cells. In fact there's one gene you might have even read about, which is called math one, or ATOH1. 

Think of it as a master control gene. When it's turned on, a certain tissue knows to make a hair cell. It's a very potent gene in the interest of regenerating hearing. It's the probably the foremost player in this approach. We've shown that with delivering this gene into an inner ear at a very early stage, we can make extra hair cells. Here's a normal cochlea with three rows of outers, and here's extra hair cells. We characterize those hair cells to show that they be seem to be doing the things that hair cells do. Most importantly, when we record from them, which shows actually their true function, they're working like hair cells when we make new ones in the inner ear. Also we've shown that they can communicate with the brain. They can attract nerves rootlets to grow to their bases. 

This is a promising advance and there's been more beyond this. With the gene transfer technique, we know the genes and there's some evidence that this potentially can be used in animal models. It's a long way from it's application to humans, but it's really one of the most promising approaches that we're continuing to work on, a gene transfer approach for hearing restoration. The other approach I'm going to skip to, but one I'm actively involved with here at the Waisman Center. As Teresa covered earlier, UW-Madison has had a prominent role with regard to stem cell research. The Waisman Center, on the sixth floor, is really kind of the nucleus of neuro stem cell research. Not only the research I'm doing with regard to stem cells and their applications in the inner ear and hair cell regeneration, but also for other neuro degenerative diseases and also for vision loss. There's a clustering of researchers here at the Waisman Center, and we can tour some of these labs if you would like. In my lab upstairs we're working with the strategy of can we take stem cells that can make any cell in the body and give them, in culture, the signals that they need to make hair cells in a dish. Then can we potentially transfer those cells to an animal and restore hearing, get them to ingraft in an inner ear and restore hearing. 

What you're seeing on the right here is, when we take stem cells that can make any cell in the body, and we culture them the right way, we can make cells that go on to form neurons like would be present in the brain, and surrounding them these are cells expressing an inner ear marker called Pax-2. What that tells us is that we're somewhere along the way towards making a hair cell. We haven't made it in culture all the way into making a hair cell, but I like to think we're about halfway there in generating hair cells. We've given these cells important initial signals to point them in the right direction to where we hope to ultimate will be. These are some of the questions we continue to address. Can we make human hair cells in the lab? Can we transplant them, and are there inner ear stem cells in the ear already that we can use to replenish? With regenerative therapies, when will they come about? This is the question that nobody knows the answer to. I have no insight on that. I would like to think it's as close to as five to ten years away, but I think that's probably optimistic. We can't base our decisions, as Ruth touched on, with regard to what we have now. We have to go with what we have now and what works well. 

This comes up clinically, and I think waiting for hair cell regeneration, it's an open ended question at this point. And then how, I covered some of the different approaches, and then where hopefully, we'll have a part in it here at UW-Madison. Here's my summary slide. Cochlear implants, as we discussed, on multiple talks this morning, are playing an increasing role. The candidacy evaluation is comprehensive, the surgical goals and risks are relatively scripted and well known. There's not a lot of variability in that on the whole. There's research into improvements in cochlear implants that's ongoing here on campus and elsewhere. And also there's active investigations into regenerative therapies for hearing loss. I want to acknowledge the Waisman Center and Marsha Mailick Seltzer, who couldn't be here with us today. Again, thanks to Teresa, for all her efforts with organizing things today, and Kerry McConnell is the coordinator of our cochlear implant program here at the UW, and I wanted to acknowledge her efforts in having this come to fruition. 

Thank you very much. I'm not sure I have time for questions or not. [applause]    It's a joint effort in