April 28, 2008 Issue

               HEARING LOSS HELP E-zine
"The premier e-zine for people with hearing loss"

Volume 3, Number 3              April 28, 2008
Publisher: Neil Bauman      neil@hearinglosshelp.com
            http://www.hearinglosshelp.com
    Copyright Center for Hearing Loss Help 2008

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                      "Hearing loss may change your life,
                        but your life need not be any less
                                rewarding and fulfilling
                        because you have a hearing loss."

                                                              — Neil Bauman, Ph.D.

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Please recommend and/or forward this issue of Hearing Loss Help e-zine to at least one of your hard of hearing friends, or to anyone you know that is interested in successfully living with their hearing loss. We just ask that you keep this e-zine intact and only forward it in its entirety.
 

================================================== In this issue ==================================================

1. News Items

2. Beware of (Ototoxic) Drugs That Can Damage Your Ears

3. Tinnitus

4. Answers to Your Questions

5. Coping Strategies

6. Information on Hearing Aids, Cochlear Implants and/or Assistive Devices

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1. News Items
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Hearing Loss (Needlessly) Adversely Affects Marriages

by Neil Bauman, Ph.D.

Hearing loss in a spouse adversely affects marriages. This should be no surprise. In fact, according to a recent survey of baby boomers with hard of hearing spouses, 48% "of the respondents feel that their marriage has suffered because of their spouse's hearing loss." (1)

This does not have to be. Hearing loss can bring about changes in a marriage, but these changes do not have to adversely affect the marriage itself. Let's look at this a little closer.

One of the findings was that 65% "feel annoyed when their spouse can not hear them." Instead of being annoyed and letting that affect the marriage, why don't these spouses practice good hearing loss coping strategies so that their spouses do hear them the very first time? When they do this, the annoyance factor fades away.

A second finding was that "another 16% feel ignored". I think this applies much more to family gatherings rather than just spouse to spouse communication. In groups its so easy to ignore the person that misses what is said. Because they miss things, they often don't respond—and thus become "invisible" to the group. The hard of hearing person is not intentionally ignored—it just happens. This is why practicing good coping strategies, including being assertive, is so important. So too are using hearing aids and any assistive listening devices (ALDs) that will help the hard of hearing person hear better.

A third finding was that "8% feel sad or hurt." I'm surprised this figure is so low. Hearing is important to us. We value it, so when we lose it, we feel the loss—and therefore must grieve this loss. Some of the emotions we experience during the grieving process include sadness and feeling hurt. These feelings should go away as we work through the grieving process and learn to become well-adjusted hard of hearing people. In addition, the hearing spouse must also grieve—not for the hearing loss since they don't have any—but for the loss of the free and easy communication they once had with their now hard of hearing spouse.

To learn more about the grieving process in relation to hard of hearing people read our short book, "Grieving For Your Hearing Loss—The Rocky Road From Denial To Acceptance."

A fourth finding was that 60% "find themselves in recent years talking louder daily so their spouse can hear them." I don't see that talking louder as such, is a problem, but a sign of using an effective coping strategy. Speaking louder so a spouse can hear you the first time has got to be far less annoying than endlessly repeating yourself in your regular voice, and in the end your spouse still doesn't get it. Of course, the hard of hearing spouse should do what he/she can to help this situation—and that means getting hearing aids if they will help, and/or using assistive listening devices.

A fifth finding was that denial often rears ins ugly head. In fact, 57% "feel their spouse is reluctant to get his or her hearing checked." Why? Well, "46% feel that denial is the number one reason" their spouse refuses to have a hearing test. I have heard the shocking statistic that 6 out of 7 hard of hearing people either deny they have a hearing loss, or do nothing about it. that is what causes problems in marriages. If the hard of hearing spouse would acknowledge that he/she has a hearing problem (and a hearing test will confirm that), then
together the marriage partners can work on finding effective solutions so that hearing loss will not harm their marriage.

There are ever so many effective coping strategies that spouses can employ to make communicating with each other easier. Some of them involve using assistive devices and hearing aids, while others don't cost a cent. There are a good number of these freebie effective coping strategies in our very readable book, "Talking With Hard of Hearing People—Here's How To Do It Right!"

(1) "Being Hard of Hearing Can Cause Hard Feelings Between Spouses" in: Advance for Audiologists, April 11, 2008.
 

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Cure for Single Sided Deafness?

by Neil Bauman, Ph.D.

A mother wrote: "I read your article on the Internet concerning sudden sensorineural hearing loss (SSHL). My daughter lost her hearing in her right ear when she was 12 years old. We believe it was due to a virus. The Doctor told us at the time, that she could have an implant but to wait because in about 10 years a new treatment would be available. He said a shot was being developed that would stimulate the nerve endings to "grow" and she would get her hearing back. I have yet to find any information about this treatment on line. Have you ever heard of it? My daughter is just finishing her first year of college now. She has learned to live with the deafness of her right ear, but still remembers the new treatment the Doctor told her about, and if possible, would like to have it done."

Your doctor was being pie-in-the-sky optimistic. What he was talking about back then is basically hair cell regeneration, and now 7 or 8 years later it is still 20 or 25 years away if it ever happens, according to the researchers I have talked with. There are no guarantees that all the research they are doing will ultimately prove successful, or even successful enough to begin human trials. At this time, they are moving ahead in the belief that their research will ultimately prove successful. Maybe when your daughter is 40 or 50 it will be available. But it certainly isn't here yet.

Because your daughter has normal hearing in one ear, she isn't eligible for a cochlear implant in her deaf ear. However, there are three special kinds of hearing aids that can help her overcome her single-sided deafness.

First, there are CROS aids. These special hearing aids basically take the sound from the deaf side of the head and route it to the good ear. That is why they are called CROS aids—which stands for "Contralateral Routing Of Sound". You
can learn more about CROS aids in my short article called "What are CROS and Bi-CROS Hearing Aids?".

Second, there is the BAHA (Bone Anchored Hearing Aid). In this case, a titanium post is screwed into the mastoid bone behind the ear, and when it heals, a "hearing aid" is snapped on to this post. The amplified sounds vibrate this post which passes these sounds to the good ear via bone conduction. You can learn more about the BAHA here.

Third, the newest kid on the block is the TransEar hearing aid. This is a BTE (behind-the-ear) hearing aid with a difference. You wear it on your deaf side. The TransEar has a special ear mold with a miniature oscillator embedded in it. The ear mold fits tightly in the ear canal and vibrates the skull bone, thus passing these sounds to the good ear via bone conduction, much like the BAHA does. You can learn more about the TransEar here.

In addition to these three devices, there are a number of "tricks" a person with single-sided deafness can use to help them hear better. For example, in meetings and classes, the person should sit to the side of the room so that their deaf ear is towards the wall. That way their good ear hears into the whole room. No one can then talk from their deaf side. In like manner, if possible, they should arrange their office so that people have to approach and speak to them from their hearing side.
 

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Yelling? I'm Not Yelling. I'm Just Talking!

by Neil Bauman, Ph.D.

A man wrote: "For the last 10 or so years I have noticed a decline in my hearing. This year when I went to get tested, it was 55 dB in each ear.

A question I have is when I talk everyone says that I'm yelling at them, but to me I'm just talking. I stop and think there is no way I'm yelling. They tell me I cannot hear myself talk so I say things a lot louder, is that possible?"

Very much so. You don't hear your own voice as loud as you used to, so you speak up so you hear your voice at its accustomed volume. "Yelling" is a bit of an overstatement—but since you are definitely talking louder than normal, many people call it "yelling". However, we know that we are not truly yelling because we know the effort it takes to really yell, and we are not doing that!

By the same token, when you get hearing aids, just the opposite can happen. Your amplified voice now seems so loud in your ears that you drop your voice and talk much softer than normal. People now have trouble hearing you. Fortunately, in time, you get used to how loud your voice should sound, and all will be well.

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2. Beware of (Ototoxic) Drugs That Can Damage Your Ears
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Phantom Voices From Taking Various Drugs

by Neil Bauman, Ph.D.

A mother wrote: "My 6 year old daughter just recently told me she is hearing voices talking. She is happy and socially adjusted, thus I don't believe it is psychotic in nature.

She has been taking Zyrtec for approximately 1 year. She said she had already told me before, but I must have dismissed it. She is not able to tell me how long it has been happening, but she states it did not happen while she was in preschool a year ago. I suspect she may be having ototoxic side effects from the Zyrtec. I stopped the medication yesterday and am giving her Loratadine instead to manage her allergies since it is allergy season. I am concerned that her doctors may think she has a psychosis or some psychological problem. Her doctor suggested a hearing test. Do you believe this is necessary? If it is a side effect of the medication, has it caused permanent damage? Will it go away if we stop the medication?"

I agree with you. It does not sound like your daughter has an mental problem. First, I'd check to find out the kind of voices she hears. Are these "personal" voices talking to or about her—or are they impersonal voices such as you would hear on the radio or TV? If the latter, then she likely does not have a
mental problem.

Second, find out whether these voices are distinct—can she understand everything they are saying, or are they vague like people (or a TV) talking in another room—you know they are talking but can't really understand what they are saying? Again, if the latter, they are likely not of a psychotic origin.

Third, find out when she hears them. Is it all the time, or when it is quiet such as when she is in bed, but not when she is up? More often people hear these non-psychotic phantom sounds when they are not actively doing anything and the house is quiet, thus, this occurs when they go to bed.

I agree with you that she may be experiencing an ototoxic side effect of the drug she is taking. Since she began hearing these phantom voices after she began taking Zyrtec (Cetirizine), and since Cetirizine can indeed cause hallucinations, you may be correct in your assumptions.

If stopping the Cetirizine makes these phantom voices go away, that's stronger evidence yet. However, replacing the Cetirizine with Loratadine (brand name Claritin) may not solve the problem. You see, Loratadine is also as H1 blocker as is Zyrtec, and it can also cause hallucinations. Thus, there may, or may not, be any change in her hearing voices. You can find a complete listing of the drugs that are known to cause these phantom sounds in our book, "Phantom Voices, Ethereal Music & Other Spooky Sounds".

Having a hearing test is a wise precaution, especially testing her in the frequencies above 8,000 Hz because Cetirizine can also cause hearing loss. Actually Cetirizine is the most ototoxic of the H1 blockers. Loratadine, or any of the other drugs in this class, would likely be easier on her ears than Cetirizine.

I think that if you stop these drugs, the phantom voices should disappear in a couple of weeks or so, but as with anything connected with drugs, there are no guarantees.

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Hearing Loss from Autoimmune Disease Drugs?

by Neil Bauman, Ph.D.

A lady asked: "I have been diagnosed with two autoimmune disorders (celiac disease about 15-years ago, for which I follow a gluten-free diet without any problems) and, more recently, rheumatoid arthritis. I've been taking Methotrexate by injection, as well as a daily dose of Meloxicam (an NSAID) for about a year now.

I've had remarkable improvement in my arthritis symptoms, but have noticed a real change in my hearing on one side—loads of tinnitus and moderate hearing loss in high and low tones. I've read that the medications I'm taking can be ototoxic (although my physicians don't seem to know anything about that).

Is there some way to determine whether my symptoms are the result of my medications, or whether this could be autoimmune related hearing loss?"

Good question. Both of the drugs you are on can definitely increase your tinnitus. If fact I have heard from women who have taken either one of your drugs which resulted in loud tinnitus when they took them—so I suspect the drugs are likely causing the loud tinnitus in your case as well.

I have not seen any information specifically linking Meloxicam to hearing loss. (Incidentally, Meloxicam belongs to the Oxicam drug class. It is not a NSAID.) However, two other drugs in the Oxicam class can cause hearing loss, so it is
possible that Meloxicam can also cause hearing loss—just that it has not yet been reported in the literature.

Methotrexate may or may not cause hearing loss. The results of one study I saw were inconclusive—some people got hearing back and others lost more.

Have your doctors tested you for AIED (autoimmune inner ear disease)? The standard treatment for AIED is Prednisone. If your hearing comes back when you take Prednisone, they say you likely have AIED, and if it doesn't, then you probably don't.

Unfortunately, there is no easy way to pinpoint the source of your hearing loss when there are several factors involved.

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3. Tinnitus
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Can Niacin (Vitamin B3) Cure Tinnitus?

by Neil Bauman, Ph.D.

A man wrote: "Several years ago at a hearing clinic, I told the young lady that I had ringing in my ears. She asked me if I had ever taken Niacin, and I hadn't. She said it helps some people. I took Niacin pills for a good while, and it seemed to rid me of the ringing in the ears. I did get a flushing from taking Niacin. She suggested Niacinamide, and that seemed to help the flushing.

For one reason or another, I have not had ringing in my ears for a lot of years, so I no longer take Niacin or Niacinamide.

I would like your thoughts about taking Niacin or Niacinamide for ringing in the ears. Do you know of a connection here, or was it helping me a fluke?"

Niacin (Niacinamide) or Vitamin B3 helps some people with tinnitus because it increases blood flow to the peripherals which includes the inner ears (hence the flushing—it shows it is doing its job).

If your tinnitus was caused by a lack of blood to your inner ears, then taking Niacin really can work—its not a fluke. However, Niacin does not work for everyone—only for those with circulation problems to their inner ears. For example, nothing I've tried has helped my tinnitus because mine is probably the result of my severe hearing loss, not lack of blood flow to my inner ears.

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4. Answers to Your Questions
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If you have a question, or if something has been puzzling you concerning your ears, email it to mailto:neil@hearinglosshelp.com and put "e-zine question" as the subject. Suitable questions will be answered here.
 

Vertigo Attacks—What's Going On?

by Neil Bauman, Ph.D.

A woman explained, "I read one of your articles on the Internet about SSHL (Sudden Sensorineural Hearing Loss), which I had when I was 11 years old. I had 80% loss in my left ear, which has been permanent. I am now 54 years old. The diagnosis of the cause of the hearing loss was an unknown virus. At the time of the hearing loss I did experience vertigo.

My question is, over the years I have experienced periods of vertigo. Usually one episode every 2 - 3 years. In the past 5 years I have had 4 or 5 episodes. I do not experience hearing loss or tinnitus. The vertigo becomes severe, and I usually have to lie down with my eyes closed for 24 hours on average. Plus in the last few episodes I have had extreme nausea (vomiting every few hours for 24 hours). I have been through extensive tests with an ENT doctor, also had an MRI, and his only opinion is that the vertigo is related to some extra sensitivity related to my nerve deafness. My question is, do people with SSHL often experience vertigo later and throughout their lives as I have described?"

I'm not surprised you had some vestibular (balance) problems in addition to your sudden hearing loss. The virus that gets into your cochlea and causes hearing loss, often at the same time, gets into the vestibular system and causes balance problems such as your vertigo. However, that happened many years ago now. I wouldn't have expected vertigo from back then to still occur. Perhaps these episodes of vertigo are not directly related to the original viral attack.

One possibility is that you may have a form of Meniere's disease that only affects the vestibular system and not the whole inner ear. It may be called endolymphatic hydrops, but more commonly it is known as vestibular hydrops. This could account for your periodic attacks of vertigo without the accompanying tinnitus and hearing loss. Have your doctors considered this?

Do you have any allergies at all? If so, do the episodes of vertigo correlate to the allergy outbreaks? Often allergies are the underlying cause of Meniere's disease.
 

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How Can I Improve My Poor Discrimination?

by Neil Bauman, Ph.D.

A man asked: "Is anything that can be done about poor discrimination (word recognition) besides learning techniques for coping with it? I have worn hearing aids for many years but have never received a plain answer to that question."

There's really not all that much that can be done for poor discrimination besides learning how to best cope with it. Here are some things that may help though.

1. Poor discrimination is often the result of not being able to hear the higher frequencies well, or at all, since most of the "intelligence" in speech resides in the higher frequencies. If you can still hear the high frequencies somewhat, then having hearing aids and/or assistive devices that are specifically adjusted to amplify these higher frequencies to your optimal level will help. So will using high-fidelity sound equipment. The better the quality of the sound, the better we can understand it—even with our poor hearing.

If you cannot hear the high frequencies at all, then using a frequency-transposition hearing aid may help you by shifting sounds down to the frequency range you can still hear. Some people have good success with these special hearing aids. There are a couple of companies that make these hearing aids. Perhaps the best known is the Sonovation line of ImpaCt frequency transposition hearing aids, but the Widex Inteo also has this feature too. Widex calls it the "Audibility Extender".

2. Amplification technology can only go so far. When it can't help anymore, then getting cochlear implants will very often remarkably help improve your discrimination (and hearing too of course). When hearing aids can no longer significantly help you, this is the next logical step to take.

3. As far as coping strategies go, speechreading used in conjunction with your hearing aids can also remarkably improve discrimination. Studies have shown that when used with hearing aids, speechreading can push your discrimination
back up around the 80% level. Finally, if all else fails—use real time captioning—then your discrimination is essentially back to 100% (assuming, of course, that your captionist can hear the speaker accurately).

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5. Coping Strategies
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Learning to Speechread

by Neil Bauman, Ph.D.

A man asked: "I would like to know what you have to say about how to learn speechreading. Is there a particular technique? Is there a book?"

Speechreading is an excellent coping strategy, however, you can't really learn to speechread from a book. You need to see people's lips in action. Of course, you can learn a number of good things about speechreading from books—but that is not learning to speechread.

What you need is either live classes (if you can find them—they are not always easy to find in any given location) or do the next best thing and learn via CDs or video tapes.

One big advantage of CDs over video tapes is that the programs on the CDs can be interactive, whereas the video tapes do not provide any feedback. Furthermore CDs make it very easy to repeat a segment/question to increase learning.

One CD program that I find particularly good is the excellent "Seeing and Hearing Speech" program.
 

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Hearing Loss isn't the Only Problem—Discrimination is Important Too

by Neil Bauman, Ph.D.

A lady wrote: "My mother has been losing her hearing for quite some time now. We have to speak very loud in order for her to hear us. She has tried various hearing aids and sound magnifiers (for church), but she is very frustrated because they don't quite do the job. At 89 I don't think she is a candidate for surgery. I told her that maybe she is at the point that nothing is going to help her because the hearing mechanics in her ear are gone. Of course she feels left out of things and is beginning to withdraw a little."

The first question I have is what are her discrimination (word recognition) scores? I'm thinking that the reason amplification isn't giving the level of success you would expect is that she can't understand what she hears, even when speech is amplified to her most comfortable level. In other words she has poor discrimination.

If this is so, then amplification alone isn't the answer. Real time captioning (CART) at church and meetings would help her far more than amplification in this case.

As you already know, trying to hear in groups and family gatherings is largely a waste of time for her. However, all is not lost. She does not have to be left out. The secret is to converse with her one-to-one in a quiet location. Conversation under these conditions can still be quite effective if she is close to the speaker (nose-to-nose so to speak) so she can both speechread a bit and hear a bit).
 

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Restricting Activities Because of Large (Enlarged) Vestibular Aqueduct Syndrome (LVAS/EVAS)

by Neil Bauman, Ph.D.

A mother asked: "Do you or don't you restrict your child's activities due to their LVAS (Large Vestibular Aqueduct Syndrome)?

When my daughter (almost 12) was diagnosed with unilateral LVAS at age 8, the ENT said to avoid loud music (to protect her normal ear), scuba diving, and head trauma.

I have found information saying kids should avoid diving (which my daughter does and enjoys), roller coasters (which my daughter has ridden and loves), doing "headers" in soccer (which she practiced at a recent soccer clinic), contact
sports like basketball (which she played for the past 3 years), and playing the trumpet (which she is supposed to start next fall). She is very active.

I am questioning whether I should try to convince her to change the instrument she has selected to play in band next fall. We had a band night where they could try all the instruments, which she did, and she loved the trumpet. The teacher said she was a natural and had done better than any incoming 6th graders he'd heard that night. So naturally we signed her up to play trumpet. But I don't want to put her hearing at risk either.

Also I'm wanting to know if I should stop her from diving off the diving board this summer, not sign her up to play soccer next fall, and limit her at Six Flags to only non-roller coaster rides. On the other hand, she's done these activities in the past, and her hearing in her LVAS ear has remained pretty stable. I would hate to limit activities she really enjoys."

You are not alone in trying to determine which activities your LVAS child should or should not do. Many parents of children with Large (or Enlarged) Vestibular Aqueduct Syndrome (LVAS/EVAS) often agonize over this very question.

Fortunately, if a child has a history of LVAS for a few years such as your daughter has, the question is relatively easy to answer—no matter what the doctor gives as guidelines. Let me explain.

All of the above activities have the potential to cause hearing loss in people with LVAS. But just because there is the potential doesn't mean it will happen. You have to consider each child on a case by case basis.

Since your daughter has been doing a number of these activities for some time, all you have to do is ask yourself, "In the past few years, have any of these activities caused more hearing loss or balance problems in my daughter?" If the answer is "no", then let her continue to do these (and related kinds of activities), because obviously her ears are not sensitive to these kinds of activities.

However, if your daughter lost more hearing or had balance problems each time she did one of the above, then obviously these activities are not the right ones for her, and you should restrict her to those activities that have not caused hearing loss/balance problems in the past.

In your daughter's case, you've answered your own question. These activities haven't bothered her in the past, so let her do them in the future—unless you subsequently find that they really are damaging her ears.

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6. Information on Hearing Aids, Cochlear Implants and/or Assistive Devices
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T-Links Too Loud?—Here's the Cure

by Neil Bauman, Ph.D.

A man wrote, "I love my T-Links. One thing I find is the sound is too loud with the T-Links, Oticon hearing aids, and many phones—even when set to their minimum volume. Any suggestions?"

One of the reasons your T-Links sound so loud is that they are very close to you t-coils. The solution should be simple.

Have you audiologist reduce the amplification on the t-coils (in t-coil mode) to something that is just right when using the T-Links. It can be that simple to fix.

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Are T-Links Really Necessary When Using Cell Phones?

by Neil Bauman, Ph.D.

A man wrote, "Dr. Neil: I have question. Are there cell phones that have the t-coil built in so you just hold the cell phone close and sound jumps to hearing aids t-coil? Thus, use of T-Links or neckloops are not necessary?"

I've got good news for you. Yes—most cell phones are that way now. Therefore, all you need to do is hold your cell phone up to your hearing aid (in t-coil mode) and listen. If you hear well without any interference, that is all you need.

However, some phones and hearing aids still have too much interference (typically a loud buzzing) and by using the T-Links, you keep the phone far enough away from your hearing aids that you do not get this interference. (The interference drops off rapidly with increasing distance.) That is one reason to use the T-links.

Another reason you might want to use the T-Links is to have hands-free use—for when you are driving, or walking around. That way, you can have the phone in your pocket and hear it just fine. If you have a Bluetooth enabled phone, using a Bluetooth neckloop would have these same two advantages.

You can learn more about the T-Links here, and learn more about a Bluetooth neckloop here.

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A Dozen Advantages of Loop Systems

by David Myers, Ph.D.

Here are a dozen advantages of loop systems. They . . .

• Are hearing aid compatible. This also means there's no need when at worship to juggle between hearing aids out/headset on (during sermons) and hearing aids in/headset off (during singing).
   
• Can harness, at no added expense to the hearing aid wearer, the same telecoil technology used by hearing aid compatible telephones.
   
• Require (for those with telecoils) no pickup and remembering to return portable receiving units and headsets.
   
• Require purchasing/maintaining/replacing fewer portable receiving units (for those as yet without telecoils or heading aids).
   
• Operate on a universal frequency (FM systems operate on differing frequencies, requiring receivers for each venue).
   
• Serve those with most new cochlear implants (which come with telecoils) as well as those with hearing aids (especially those most needing assistive listening, who generally have behind-the-ear aids, which generally include strong telecoils).
   
• Are inconspicuous. Loop systems offer an easy and invisible solution to an invisible problem, thus are much more likely to be used.
   
• Work in transient situations. They can serve the hard of hearing at ticket counters, teller windows, airport gate areas, train stations, etc.—venues where other assistive listening systems are impractical.
   
• Contain sound. Because sound broadcast through hearing aids is contained within one's ear, there is no risk of leaked headset sound bothering others nearby.
   
• Afford flexible use. Can allow either direct listening or loop broadcast modes, or both. Also typically allow M/T (mic + telecoil) settings to allow both assistive listening from PA system or TV and normal listening of conversation or singing from people nearby.
   
• Deliver personalized in-the-ear-sound—sound customized by one's own hearing aids to address one's own hearing loss.
   
• Are, for all these reasons, much more likely to be used—and to be increasingly used, once installed (as people purchase future aids with T-coils). (1)

To learn more about these wonderful loop systems, read the article, "Loop Systems—The Best-Kept Secret in Town".

(1) Used by permission http://www.puredirectsound.com/id11.html
 

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                       HEARING LOSS HELP E-zine

Neil Bauman, Publisher               Center for Hearing Loss Help
49 Piston Court                       Stewartstown, PA 17363 USA
Phone: (717) 993-8555                       Fax (717) 993-6661
http://www.hearinglosshelp.com     neil@hearinglosshelp.com

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