B. bassiana fungal treatment on spruce bark beetle, Ips typographus (L.), was tested under field conditions. Altogether, it was detected that the effect of B. bassiana preparations on bark beetle infestations in terms of possible environmental effects is minimal compared to the severe damage and hence yield loss caused by this insect species worldwide. Even if the relatively low effects on I. typographus stages, including adults, larvae, pupae and even next-generation young adults, were reported, it remains clear that the present novel approach using a natural biological control agent rather than toxic synthetic insecticides is timely and may be potentially beneficial to the forestry industry as a rational control approach to combat this pest.The effect of Ips typographus (L.), attack progression  and parental and offspring mortality rate were assessed in managed forests of the Poiana Ruscă and Bihor Mountains, along with Western Romanian Carpathians using fungal (Beauveria bassiana) treatments. The results show that the effect of B. bassiana on adult  gallery length was similar to the untreated variant and was less effective than the synthetic insecticide lambda-cyhalothrin applied at a dose of 50 g/L. Additionally, its effect on the mean larval gallery number per maternal gallery was low. B. bassiana did not have a significant influence on the attack progression. Significant correlations between log diameter and I. typographus attack progression were detected; such differences were higher than the effect of any treatment. Altogether, abiotic  and biotic factors (log diameter) influenced the bark beetles’ attack progression and reduced the entomopathogenic fungal effects. Considering the efficacy of the B. bassiana treatment on logs infested with I. typographus, the results showed that parents and offspring were infected, but even if the fungal treatment was applied in high concentrations, the mortality rate remained relatively low. Further research is necessary to test if different B. bassiana strains and their commercially recommended concentrations might be more effective under dry and warm climate conditions, respectively. The spruce bark beetle,  Forests are one of the planet’s most valuable resources, being constantly under abiotic, biotic and anthropogenic pressure. One of the factors significantly influencing forest dynamics is drought, which results in reduced tree growth and accelerated drying. In Europe, the area of forest affected by drought and drying exceeded 500,000 ha between 1987 and 2016 [A result of such obvious climate change is the periodic occurrence of storms that affect deciduous stands and, especially, coniferous forests, spruce trees being highly susceptible to climate-induced destruction and disease in Europe . The freIps typographus (L.) (Coleoptera: Scolytidae). The species is a secondary pest that can produce mass outbreaks under certain conditions and can even attack healthy standing spruce trees  during such outbreaks. Several methods have been investigated to control outbreaks, ranging from felling and extracting attacked trees or peeling dry trees to using synthetic pheromones to capture adults or spraying logs with synthetic pyrethroids. Each of these methods has its drawbacks, which is why new, innovative, highly effective and environmentally friendly solutions are urgently required and need to be tested. The use of microbiological preparations, such as entomopathogenic fungi, B. bassiana, may prove to be a solution in forest management to limit bark beetle attacks.Prolonged droughts, rising temperatures, severe storms and fires are factors that influence forest dynamics differentially from region to region and create favorable conditions for plant diseases and pests. One of the most damaging insect pest species under the above-mentioned abiotic conditions remains the eight-toothed spruce bark beetle, B. bassiana is a naturally occurring pathogen of I. typographus [ographus . Its patographus ,6,7; howographus . The effB. bassiana-based products, the followings questions being posed: (1) How does the commercial product Metab (B. bassiana product) applied at different concentrations influence the length of maternal galleries and the number of larval/maternal galleries? (2) Does B. bassiana cause mortality in adults and offspring? (3) Does B. bassiana cause mortality in young adults in the next generation? (4) Is Metab more effective than a commercially used synthetic insecticide? In this light, the bark beetle attack development was assessed under fungal and synthetic insecticide treatments in managed forest plots and in buffer zones of protected areas.Therefore, in this study, we have attempted to answer some of the questions related to the effective use of In order to answer the questions, three experiments were set up between 2019 and 2021 and conducted in three sites  parallel in the vicinity of stands in which spruce represented 90% of trees and larch represented 10% of trees. The distance between the experimental sites was about 200 m. The sites were located outside the natural area, in the Poiana Ruscă Mountains of the Western Romanian Carpathians, at an altitude of 1100 m above sea level (a.s.l.) . The forest stands had an average age of 110 years, a consistency of 0.9 and a production class of II A,B.2 bark.Trees were selected as wind felled trees during the winter period, which still had green crowns and no obvious spruce bark beetle infestations. They were cleaned of branches and sectioned every two meters, and the resulting logs were placed horizontally (so that they did not touch the ground) in Latin rectangle test platforms with six variations and four repetitions for each experiment. The logs were placed randomly and labelled. The diameter of the logs was then measured at the middle, and bark area was calculated for each one. Each sample was primed at the middle with the commercial pheromone Atratyp. The samples were sprayed as follows: variant 1 (V1) with water; variant 2 (V2) with Metab 75 mL/10 L water; variant 3 (V3) with Metab 105 mL/10 L water; variant 4 (V4) with Metab 135 mL/10 L water; variant 5 (V5) with Metab 165 mL/10 L water; variant 6 (V6) with lambda-cyhalothrin 50 g/L (Karate Zeon) 50 mL/10 L water. The spray solutions were prepared one day prior to the use of the microbiological product, according to the manufacturer’s instructions. To activate the microorganisms, the Metab control product and the Nutriaction product were always added in double the amount of the test product. Thus, for example, for (V2), 150 mL Nutriaction was added; for (V3), 210 mL Nutriaction was added; for (V4), 270 mL Nutriaction was added; for (V5), 330 mL Nutriaction was added. The Zeon Karate solution was prepared shortly before spraying. The amount of solution applied was 300 mL/m2 of bark; (2) 10 attack systems were chosen from the middle of each bark sample, and the lengths of 10 maternal galleries per sample were measured; (3) existing larval galleries were counted in the measured maternal galleries  The number of entries per bark sample subsequently expressed per 1 malleries C–E.I. typographus in the Apuseni Mountains  (The choice of the site for the experiments in the year 2020 was based on reports of outbreaks of 4′25″ E) A. In thi4′25″ E) .B. bassiana 50 g/L; variant 3 (V3) was sprayed with B. bassiana 100 g/L; variant 4 (V4) was sprayed with B. bassiana 200 g/L. The amount of solution applied was 200 mL/m2 of bark. The concentration of B. bassiana powder was 2 × 109 CFU/g. Throughout the experimental period, the air temperature and humidity were recorded using the Hexo device  was sprayed with water; variant 2 (V2) was sprayed with o device . From thB. bassiana preparation (2 × 109 CFU (colony forming unit)/g)) on the adults of the new generations of I. typographus. Among the trees with broken, calcined tops, those with no insect entry were chosen for the experiment. After cleaning the stems from branches, they were sectioned into one-meter-long sections with diameters between 16 and 21 cm. The area of existing bark was calculated for each section. Logs were randomly placed in the forest by hanging vertically from a dry wood support. This was followed by labelling the four variants with six repetitions set for testing. The samples were installed on 30 June 2021, before the onset of the summer flight, and sprayed on 30 June and 14 July 2021 with the following experimental variants: variant 1 (V1) was sprayed with water; variant 2 (V2) was sprayed with B. bassiana 50 g/L; variant 3 (V3) was sprayed with B. bassiana 100 g/L; variant 4 (V4) was sprayed with B. bassiana 200 g/L. The amount of solution applied was 200 mL/m2 of bark. Other experimental conditions and procedures were as previously detailed above.A new experiment was performed in the same experimental area as the previous one. Here, the aim was to observe the effects of the The data of the first experiment, relating to the average length of the maternal gallery, and the data related to the mean larval/maternal galley were normally distributed; therefore, ANOVA followed by Tukey’s test were used for each experimental site  and for the two sets of assessments separately to compare treatments.p < 0.01.Principal Component Analyses , where the logs’ diameter was considered as the main component, and the adult gallery length was considered as the variable. Linear correlations were also computed between variables . The analyses were conducted in PAST, version 4.2. Data from the second and third experiments, following parent adults, larvae, pupae and young adults’ survival rate, did not meet the assumption of normality; therefore, a Kruskal–Wallis test followed by a Wilcoxon test were used to compare survival rates. The data were also tested using PAST, version 4.2 , with statistical differences assessed at a significance level of In total, 148 logs of 50 cm in length were assessed in the first experiment, and 1480 maternal galleries and corresponding larval galleries were assessed and compared for each treatment. The effect of lambda-cyhalothrin 50 g/L was significant; smaller maternal galleries were detected after the first treatment in OSAL 1, 2. No effect between treatments at OSAL 3 was observed .The same results and a significant effect of the synthetic insecticide were observed at assessment 2 in sites (OSAL) 1 and 2, while the effect of treatment V4 (Metab 135 mL/10 L water) was less obvious than the others in site 3. No differences between the control treatment and the other treatments were detected .Considering the treatment effects of the , at the first assessment, a significant influence of the lambda-cyhalothrin was observed at sites 2 and 3, while in site 1, the effects of Metab at 75 and 105 mL (V2 and V3) were significant . For the.Log diameter had positive effect on adult gallery length at each treatment, log diameter determined more than 90% the presence of bark beetles, and was highly correlated with adult gallery length .B. bassiana concentration. The mortality rate increased in accordance with B. bassiana increasing concentrations for all developmental stages and was found to be between 28.5% and 46.8% for larvae, 7.5% and 34.3% for pupae, and 16.1% to 29.4% for young adults. By assessing the adults, larvae, pupae and the young adult (next genera-tions) survival rate, it was observed that B. bassiana treatment was less effective. By comparing the rate of survived and dead individuals, the survived rate was higher for larvae, pupae and for the young adults . Adult mortality rate in treated plots changed between ~7% at the lowest, and ~77% at the highest g adults .B. bassiana on the maternal gallery length and the average larvae gallery number per maternal gallery was less obvious than the synthetic insecticide lambda-cyhalothrin 50 g/L. The fungal treatment effect was rather similar to the untreated variant/s. The rates of infection detected in this experiment were seemingly highly, influenced by the favorable environmental conditions for bark beetles, which was also mentioned by other authors [I. typographus infestation since, as the diameter increases, the infestation rate also increases [I. typographus infection, this being higher that the effect of the fungal treatments. Beside log diameters, high temperatures also positively influenced I. typographus infestation and reduced the effect of B. bassiana, as similarly demonstrated by other authors [According to our results, the effect of  authors . In our ncreases ,11. In o authors ,13,14. R authors . I. typographus infestation capacity and can be used as broad indicators when forecasting probable tree loss. These conditions were present during the whole experimental period  have highly positive effects on l period .B. bassiana under field conditions had a relatively low effect on I. typographus stages, including adults, larvae, pupae and even next-generation young adults. Even when high product concentrations were used, the mortality rate remained relatively low. This result is in accordance with the results obtained by other studies [B. bassiana preparations in the field can cause 93% [B. bassiana preparations can be applied terrestrially, aerially or in combination with pheromones in traps, as previously suggested [B. bassiana preparations on bark beetle infestations in terms of possible environmental effects is minimal compared to the severe damage and hence yield loss caused by this insect species worldwide, especially in Europe and North America [The application of  studies . In contause 93%  to 100% ause 93%  mortalitause 93% . Furtheruggested . It rema America . The eco


Untreated conductive and mixed hearing losses as a result of middle ear pathology or congenital ear malformations can lead to poor speech, language and academic outcomes in children. Lack of access to centralised hearing healthcare in resource-constrained environments limits opportunities for children with hearing loss. Red Cross War Memorial Children’s Hospital (RCWMCH) is one of only two dedicated paediatric hospitals in sub-Saharan Africa. Between 2016 and 2021, 29 children received implanted bone conduction hearing devices, and 104 children were fitted with bone conduction devices on softbands. The authors’ experience at RCWMCH suggests that bone-anchored hearing devices, either fitted on softbands or on implanted abutments, can provide solutions in settings where patients have limited access to hearing healthcare and optimal classroom environments. Hearing healthcare should be accessible and delivered at the appropriate level of care to mitigate the adverse effects of hearing loss in children.This article describes strategies employed at RCWMCH such as fitting bone conduction hearing devices on a softband immediately after hearing loss diagnosis and conducting follow-up via remote technology to make hearing healthcare more accessible to vulnerable populations. The World Health Organization WHO,  estimateThe adverse effects of hearing loss, irrespective of its aetiology, on childhood development manifest as delays in speech and language development  in the Western Cape province of South Africa over six years, followed by recommendations for accessible service delivery in resource-constrained settings.Red Cross War Memorial Children’s Hospital is one of only two dedicated paediatric tertiary-level academic hospital in sub-Saharan Africa and serves as a central referral hospital for patients across the entire Western Cape who require specialised healthcare services. The audiology department at RCWMCH provides diagnostic audiology and intervention services to children from birth to 13 years from the public healthcare sector.A retrospective review of clinical data, using an electronic departmental database, was conducted. Purposive sampling was used by the primary investigator to identify children between 0 and 13 years, who were fitted with bone conduction hearing devices, either on a softband or implantable abutment, between January 2016 and December 2021. The departmental database was established in 2016; therefore, data were reviewed from 2016 to 2021 to include a wide lens of records.Participants were identified retrospectively using an electronic departmental database from which their demographic and clinical information was recorded. Data were anonymised by assigning an alphanumeric code to each participant.All data were captured on an Excel spreadsheet, using Microsoft Excel 2022 . The data were analysed using SPSS 27, version 27.0 . Descriptive analysis was used to report on the findings.This article followed all ethical standards for research without direct contact with human or animal subjects.n = 104) and permanent implanted abutments (n = 29). The retrospective departmental database review indicated that a total of 9215 children were seen by the audiology department at RCWMCH during January 2016 and December 2021. Of these, 498 children were fitted with amplification devices, of which 133 were bone conduction hearing devices on softbands (n = 71). Nearly one-third of our sample  presented with single-sided hearing loss. It is notable that during 2020, when the COVID-19 pandemic was at a peak globally, the number of bone conduction implants and devices issued on softbands decreased. The decrease was likely because of audiology outpatient services de-escalating and patients having restricted access to nonemergency healthcare services.The majority of patients who received either implanted or softband bone conduction hearing devices during 2016 – 2021 presented with CHL  is documented via data logging software in the device. Patients who present with CHL caused by tympanic membrane perforations or chronically leaking ears, and who are too young for surgical intervention, are fitted with bone conduction devices on a softband until they are old enough for surgery. The bone conduction processor fitted to a softband means that the device can be issued on the day of diagnosis. This rapid response speaks to the principles of primary healthcare in terms of accessibility and acceptability.Functional hearing outcomes are measured by validated parent–teacher feedback questionnaires, such as the Parents’ Evaluation of Aural/Oral Performance of Children (PEACH) and the Teachers’ Evaluation of Aural/Oral Performance of Children (TEACH)  can be sent to the ear, nose and throat (ENT) surgeon, who can refer the patient directly to the appropriate level of care . Patients’ travelling distance to a centralised tertiary service can be reduced in this way, and infections that arise as a complication of the abutment surgery can be treated timeously. For patients who do not have access to a smartphone or mobile data, written information on wound care is given, and they are advised to come to the hospital immediately if any postoperative wound complications (such as skin redness or crusting) are observed.South African classrooms are often large and noisy, and resources such as FM systems and remedial support are not routinely available in many public schools. In order to facilitate inclusivity within the South African public education sector, bone conduction devices are offered to children with single-sided hearing loss, where the bone conduction device acts as a cross-router for better localisation. Bone conduction devices are often issued for children with single-sided hearing loss based on teacher feedback of poor scholastic performance. Functional listening progress  is measured by the TEACH questionnaire, as described earlier. Such a strategy manages the often-overlooked issue of unilateral hearing loss, which has a negative impact on children’s social and academic advancement.The above description of a system to manage hearing healthcare in a resource-constrained environment has implications for planning and policy in similar settings in South Africa and other sub-Saharan African facilities. A review of the guidelines for medical and audiological treatment of conductive, mixed or single-sided hearing loss in children is necessary, especially when delayed speech development and poor scholastic performance are reported.


The relationship between speech recognition and hereditary hearing loss is not straightforward. Underlying genetic defects might determine an impaired cochlear processing of sound. We obtained data from nine groups of patients with a specific type of genetic hearing loss. For each group, the affected cochlear site-of-lesion was determined based on previously published animal studies. Retrospectively obtained speech recognition scores in noise were related to several aspects of supra-threshold cochlear processing as assessed by psychophysical measurements. The differences in speech perception in noise between these patient groups could be explained by these factors and partially by the hypothesized affected structure of the cochlea, suggesting that speech recognition in noise was associated with a genetics-related malfunctioning of the cochlea. In particular, regression models indicate that loudness growth and spectral resolution best describe the cochlear distortions and are thus a good biomarker for speech understanding in noise. The relationship between speech recognition and the degree of sensorineural hearing loss is not straightforward. Patients, for example, with an average sensorineural hearing loss of 70 dB HL and an adequate amplification may have speech recognition scores that vary between 10 and 80% ,3,4,5. I1,2,4 kHz) of 90 dB HL had an average phoneme score of 40%, whereas this percentage for DFNA2 patients with the same degree of hearing loss was approximately 80%. Speech recognition scores in silence and in noise thus seem to be rather uniquely related to the underlying genetic type of hearing impairment [While hearing loss does explain some of the difficulties patients report, it has become clear that it cannot be the only factor. This is, for example, illustrated by patients with autosomal, a dominantly inherited form of hereditary hearing loss type 2 and 9 (DFNA2 and DFNA9), who have comparable high-frequency hearing losses at a relative young age . DFNA9 ppairment . In line with these findings, we hypothesize that variations in speech recognition between patients is not primarily related to the degree of hearing impairment but also the degree of impaired cochlear processing. The latter mainly depends on which part of the cochlea is affected, e.g., hair cells responsible for mechanotransduction ,15, the These new insights highlight that the site of pathology, or cochlear site-of-lesion, may ultimately determine the thresholds and the ability to understand speech in quiet and speech-in-noise. In this work, we further highlight this by studying specific groups of patients. Over the last decade, we published the results on psychophysical and speech-in-noise tests obtained in nine different groups of hearing-impaired patients with a particular type of genetic hearing impairment ,27,28,29In 2004, De Leenheer et al. introduced a test battery consisting of psychophysical  and speech recognition in noise tests to assess cochlear processing . Over tiLoudness growth was measured with 0.5 kHz and 2 kHz tones. The best-fit curve through the loudness growth data was calculated, and its slope was the primary outcome measure . It was decided to present the slope relative to (divided by) the slope of normal hearing subjects. This means that a relative slope of 1 reflects a loudness growth similar to normal hearing subjects. In the case of loudness recruitment, the relative slope is larger than 1 [The test battery consisted of four tests performed in a standardized way in all patient groups. r than 1 . Gap detection (GDT), or the shortest perceived period of silence between two noise bursts, was measured using band-filtered white noise with center frequencies of 0.5 kHz and 2 kHz. The smallest detectable gap is presented relative to (divided by) the norm value to obtain a relative measure. A value of 1 means that the smallest gap detected is not different from the norm, and a value larger than 1 indicates reduced temporal precision.The difference limen for frequency (DLF) was measured at 0.5 kHz and 2 kHz with frequency-modulated tones. The lowest modulation frequency that the patient detected was taken as the DLF, and it is presented relative to (divided by) the norm value. speech recognition in noise test, also referred to as the Plomp-test [If CDF = 0, then the SRT-in-noise is normal. If CDF > 0, the patient has more difficulty understanding speech-in-noise than the controls. Often this term refers to suprathreshold deficits, such as reduced frequency selectivity or impaired temporal processing. The critical signal-to-noise ratio was measured using the omp-test ,11. In tHowever, as pointed out by Houtgast and Festen (Houtgast and Festen 2008), the D-factor  may alsoTo investigate the present research hypothesis, we decided to homogenize the nine groups of patients and to only include data of patients aged between 17 and 70 years. These inclusion criteria were previously introduced and relate to presbyacusis as a factor that might interfere with hereditary hearing impairment  and can In retrospect, the speech recognition in noise scores is related to the loudness growth data, gap detection threshold, and difference limen for frequency, using regression analyses. Additionally, compared to the literature, the speech-in-noise data are related to the generic variables of age and hearing loss. As the outcomes of the speech-in-noise test primarily depend on the processing of high-frequency information , the psyThe Cochlear Distortion Factor  is affecp < 0.001) with an r2 of 0.3. Interestingly, only the CDF was significantly related to the PTA; the CDF increased by 1.5 dB per each 10 dB increase of the hearing threshold (PTA). The factor age, however, is not significantly related to the CDF. Since age and PTA are strongly correlated, as we know from age-related hearing loss (ARHL), we also tested the effect of age by omitting the factor PTA in the linear model. In this model, age is also not significant. This is an important finding because cognition is highly correlated with age and is known to also affect the CDF [Following the literature ,36, the  the CDF ,38. So, ‘patient group’. For some groups, such as the Usher2A patients, most patients  have a CDF that falls above the regression line and its 95%-confidence interval. In another group, such as the DFNA13 group, half of the participants (4 out of 8 patients) have a CDF that falls below the regression line. This indicates that, although CDF and PTA seem related, the regression model with only PTA and age fails to capture most of the variance. Indeed, by adding the variable ‘patient group’ as a categorical variable, the model captures more explained variance from r2 = 0.42 (variables PTA and age) to r2 = 0.75  = 9.53, p < 0.001). Despite the apparent relation of CDF with PTA, it can be observed that the CDF also varies with respect to the factor 2) from 0.63 (only SLG) to 0.88  = 18.6, p = 0.004)). Adding the difference limen for frequency (DLF) instead of gap detection also improved the r2 from 0.87 to 0.98  = 95, p < 0.001). These r2 values are very high. The final equations for the two models are: Since the variation of CDF within the patient groups is substantial, the linear regression analysis was also performed on the mean CDF data for each group and the three psychophysical variables. The linear regression analysis using the relative slope of the loudness growth curve (SLG) and the relative gap detection threshold (GDT) as variables raised the explained variance (rp = 0.28). The third model was thus rejected as model 2 has only two explaining variables while it explained the data equally well.According to these two models, a normal-hearing subject  has a CDF factor of 0.9 dB and −0.7 dB, respectively, for model 1 and model 2, thus being close to the expected CDF of 0 (no cochlear distortion). At a group level, the CDF could therefore be predicted by the combination of the loudness growth (SLG) and either the relative gap detection threshold (model 1) or the relative difference limen for frequency (model 2). The fits are both significant, show a high degree of explained variance, and show that the two models also hold for normal-hearing participants. A third model where all three variables were used in the linear model was also considered. While it also explained 98% of the variance, an ANOVA comparing this model with model 2, the best model, yielded a non-significant result  or site-of-lesions, where some forms are more detrimental to understanding speech-in-noise than others. This, in turn, may explain the often-reported poor relationship between hearing loss (PTA) and speech recognition. Moreover, regression models indicate that loudness growth and spectral resolution best describe the cochlear distortions and are thus a good biomarker for speech understanding in noise.With growing knowledge in the field of genetic hearing loss and molecular biology of the inner ear, the classification system as introduced by Schuknecht and Gacek has been debated over the years ,40. NeveCOL11A2 on cochlear function in patients with DFNA13. This deficient gene exhibits a loss of organization of the collagen fibrils in the tectorial membrane, thus affecting the viscoelastic properties of this membrane. Owing to the near-normal CDF and near-normal slopes of the loudness growth curves and the tectorial membrane anomaly, it was stated that the hearing impairment acted as a cochlear conductive type of hearing loss. In a second study, similar outcomes  were reported in patients with DFNA8/12 [TECTA gene. Pathogenic variants in genes that affect the tectorial membrane function, such as COLL11A2 and TECTA, are thus likely causing hearing loss with near-normal speech-in-noise performance and normal loudness growth. Subjects in these groups perform well when audibility is restored by using, e.g., hearing aids.The first published study from our group  and Ohlemiller (2004). Based on the outcomes of the psychophysical tests and the present knowledge of pathology on a cellular level , Usher sYet, categorization of the type of cochlear hearing loss might be complicated by inter-subject variations, as was found in the outcomes of patients with the non-ocular Stickler syndrome . Note, hIn summary, there is a group of patients that have no apparent cochlear distortion and show normal speech perception . In these groups, pathogenic variants have an impact on how the tectorial membrane functions. Yet, while there are several genes where pathogenic variants affect the tectorial membrane, not all cases lead to (near) normal speech perception and normal loudness growth. Instead, in some groups, it may reflect a combination of sensory and cochlear conductive hearing loss . In these groups, the connection of the tectorial membrane with the OHCs also seems affected, leading to more sensory loss or mixed loss.Lastly, the groups identified as a sensory loss, such as the groups of patients with DFNA22, Usher type 2a, HDR syndrome, and DFNA10, perform worse than normal, even when correcting for audibility. These groups show a higher CDF and thus show worse performance on speech-in-noise tests related to the underlying pathology of hair cells. 2 = 0.98) than the loudness perception combined with temporal processing abilities (r2 = 0.88). A model where all variables were considered was less parsimonious, did not yield a better fit, and was therefore rejected. While speculative, the fact that the loudness perception and spectral abilities are the most critical variables but to a lesser degree, the temporal coding may indicate that the groups studied show affected cochlear processing rather than more upstream problems with, e.g., temporal coding. Notably, these analyses were performed at the group level since a substantial variation of the speech recognition in noise was observed within each group. In the studies reviewed and selected, the speech-in-noise performance was measured as well as the psychophysical variables, such as the slope of the loudness growth curve, the gap detection threshold, and the difference limen for frequency. These variables may predict speech-in-noise performance ,42,43. AA limitation of the present retrospective study is the limited number of groups and the limited number of patients per group . Recruiting sufficient numbers of patients with a well-established genetic hearing loss diagnosis is troublesome because most types of genetic hearing loss are rare or very rare. Pooling data from different centers is thus essential to deal with the low numbers and should be part of future research. A second limitation is that, despite our efforts to limit the range of hearing loss, the patients per group were still heterogeneous regarding their PTA  to underlying psychophysical features. To further study cochlear processing, it is recommended to use a universal test battery, such as the ‘Auditory profile’ test battery ,49, or mA better understanding of aspects of hearing impairment, as captured by a ‘deep phenotype’ of hearing loss, may reveal essential biomarkers desperately needed in advancing treatment ,52. We sThe categorization of cochlear hearing loss, e.g., cochlear conductive versus sensory, is very important for rehabilitation. Suppose the hearing loss is, for example, of the cochlear conductive type. In that case, linear amplification using hearing aids might be beneficial for patients, similar to the ‘classical’ fitting of a (true) conductive hearing loss. In contrast, in the case of outer hair cell loss, a more compressive form of amplification might be the better choice to deal with loudness recruitment. Furthermore, in the latter group, noise reduction and speech enhancement strategies might be beneficial in dealing with the broader rather than the normal auditory filters . Based oMoreover, the categorization and identification of the site-of-lesion is important for patient selection for upcoming trials ,52. A deIn summary, different types of genetic hearing loss might uniquely affect cochlear processing, resulting in different auditory profiles that can be assessed by psychophysical tests. Such knowledge might help shape the expectations of patients referred for hearing aid fitting in the clinic and provide some insight into better ways to start hearing loss rehabilitation or even provide a treatment. Furthermore, the lack of predictive power at the individual level suggests that other variables could explain more of the variance we observe within the groups. This deep phenotype of hearing loss is needed, if only to have a good tool for selecting suitable patients for new and upcoming inner ear therapeutic studies , as an e


Stapedotomy or stapedectomy operations are often performed to treat otosclerosis. During the operation, the space created by bone removal is usually filled with a closing material such as fat or fascia. In this study, the effect of the Young’s modulus of the closing material on the hearing level was investigated through the 3D finite element model of a human head including auditory periphery. The Young’s moduli of the closing material used to implement stapedotomy and stapedectomy conditions in the model were varied from 1 kPa to 24 MPa. The results showed that the hearing level improved when the closing material was more compliant after stapedotomy. Therefore, when the stapedotomy was performed using fat whose Young’s modulus is lowest among the potential closing materials, the hearing level recovered the best among all simulated cases. On the other hand, in stapedectomy, the Young’s modulus did not have the linear relationship between the hearing level and the compliance of the closing material. Hence, the Young’s modulus causing the best hearing rehabilitation in stapedectomy was found not at the end of the investigated range of Young’s modulus but somewhere in the middle of the given range. Otosclerosis is a disease in which the stapes annular ligament (SAL) is stiffened, resulting in conductive hearing loss (CHL) . Owing tIn this study, we aim to investigate the effects of the closing material on the hearing levels after stapedotomy or stapedectomy operations. Using a three-dimensional (3D) finite-element (FE) model, the basilar membrane (BM) velocity was calculated by varying the Young’s modulus of the closing material to evaluate the recovered hearing levels after the operations.The used abbreviations in this study are summarized in The present study was conducted with a previously developed 3D FE full-head model . AlthougAlthough the head model was validated several times in the previous studies, the closing material elements to represent the stapedectomy were newly generated with lower Young’s modulus. Therefore, the volume velocity of the oval window replaced by the closing materials was calculated to confirm the convergence with decreasing the mesh size of the elements as 0.2, 0.1, 0.05, and 0.02 mm see . Since mi.e., 8 and 0.4 GPa, respectively, so that the model would have consistent promontory accelerance and best frequency (BF) map with the reference , BF map, and BC hearing loss from the otosclerosis condition were recalculated for model validation, as shown in the “Results” section. Furthermore, the detailed material properties of head and auditory periphery models are summarized in Most material properties of the full-head model were identical to those in the previous study, except for the cortical and cancellous bones (diploë) in eference . Howevereference . In otheThe Young’s modulus of the normal SAL has been considered to be around 0.7 MPa . HoweverBM) is related to the hearing threshold in both air-conducted (AC) and bone-conducted (BC) hearing. The AC stimulation was implemented by assigning a uniformly distributed dynamic unit pressure on the surface of the tympanic membrane (TM). Boundaries of the head and auditory periphery components, such as the ends of the ligaments and tendons, edge of the tympanic annulus, and outer bony shell of the cochlea, were fixed. On the other hand, the BC excitations were implemented by assigning a sinusoidal force on the screw component in the typical position for a bone-anchored hearing aid (BAHA). The screw component was inserted perpendicular to the skull surface at the BAHA position. The direction of the sinusoidal force was determined as the direction in which the screw component was inserted. In this study, it is assumed that the velocity of the BM  along the BM length at each simulated frequency. Based on these calculated velocities, the specific position showing the maximum velocity among the 180 positions corresponding to an input frequency was defined as the ‘BF position’. In addition, since the BF position is the same between the normal and the specific condition except when the input frequency is different, the hearing loss (or gain) was calculated by the difference in BM velocities at the BF position according to the input frequency between the normal and the specific condition .For the model validation, we compared the simulation results with clinical data obtained from stapedotomy operations. The Institutional Review Board of Seoul National University College of Medicine/Seoul National University Hospital approved this study (IRB No. 2209-120-1360) and waived the need for informed consent owing to the retrospective design and use of anonymous clinical data for analyses. A total of six patients (10 ears) who were diagnosed with otosclerosis between January 2020 and May 2020 and underwent stapedotomy were included in the study. The mean age of in total six patients who were involved in clinical analysis was 44.3 ± 17.9 years. A platinum piston wire prosthesis  was utilized and moved over the stapedotomy opening. The piston wire prosthesis was advanced into the vestibule and crimped over the incus. The prepared soft tissue was placed around the gap between the hole and prosthesis. The soft tissues were not distinguished as fat or fascia in the operations. The results of the pre-operative and post-operative PTAs at 1 year after surgery were collected and analyzed. It should be noted that masking was performed to prevent cross hearing in the measurement when the hearing threshold difference between both ears in a patient exceeded the interaural attenuation.Although the full-head model was validated in a previous study, revalidation of the model was needed owing to the changes in the Young’s moduli of the skull in the present study. Therefore, the promontory accelerance, BF map, and BC hearing loss in otosclerosis were recalculated, as shown in i.e., pre-operative) and stapedotomy  conditions, respectively. The error bars in The hearing threshold level can be defined as the pressure level on the TM when the human perceives a sound. At this time, the pressure level represented by sound pressure level (SPL) on the TM can be converted into 0 dB hearing level (HL). For example, according to ISO 8253-1, a 13.5 dB SPL results in human perception of sound at 0.5 kHz. Thus, 13.5 dB SPL is considered as 0 dB HL at 0.5 kHz . The HLsThe AC HLs in post-operative simulations were within the standard deviation of the clinical data along the input frequency changes. The AC HLs for the pre-operative simulations were within the standard deviation of the clinical data at high frequencies above 2 kHz. However, there were 20–40 dB differences between the simulation results and clinical data at low frequencies below 2 kHz. This difference is further explored in the “Discussion” section.i.e., pre-operative) are represented by black solid lines in i.e., post-operative) conditions are shown with red and gray lines, respectively. Specifically, the post-operative cases are separated into three types whose Young’s moduli of the closing materials are 1 kPa, 1 MPa, and 24 MPa, which are represented by solid, dotted, and dashed lines, respectively.The hearing losses in the pre-operative and post-operative conditions were calculated by subtracting the BM velocities for each condition from those for the normal condition. Since the BF position is the same regardless of the operation condition unless the input frequency is different, the position where the BM velocities are calculated was the BF position corresponding to the input frequency. The hearing losses of otosclerosis . This difference can cause the higher hearing threshold in the model than that in a patient. In addition, the simulation and clinical data show about 10–20 dB difference in hearing level at 4 kHz. However, the large error bars indicate that there are large variations in the patients’ responses. As mentioned above, various statuses of patient SALs may cause these large errors. For further study, it is necessary to measure the SAL stiffness in otosclerosis patients before stapedotomy or partial stapedectomy surgery, as different occlusive materials may be used depending on the type of surgery. Since the cochlear input impedance of a post-operative patient can be determined by a combination of the SAL and the closing material, the optimized closing material in accordance with operation type for the patient can be effectively determined through the SAL stiffness. The relevance between the closing material and operation type is explained below.In the process of validation, although most results from the promontory accelerance, BF map, and hearing loss in the BC condition for the Carhart’s notch were reasonably consistent with those of previous studies, the AC HL of the otosclerosis simulation [black solid line in i.e., 24 MPa, the high stiffness caused less movement but greater in-phase motions of the closing material, as described in The AC hearing loss in stapedotomy is proportional to the Young’s modulus of the closing material, while there is no proportional relationship between the Young’s modulus of the closing material and hearing loss in the stapedectomy simulation. The non-proportional relationship in stapedectomy can be explained by the deformed shape of the closing material replacing the stapes footplate. In the stapedotomy, a large portion of the stapes footplate remains despite the perforation. Therefore, the remaining stapes footplate shows in-phase motions due to its high stiffness. However, in the stapedectomy, the stapes footplate was thoroughly replaced by the closing material; thus, when the Young’s modulus of the closing material was sufficiently compliant, such as 1 kPa, although the area of the prosthesis tip moved into the cochlear fluid, the closing material surface bulged into the cochlear fluid, as described in Although the current study using the FE model clarified the effect of the closing material on the hearing level, the following limitations should be considered for better understanding of stapedectomy and stapedotomy. Firstly, the current FE model has a different boundary condition than a clinical case for the connection between the prosthesis and the incus. While the prosthesis is attached to the lenticular process in the current model, a prothesis is crimped to the long process (even to other locations) in real patients. Although the effect of the closing material stiffness on the hearing level could not be affected by the connection condition, the attaching condition can directly affect the hearing level. Therefore, variance of the connection condition can be a future study topic for better understanding of stapedectomy and stapedotomy. Secondly, after stapedectomy or stapedotomy operation, the state of the interface between the closing material and the bone around the closing material, or between the closing material and the prosthesis can change over time. Therefore, in the next investigation, the effect of the interface change over time should be considered for better understanding of hearing rehabilitation. In short, since the FE model inherently contains simplification, it cannot fully reflect the biological situation. Therefore, care is needed in the analysis of the results.BM was used to calculate hearing loss, and the effects of the Young’s moduli of the closing materials on hearing losses in the AC case were investigated. According to the results, the level of hearing loss was proportional to the Young’s modulus of the closing material in the stapedotomy. On the other hand, there exists an optimized Young’s modulus of the closing material in the stapedectomy that allows the best hearing rehabilitation. Based on the results, more compliant closing materials can be used to achieve better hearing rehabilitation in the stapedotomy, whereas an appropriate Young’s modulus of the closing material is able to improve hearing ability in the stapedectomy. Hence, fat is better as a closing material than fascia in the stapedotomy, whereas the fascia with 1 MPa Young’s modulus is better than the other types of fascia (with Young’s modulus of 24 MPa) or fat in the stapedectomy.In this study, the simulations for otosclerosis and post-operative conditions were conducted using the 3D FE full-head model. The post-operative condition for stapedectomy was implemented by replacing the stapes footplate with compliant closing materials and connecting a prosthesis between the center of the closing material and the incus. On the other hand, the condition for stapedotomy was represented by placing a hole at the center of the stapes footplate and inserting a prosthesis connected with the incus into the hole. The gap between the prosthesis and the hole was filled with closing materials. The VThe original contributions presented in this study are included in this article/The studies involving human participants were reviewed and approved by Seoul National University College of Medicine and Seoul National University Hospital. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.JL: simulations, formal analysis, and writing – original draft. WG: methodology, data curation, and validation. DK: methodology, data curation, and writing – original draft. SO: conceptualization, supervision, and writing – review and editing. NK: conceptualization, supervision, writing – review and editing, and project administration. All authors contributed to the article and approved the submitted version.


The next‐generation global climate model from the NASA Goddard Institute for Space Studies, GISS‐E3, contains many improvements to resolution and physics that allow for improved representation of tropical cyclones (TCs) in the model. This study examines the properties of TCs in two different versions of E3 at different points in its development cycle, run for 20 years at 0.5° resolution, and compares these TCs with observations, the previous generation GISS model, E2, and other climate models. E3 shares many TC biases common to global climate models, such as having too few tropical cyclones, but is much improved from E2. E3 produces strong enough TCs that observation‐based wind speed thresholds can now be used to detect and track them, and some storms now reach hurricane intensity; neither of these was true of E2. Model development between the first and second versions of E3 further increased the number and intensity of TCs and reduced TC count biases globally and in most regions. One‐year sensitivity tests to changes in various microphysical and dynamical tuning parameters are also examined. Increasing the entrainment rate for the more strongly entraining plume in the convection scheme increases the number of TCs . Variations in divergence damping did not have a strong effect on simulated TC properties, contrary to expectations based on previous studies. Overall, the improvements in E3 make it more credible for studies of TC activity and its relationship to climate. The new NASA GISS‐E3 global climate model at 0.5° resolution simulates more realistic tropical cyclone activity versus the E2 versionHurricane intensity storms are now simulated, and the average storms are comparable to other 0.5° climate modelsTropical cyclone counts in E3 are very sensitive to convective plume entrainment rates but not to divergence damping coefficients There is much interest in how these storms will change as a consequence of anthropogenic global warming, but predicting these changes with global climate models (GCMs) has proven challenging due in part to the dependence of TC dynamics on processes that are unresolved at such models' typical spatial resolutions. All else being equal, higher horizontal resolution in GCMs typically improves TC activity characteristics  ModelE3, the next generation GCM still under development at GISS: one from early in the model's development and previously used by Cesana et al.  and CamaIn addition to making comparisons between the two versions of E3 analyzed here, and between these and observations, we are also interested in understanding how the GISS TCs depend on the model physics and the extent to which various parameters can be tuned to improve TC representation. To this end, we have run numerous short experiments with E3 in which individual tuning parameters were changed, and we examine the resulting changes in TC properties as well as other climate variables and the errors in these variables with respect to observations. These are inspired by past experiments showing the sensitivities of TC properties to entrainment rate parameters in E2  reflected shortwave (SW) radiation, varying regionally. The broad increase in reflected SW radiation contributed to a larger TOA energy imbalance found in V2, which is discussed in Section Version 1 (V1) of the model is an early version of E3 that was used for NASA's contribution to the study by Camargo et al.  on whethThe two model versions were run with default entrainment and divergence damping parameters from 1980 to 2000, forming 21 Northern Hemisphere TC seasons (January to December) and 20 complete seasons for the Southern Hemisphere (July to June) and are referred to as 20‐year test runs. Most of this paper analyzes these test runs, while Section For our database of observed TCs, we use the International Best Track Archive for Climate Stewardship , have a sea level pressure minimum within 4° of the vorticity maximum, and to be located between 70°N and 70°S. Once identified, the storm candidates are tracked forward in time searching within 1,500 km of the previous position (defined as the location of the SLP minimum), and further criteria are applied for tracks to be included. TCs must, on three separate (not necessarily consecutive) days, exceed the cyclonic 3.5 × 10−5 s−1 vorticity threshold, have a warm core temperature anomaly exceeding 1°C, and have maximum surface wind speed, defined here as the wind speed at 10 meters in the postprocessed model output, exceeding 15.2 m/s (but the winds can drop below this threshold at times during the trajectory). In addition, the 10 m winds must at some point exceed 17.0 m/s, or tropical storm intensity. As pointed out by, for example, Sugi et al.  wind speed and minimum central pressure. Figure The maximum wind speeds have improved significantly from E2 to E3. The median TCs in E3 are of similar strength to those in the upper quartile for E2, and the strongest storms in E3 reach hurricane intensity . However, TCs in excess of 80 knots are still absent from E3. The further refinements of E3 from V1 to V2 led to still stronger TCs, but the improvement is much less than from E2 to E3. Notably, the median lifetime maximum wind speed of about 25 m/s in V2 is comparable to those of other GCMs at similar resolution , includFigures Figure Figure 4.2<920 hPa bin is excluded because no storms reached that pressure in V1 and only one did in V2; we include this storm in Figure To better understand the physical properties of the storms, we show in Figure The pattern of kidney‐shaped tangential wind contours and more concentric pressure contours is also seen in the modeled and reanalysis TCs shown in Roberts et al. , especia<0.5 mm/day) surrounding the core, while there are isolated areas of heavy precipitation to the south of the TC. This suggests that the broad swath of light precipitation surrounding the TCs in Figure The strongest storm in the V2 20‐year integration, whose properties corresponding to Figure We have also examined TC structure from a radial‐height perspective, following the methodology of Kim et al.  and Moon5ϵ1 and ϵ2, respectively, in the two‐plume cumulus convection parameterization, originally described by DelGenio and Yao  from the 20‐year runs with the default values of the parameters analyzed in the previous sections. The parameters changed in the experiments and their default values are listed in Table  and Yao , which w and Yao  and has ϵ2 has a systematic effect on TC properties, with higher values of ϵ2 associated with more and stronger TCs. Accordingly, many of the sensitivity tests were redone with ϵ2 increased to 0.9 from its default value of 0.6; these experiments are shown as green curves in Figure ϵ2 are shown in black. The experiments with ϵ2 = 0.9 consistently have higher TC counts and stronger TCs than those with ϵ2 = 0.6 across all of the values tried for the other parameters. However, increasing ϵ2 also affects other climate variables. Most importantly, the ϵ2 = 0.9 runs consistently have a TOA radiative imbalance of about −6 W m−2 (defined positive downward) in the annual mean, versus a default value that is close to 0, and this imbalance is insensitive to changing any of the other parameters. Increasing ϵ2 also leads to greater cloud cover , a greater fraction of convective cloud, and a higher liquid water path, while having little effect on ice water path. Physically, these results are suggestive of a mechanism in which the increased entrainment rate leads to less deep convection, less convective subsidence drying, more shallow convection, a moister lower troposphere, and more clouds. The greater cloud cover causes a higher planetary albedo, which leads to the greater radiative imbalance, and the greater liquid water path makes TC formation easier.Figure ϵ2, the other parameters have little systematic effect on any of the TC or climate variables. Most notably, we find little sensitivity to the divergence damping parameters. This is in contrast to Zhao et al. . Changes in liquid and ice water path tend to oppose each other in V2 to a greater degree than in V1.Experiments varying To further assess how climate and TC properties vary across these sensitivity tests in relation to each other and to observations, we plot matrices of error metrics in the V1 sensitivity tests relative to observations in Figures ϵ2 to 0.9 allows genesis density to sometimes exceed observations when other variables are changed (though the TCs are not necessarily in the correct locations). The model has a high bias in precipitation in most sensitivity tests, which is further increased by increasing ϵ1 and is only reduced by decreasing ϵ2 from the default value, which exacerbates the low bias in TCs frequency.  TOA imbalance is mainly due to too much outgoing shortwave radiation, consistent with the increase in cloud cover shown in Figure From Figure s et al. , have arm et al. , who chaϵ2 is increased from its default value, we see that while errors in the global means are small, in some cases RMSE is relatively large compared to other experiments. Given the small number of TCs in one year, errors in the spatial distribution especially for genesis density would be expected. However, the experiments with ϵ2 set to 0.9 generally have higher RMSE for precipitation and zonal mean atmospheric temperature than those with varying divergence damping terms and ϵ2 at its default value. Other variables, such as OLR and outgoing shortwave radiation (OSR), show more straightforward relationships between the two error metrics, with smaller global mean errors corresponding to smaller RMSEs, while some variables with little change in the global mean error across experiments, such as sea level pressure and cloud optical depth, have no apparent pattern in the normalized RMSEs due to amplification of noise by the RMSE normalization.Measuring error by differences in global mean quantities does not account for the possibility that the model could get the global mean right but have the wrong spatial distribution. The normalized RMSE shown in Figure To see how these errors are affected by the change from V1 to V2, we show in Figure The similarity of V1 and V2 storms, combined with the relative insensitivity of TC variables to most tuning parameters and the common cube‐sphere dynamical core with E2, suggests that the improvement in TCs from E2 to E3 is primarily a result of increased resolution, but the improvements from V1 to V2, which retained the same default values of the entrainment and damping parameters, show that improving model physics can still lead to better representation of TCs. Future model runs with the final version of E3 at C180 resolution will likely show reduced biases in climate variables relative to V2, especially in the TOA radiation imbalance that was corrected in subsequent model development, with TC representation perhaps slightly further improved. It may also be possible to increase the number of TCs, as well as improve the representation of the seasonal cycle of TCs and reduce other climate biases, using stochastic parameterizations, as was done by Vidale et al.  for two 6In this study, we have explored the characteristics of the 0.5° resolution version of the GISS ModelE3 GCM, in two different versions across its development cycle. The representation of TCs is much improved from the CMIP5 GISS‐E2 GCM, with some TCs reaching hurricane intensity and the average storms in E3 having similar wind speeds to those of other half‐degree GCMs, obviating the need to use a tracker with a wind speed threshold well below that in observations. The model continues to show common biases in GCMs, such as having too few TCs, especially in the North Atlantic, and lacking storms of major hurricane intensity, although it is better at capturing more intense minimum central pressures than E2. The changes made between April 2018 (V1) and March 2019 (V2) further reduced biases in TC counts, intensities, and lifetimes, while also re‐introducing the excess of TCs in the North Indian basin during the summer monsoon (though to a much lesser degree than in E2). Our analysis of the simulated TCs' composite spatial structures shows that E3 reproduces spatial structures in winds, OLR and precipitation comparable to those seen in other models at similar resolution. Our analysis of azimuthally averaged TC properties Figure  shows thϵ2, leads to more TCs. It also introduces greater errors in global mean energy imbalances at the surface and top of atmosphere, but experience suggests that these can be largely reduced by adjustments to other parameters, such as ice fall speed, without losing the benefits gained by increasing entrainment. We did not find divergence damping terms to be important for TCs, in contrast with experiments with the GFDL model by Zhao et al. (ϵ1 = 0.3 and ϵ2 = 0.6) led to reduced TC counts, but subsequently increasing rain reevaporation dramatically increased them. Our results suggest that retaining the two‐plume scheme and changing the evaporation rate of the more strongly entraining plume instead of the weaker one provides a more useful, singular “knob” to optimize TC properties, without the need to change rain evaporation rates. Overall, biases in most climate variables across the sensitivity tests are slightly larger in V2 than in V1, but with both versions being snapshots in a years‐long process of model development that has not neared its end—particularly as there is no C180 version of Model E3 in the CMIP6 ensemble—it would be wrong to draw any inference of a trajectory in these errors from just these two versions.Our various sensitivity tests show that the most important parameter affecting TC numbers and intensity in E3 is the entrainment rate constant for the strongly entraining plume in the two‐plume convection scheme. Increasing this parameter, o et al. , who fouo et al.  found thOverall, we can conclude that the E3 version of the GISS GCM, when run at approximately 0.5° resolution, has much improved representation of TCs from the previous generation, and is now comparable to other GCMs of similar resolution, at least according to the average intensity storms. This indicates that E3 will be useful for future studies of TC responses to climate variability and change, whether on its own or as part of multi‐model ensembles.Supporting Information S1Click here for additional data file.


Paradoxical embolism (PDE) originates in the venous system and ends up in the arterial circulation via cardiac or pulmonary shunts. Cases of PDE from venous thrombosis resulting in acute myocardial infarctions (MIs) are seldom reported in the literature. Diagnoses can often be missed if further workups are not pursued in patients without any underlying risk factors for coronary artery disease (CAD). Here, we report a case of a paradoxical embolus that crossed the patent foramen ovale (PFO), causing ST-elevation MI (STEMI) from an embolized venous thrombus originating in the left distal posterior tibial vein. Venous thromboembolism (VTE) is a common phenomenon encountered in healthcare practice as deep vein thrombosis (DVT) and pulmonary embolism (PE). Usually, DVT and PE originate and can embolize to other locations in the venous system. Interestingly, when a venous clot ends up in the arterial circulation, it is then called a paradoxical embolism (PDE) . Most VTMyocardial infarction (MI) from PDE is a rare diagnosis that requires a high degree of clinical suspicion and thorough workup as it is a diagnosis of exclusion. Other causes of MI, including but not limited to coronary artery disease (CAD), vasospasm, valvular or conduction defects such as atrial fibrillation (AF), and less commonly, collagen defects and vasculitides, must be first ruled out . PFOs arThe combination of low prevalence and other common causes for cardiac arrest makes MI from PDE a unique and difficult diagnosis to make on initial presentation. Our report presents a case of a PDE causing ST-elevation MI (STEMI) secondary to a thrombus originating from the left distal posterior tibial vein.This study was previously submitted as an abstract at the 2021 American College of Prosthodontists (ACP) Connecticut Chapter on October 15, 2021.mitral valve not closing properly that required prolonged monitoring but no intervention. There is no family cardiac history. He is a nonsmoker. The patient reported recent swelling of his legs following a long bike ride but continued to cycle 30 to 60 miles per day.A 31-year-old physically fit Latino male with no prior medical history was brought to the emergency department (ED) with acute substernal chest pain radiating to the left arm that woke him from sleep. The patient had a distant history of a On arrival, he was diaphoretic, afebrile, and normotensive, with a heart rate (HR) of 59 beats per minute, respiratory rate (RR) of 16 breaths per minute, and saturating well on room air. Echocardiogram (EKG) showed normal sinus rhythm with left axis deviation and diffuse ST elevation in the anterolateral leads. Chest X-ray was unremarkable. Cardiac biomarkers were elevated  and creatinine kinase 1061 U/L). The patient was anticoagulated with heparin 5,000 IU and Brilinta  180 mg then emergently transferred to the catheter lab. A coronary angiogram revealed an 80% de novo occlusion of the proximal left anterior descending , lisinopril, and high-intensity statin per the cardiologist’s recommendations. The patient was discharged with therapeutic apixaban with plans to continue prophylactic dosage for six months. Extensive hypercoagulability workup in the outpatient setting was inconclusive. The patient has since undergone PFO closure to prevent future events.PDE in 1885 to describe an embolus passing from the venous to the arterial system through intracardiac communication. Four criteria must be met to diagnose a PDE, including a venous embolic source, a right-to-left shunt, a pressure gradient across the shunt, and an arterial embolism [The first account of PDE was detailed by Cohnheim in 1877 when he described the path of an embolus through a septal defect in the heart . Howeverembolism .Emboli may also be composed of fat, air, or amniotic fluid though most are thrombi formed in the venous circulation . DVTs haLEDVT makes up a small proportion of diagnosed DVTs as calf veins are not routinely scanned and imaging studies are less sensitive in this region . In the PFO affects 20% to 34% of the adult population although most patients are asymptomatic . PFO occPDE may also occur in association with atrial septal defects (ASDs), ventricular septal defects (VSDs), or pulmonary arteriovenous malformations (PAVMs) . In contLess than 2% of systemic arterial emboli are paradoxical, and most PDEs affect the cerebral vasculature to cause cerebrovascular events; in fact, up to 77% of cryptogenic strokes have been associated with PFO ,6,8.PDE may also embolize to the peripheral, renal, or mesenteric arteries or less commonly to the coronary arteries . MI compKleber et al. determined that patients with presumed MI from PDE are significantly younger than the general population who are affected by MI (43.0 ± 12.0 vs. 63.2 ± 12.7 years) . HoweverA diagnosis of an acute MI can be made with EKG and laboratory tests, including troponin and creatine kinase . MI fromAspiration embolectomy with or without stenting is the primary intervention for the management of MI from all causes . FollowiPDE is an uncommon cause of MI that should be considered in patients without cardiac risk factors or family cardiac history. Patients with suspected MI from PDE should be promptly diagnosed to reduce the risk of future embolic events.MI from PDE is a diagnosis of exclusion, following the initial detection of MI indicated by elevated biomarkers and EKG changes. The presence of an atrial shunt detected by TEE with a bubble study and evidence of thrombosis by ultrasound further support the diagnosis. Embolectomy is the primary intervention. Patients should be initiated on antiplatelet and anticoagulant therapy along with surgical closure of the inciting PFO.


Aim: to check the efficacy of a forma auditory training program for elderly patients fitted with hearing aids for at least three months, by means of speech recognition tests and self-assessment questionnaires. Methods: longitudinal contemporary cohort study. We selected 13 elderly hearing aid users, using intra-canal hearing aids in both ears, from both genders, with average age of 65.3 years. This group was randomly divided in Experiment Group and Control Group. The Experiment Group underwent seven formal auditory training sessions, aiming at stimulating their hearing skills for hearing closing, memory, attention, background figure and binaural integration. The participants were assessed by three behavioral tests and one self assessment questionnaire. Results: The elderly from the Experiment Group had significantly better performance in the assessments after auditory training in comparison to the Control Group. Conclusion: the formal auditory training program in a soundproof booth, associated with the use of hearing aids, improves speech recognition performance and reduces the perception of auditory handicap for the elderly who use intra-canal hearing aids.It is of paramount importance to install hearing rehabilitation programs for the elderly.  With the progress and improvements achieved in medical technology, there has been an increase in the longevity of the population, and consequently a higher incidence of organic, functional and psychosocial disorders that affect this group. Among them, hearing deterioration is one of the chronic conditions that affect the physical health in aging. Presbycusis is hearing loss caused by agingIn the hearing rehabilitation of the elderly with presbycusis it is recommended to use hearing aids. With the progress in technology, hearing aids came to the market as increasingly more sophisticated resources, which aim at supplying the needs of the hearing impaired. Nonetheless, some senior citizens can not adapt to the hearing aids and decide against using it or decide for a unilateral fitting, even when they have bilateral hearing loss. The authors also report that a central hearing impairment can negatively impact the hearing aid selection and fitting processThere are good reasons for believing in physiological changes in the central auditory system, stemming from its stimulation after fitting the hearing aidsHearing rehabilitation training programs are used to improve the communication skills of the hearing impaired. There is some evidence that formal hearing training can be efficient in the hearing challenged elderly with sensorineural hearing loss as the one found in most of the people in this age rangeIt is believed that neural plasticity is not lost with aging. This is an important report, since most users of hearing aids are elderlyDespite the large number of studies in the area of neural plasticity in the last 15 years, there is still much to study regarding the changes that happen in speech recognition skills because of the reintroduction of the acoustic signal, and if the change magnitude of these changes can be improved with formal hearing training.Based on these concerns, the goal of the present study is to check the efficacy of the formal auditory training program in elderly citizens with mild to moderately severe bilateral sensorineural hearing loss, users of intracanal hearing aids after three months of their use, by means of speech recognition tests and self-assessment questionnaires.This study is of a prospective type, clinical and Experiment, and was approved by the Research Ethics Committee of our institution under protocol # CEP 1801/06.All the participants were informed about the objectives and the methodology of the study proposed and agreed on the performance of the necessary procedures for the study execution, and signed a Free and Informed Consent Form.-Having mild to moderately severe bilateral sensorineural hearing loss 12.-Having symmetrical hearing loss of flat or slightly descending curve shape in the high frequencies;-Having speech recognition index equal to or above 72% bilaterally;-Having received a hearing aid donation in the last three months; use or have the indication to use intracanal hearing aids in binaural fitting;-Not having perceivable cognitive alteration or speech alteration;-Have more than 60 years of age.For sample selection purposes, the following eligibility criteria were established:Based on the eligibility criteria previously established, we selected elderly from the files of the Núcleo Integrado de Assistência, Ensino e Pesquisa em Audição - NIAPEA, who were fitted with a hearing aid in the year of 2005 and the first quarter of 2006. We found 54 individuals whose medical charts were analyzed in order to check to see if they matched the inclusion criteria. We excluded 40 individuals from the sample, 21 with speech recognition below 72%; nine of them were not found, eight participated in another study that involved hearing training and two were unwilling to take part in the study. Thus, from the initial sample, we had 14 elderly left. Nonetheless, one patient dropped out of the study because of health problems. Then, we had a final sample with 13 elderly, nine women and four men, at an age range varying between 60 and 74 years (mean: 65.30 years).All the participants were submitted to evaluation only after they were assigned to the Experiment Group (those submitted to hearing training) and to the Control Group (those who were not submitted to hearing training), and the individuals themselves pick a number to be randomized to which group they would be sent to. Thus, the Experiment Group (EG) had six individuals and the Control Group (CG) had seven.The elderly who were interested in participating in the Hearing Training Program, but because of this random assigning were included in the Control Group, were invited to participate in it after the end of the study.All assessment procedures, as well as the auditory training were carried out with the elderly using their intracanal hearing aid.The participants in the study were submitted to: Tonal Audiometry with the hearing aid and with ear phones, signal/noise ratio test obtained from the Recognition of Phrases in Noise (SRPN), non-sensitized Speech Recognition Index test (SRI with recording), Speech Test with White Noise (STWN) and Hearing Handicap Inventory for the Elderly - HHIE. The assessment duration time was of approximately 45 minutes.The group that received hearing training (Experiment Group) was evaluated in three different times, before starting the training (1st assessment), after eight weeks of hearing training (8th week / 2nd assessment) and four weeks after the end of treatment (12th week/3rd assessment). The group that did not receive training, called Control Group went through the same evaluation system of the Experiment Group, following the same time intervals between the evaluations, which were carried out by calling the person in.In order to characterize a double blind study, the reevaluations were carried out by a different examiner from the one that made the first assessment, who did not know whether or not the individual had been trained.Formal Hearing Training (FHT) proposed in this study was organized in seven sessions, held once a week, with duration of 50 minutes eachHearing training was carried out with earphones, thus, it was possible to train the right and left ears, separately. We established a fixed intensity for stimulus presentation  and we varied the competitive noise intensity (Speech Noise). From the first to the sixth training sessions the patients had single ear hearing tasks in the presence of a competitive noise, varying the signal/noise ratio from positive (more favorable) to negative (less favorable). The last training session involved a binaural integration task .Figure 1In all the tests and evaluations carried out, the differences between the right and left ears were not statistically significant, in other words, the ear variable is not a difference causing factor for the tests performed. Thus, in the analyses presented below we considered both ears, in such a way that the sample size doubled, providing more reliability to the results analyses.For the statistical analyses of this study we used the ANOVA Averages Comparison test and the Tukey Multiple Comparisons test. We established a 0.05 (5%) level of significance and the confidence intervals built along the study were of 95% of statistical confidence.Initially, we studied the effect of hearing training among the evaluations according to the Group (Experiment and Control). We compared the values among the three evaluations. On We noticed that there was a significant difference among the results obtained in the three assessments in all the Experiment Group tests. In order to investigate exactly where the difference occurred we used the Tukey Multiple Comparisons Test and its results can be seen on On the second stage, we investigated whether the hearing training had been effective by comparing the results obtained from the elderly who were trained (EG) and those who were not (CG). It is presented on In the first stage of this study we assessed the effect of hearing training between evaluations, per group, which revealed that the elderly in the EG - in the evaluation carried out before hearing training , had a regular performance in the SRPI test (82.67%) and as predicted, they got worse when the competitive noise was introduced (69.33%).After Formal Hearing Training (FHT) we observed a significant improvement in the results obtained from both tests (SRPI and SWWN), having the scores within normal limits, 87% and 82.33%, respectively  and 2.The same has been observed in the S/N ratio in the speech recognition perceptive index in terms of an improvement in the patients” performance after FHT (5.22 to 2.58). Nonetheless, results after hearing training did not reach the values standardized for young adults with hearing loss. .These data show that the hearing training in a sound-treated booth improves the speech recognition skills in favorable and adverse hearing settings.The subjective assessment carried out by means of a self-assessment HHIE questionnaire revealed a significant reduction of self-perception in the auditory handicap in the assessments after hearing training (from 55.67% to 21.33% and 12.33%), and the final results showed percentages below 16%, which characterizes a non-perception of the auditory handicap, in other words, the hearing and non-hearing difficulties generated by the hearing impairment are not perceived .Through hearing rehabilitation programs, it is possible to reduce the very perception of the hearing handicap in the elderly population which will reflect on an improved quality of life, promoting social contact and reducing isolation of peopleBesides the study held to investigate the effect of hearing training (1st X 2nd assessments) we carried out an assessment one month after the end of treatment (3rd assessment), in order to check if the improvements obtained would keep throughout time. In this study, we did not see differences between the results from the 2nd and 3rd assessments, although a mild improvement has been seen in the last assessment .Neural plasticity is not lost with agingAuditory plasticity has the most significant role in hearing trainingIt is believed that once the neural substrate has been changed and the behavioral pattern has been learned at the end of the training sessions, the individual goes back to his/her daily routines, the environment itself, with all its demands, reinforce the pattern learned and maintains the trend towards improvementThe amplification provided by the hearing aid does not maintain the same sound reception quality in silence or in noisy settings. This happens because the hearing aid solves the problem of sensitivity loss, but not the problems associated with speech detection and understanding in the presence of background noise. Nonetheless, the elderly in the EG showed that communication difficulties they had to face in their daily routines, were minimized with the association of hearing aids and hearing training.Based on the results found among the elderly from the Experiment Group (EG), we could notice that both the behavioral tests and the subjective assessments were improved after hearing training in a sound-treated booth, in other words, the FHT brought about the development of speech recognition skills (words and phrases) and auditory closure, as well as a reduction in the hearing handicap.These data indicate that the elderly with hearing loss are capable of significantly improve their capacity to recognize speech and reduce the impairments created by their hearing loss by means of an auditory training. These findings agree with those from similar studies found in the literatureIn comparing the results between the Group Control assessments, speech tests show that mean SRPI and SWWN values were kept the same throughout the period studied  and 2. NThus, we have noticed that the simple fitting of a hearing aid does not produce the ideal adaptation for the auditory system and the consequent improvement in speech skillsTo recover normal hearing with a hearing aid may seem to be an impossible goal for some patients; however, normal hearing does not mean not having difficulties in certain situations. When there is hair cell damage, even reaching this goal, supraliminal deficits may not compensate, as for example, frequency and temporal resolution, which impair their performance in adverse hearing environmentsThe hearing handicap self-perception results of the Control Group elderly did not show significant changes in 12 weeks. Thus, the use of hearing aids did not change the handicap self-perception along time .These findings are similar to the ones seen in this studyThen, we can think that not having the hearing training could have contributed to the worsening in the skill assessed, in agreement with some studies described in the literature, in whom the auditory training was not carried outIn the second data analysis, we studied the effects of hearing training between the groups (CG X EG). By analyzing the results from the SRPI, SWWN and S/N ratio - PRTN test, we noticed that the elderly from the Experiment Group (EG) showed a better performance as far as speech recognition is concerned with and without noise, in contrast to the Control Group (CG) in the assessments after hearing training  the elderly from the experiment and control groups were significantly different in relation to the perception they had of the hearing loss, regarding social and emotional aspects. Despite the fact that the elderly were divided in random groups by lottery, the EG elderly had a higher handicap, severe (55.67%), while the elderly from the CG of mild to moderate level (23%) in the first assessment .It”s worth stressing that the Experiment Group elderly, submitted to auditory training, were more active  than the elderly from the Control Group. We can assume that these elderly, since they are more active (EG) were more needed in communication situations and thus had a more acute perception of the negative effects of their hearing loss, as well as the limitations of sound amplification in adverse hearing environments, and consequently, this reflected in a higher degree of dissatisfaction.Nonetheless, this difference was not maintained after FHT, and in the last assessment (3rd assessment) the elderly submitted to training presented mean percentages that characterized the non-perception of the auditory handicap (12.33%), while the elderly from the Experiment Group (EG) remained with mild to moderate perception (21.33%). These findings suggest the influence of a FHT as well as a direction towards the reduction of self-perception of the difficulties caused by the hearing loss, consequently providing a quality improvement in the lives of these elderly, and also a better use of their hearing aids.Handicap variation reflects the individual differences in perception of negative effects of the hearing loss and it is also known that this disadvantage is also influenced by their life styles in their communitiesThe hearing training program in a sound-treated booth, associated with the use of hearing aids, improves the user”s performance in their speech recognition skills and reduces the auditory handicap of the elderly who use intracanal hearing aids.