Human gut microbiome has complex relationships with the host, contributing to metabolism, immunity, and carcinogenesis.Summary-level data for gut microbiota and metabolites were obtained from MiBioGen, FINRISK and human metabolome consortia. Summary-level data for colorectal cancer were derived from a genome-wide association study meta-analysis. In forward Mendelian randomization (MR), we employed genetic instrumental variables (IV) for 24 gut microbiota taxa and six bacterial metabolites to examine their causal relationship with colorectal cancer. We also used a lenient threshold for nine apriori gut microbiota taxa as secondary analyses. In reverse MR, we explored association between genetic liability to colorectal neoplasia and abundance of microbiota studied above using 95, 19, and 7 IVs for colorectal cancer, adenoma, and polyps, respectively.Gammaproteobacteria , Enterobacteriaceae .Forward MR did not find evidence indicating causal relationship between any of the gut microbiota taxa or six bacterial metabolites tested and colorectal cancer risk. However, reverse MR supported genetic liability to colorectal adenomas was causally related with increased abundance of two taxa: We find genetic liability to colorectal neoplasia may be associated with abundance of certain microbiota taxa. It is more likely that subset of colorectal cancer genetic liability variants changes gut biology by influencing both gut microbiota and colorectal cancer risk.This study highlights the need of future complementary studies to explore causal mechanisms linking both host genetic variation with gut microbiome and colorectal cancer susceptibility. Colorectal cancer is globally recognized as the third most prevalent cancer and ranks as the fourth major contributor to cancer-related mortality . The colFirmicutes and Bacteroidetes. However, their proportions and associated species are in a dynamic state and change over time, even within the same individual  to colorectal neoplasia  is an analytic approach which employs germline genetic variants as instrumental variables (IV) for exposures . The genWe adopted a bidirectional two-sample MR strategy to evaluate the causal relationship between gut microbiota and risk of colorectal neoplasia. The forward MR analysis was designed to investigate the causal effects of gut microbiota and related metabolites on colorectal cancer risk, while the reverse MR to examine whether the genetic liability to colorectal neoplasia  influenced the abundance of the gut microbiota. The study design is shown in Summary statistics of the genetic contributions to gut microbiota taxa were obtained from the MiBioGen consortium  and FINRTo complement with gut microbiome-derived metabolites, we selected six plasma metabolites with available GWAS data for analyses. Genetic predictors for choline, betaine, carnitine, TMAO, gamma-aminobutyric acid (GABA), and propionic acid were derived from a GWAS on human metabolome , which iP < 5×10−8) were selected as IVs. In total, 211 taxa  were eligible for the mbQTL  mapping analysis and of these 24 gut microbiota taxa met the P value threshold of 5×10−8 which were included in our forward MR analysis. On the basis of our previous systematic review of epidemiologic observational studies, nine gut microbiota taxa  were found to be consistently associated with the risk of colorectal neoplasia (Bifidobacterium and rs61841503 for genus Peptostreptococcaceae) using the strict 5×10−8 for the nine gut microbiota taxa of interest which present with supporting evidence in their associations with colorectal neoplasm, we chose to use a lenient P value threshold of 1×10−5 as indicated by the MiBioGen as secondary analyses. Overall, we obtained SNPs associated with the abundance of the family Fusobacteriaceae from FR02 cohort (P < 1×10−5 (r2 > 0.01) and only retained SNPs with the smallest P values for their respective traits. After LD pruning, 27 SNPs associated with 24 gut microbiota taxa  and nine, 19, 11, 10, 28, 10, 18, 18, and 16 genetic IVs were included to proxy the abundance of Gammaproteobacteria, Lactobacillales, Enterobacteriaceae, Porphyromonadaceae, Fusobacteriaceae, Actinomyces, Bifidobacterium, Roseburia, and Peptostreptococcaceae . Similarly, 6, 13, 12, 8, 10, and 2 IVs were selected as proxies for plasma choline, betaine, carnitine, TMAO, GABA, and propionic acid, respectively (Supplementary Table S3). Regarding the reverse MR analysis, because there is no open available summary data for metabolites, we only used summary-level data of the microbiota taxa from the MiBioGen consortium and the FR02 cohort  from two latest and largest colorectal cancer GWASs. Huyghe and colleagues performed a genome-wide association analysis of 23,262 cases and 38,296 controls (Table S4). SNPs associated with colorectal adenomas were selected from a GWAS including 1,406 Caucasian individuals participating in the Adenoma Prevention with Celecoxib trial, 4,175 cases of familial colorectal adenoma and 5,036 control subjects of European ancestry (Table S5).Summary-level data on colorectal cancer used in forward MR analyses were obtained from our previous meta-analysis of 12 GWASs, namely CCRR1, CCFR2, COIN, CORSA, Croatia, DACHS, FIN, NSCCG-OncoArray, SCOT, UK1, and VQ58, which comprise 16,871 cases and 26,328 controls . Each dacontrols , and Lawcontrols . We usedcontrols . After eancestry . SNPs asancestry . After rr² > 0.8) in the outcome data source. We endeavored to deduce positive strand alleles by using allele frequencies for palindromes, with the default and conservative approaches and summary statistics were harmonized using the effect allele frequency such that all outcome effect estimates reflected the exposure-increasing effect allele. For each genetic instrument, βGP represents the estimated association between the genetic variant and the exposure, while βGD represents the estimated association between the same genetic variant and the outcome. By using these estimates, the causal estimates can be derived using the Wald ratio formula (βGD/βGP). Consequently, the estimates in the forward MR should be interpreted as changes in colorectal cancer risk for per one-unit increase in log-transformed relative abundance values of gut microbiota and for per one-SD increase in plasma metabolites levels, while the estimates in the reverse MR should be interpreted as changes in the abundance of gut microbiota for per one-unit increase in the log OR of colorectal neoplasia. For microbiota taxa with only one SNP, we employed the Wald ratio method for the MR analysis. For exposures with at least 3 IVs, MR estimates were computed using the inverse variance weighted random-effects (IVW-RE) model and complemented by five sensitivity analyses, namely the weighted median  and the F-statistic being less than 10 implied weak instrument bias , and suggestive pleiotropy was observed in the MR analysis of Lactobacillales (P for pleiotropy = 0.017). For the analyses on gut microbiota taxa, there was a very low risk of weak instruments bias, given the F-statistics of all the genetic IVs were above 10. No association between the six gut microbial metabolites and colorectal cancer risk was observed in either the main IVW-RE or in any of the sensitivity analysis (Supplementary Table S8).In the forward MR analyses, we observed little associations between the abundance of gut microbiota taxa and colorectal cancer risk in the Wald ratio, IVW-RE method or in any of the sensitivity analysis (Supplementary Tables S6–S7). Moderate-to-high heterogeneity was observed in the association between abundance of In the reverse MR analyses, we found some evidence suggesting that genetic liability to colorectal neoplasia was associated with the abundance of gut microbiota.Tyzzerella3 would have 0.066  lower log-transformed relative abundance, based on the IVW-RE model. Although it did not survive the multiple test correction, the result was consistent across all the sensitivity analyses.For per one-unit increase in the log OR of genetic liability to colorectal cancer, the abundance of Gammaproteobacteria, Enterobacteriaceae, Fusobacteriaceae, Allisonella, RuminococcaceaeUCG013 and Oxalobacteraceae, RuminococcaceaeUCG009 would have 0.027 , 0.023 , 0.006 , 0.040, 0.014 higher log-transformed relative abundance and 0.018, 0.025 lower log-transformed relative abundance respectively, based on the IVW-RE model. The results for Gammaproteobacteria, Enterobacteriaceae survived the multiple test correction and were consistent across all the sensitivity analyses , which might indicate the existence of potential heterogeneity and directional horizontal pleiotropy, however, the P value for the MR-Egger intercept were 0.917 and 0.660 for these tests. The results also indicated consistency in the β coefficients of the associations between colorectal cancer, adenomas, and polyps with these specific bacterial taxa, implying a uniform direction of effect between benign and malignant lesions.For per one-unit increase in the log OR of genetic liability to colorectal adenomas, the abundance of analyses  and 3. TGammaproteobacteria , and the result was consistent with other approaches but did not survive FDR correction (Supplementary Table S9).We observed little associations of genetic liability to colorectal polyps with other gut microbiota in the reverse MR (Supplementary Table S9). We also derived genetic IVs for colorectal cancer and adenomas combined , and found that per one-unit increase in the log OR of genetic liability to colorectal neoplasia was suggestively associated with 0.017 higher log-transformed relative abundance for Gammaproteobacteria and the family Enterobacteriaceae in the reverse MR conducted on MiBioGen consortium datasets. Using the summary-level data from the FR02 cohort, suggestive evidence suggested that genetic liability to colorectal adenomas was associated with the abundance of the family Fusobacteriaceae. According to Brenner and colleagues, the adenoma–carcinoma sequence refers that majority of colorectal cancer cases are typically preceded by dysplastic adenomas, which may advance to malignant forms , thus we used a lenient threshold (P < 1×10−5) for the selection of genetic IVs as a less stringent analysis. There exists a strong correlation between the significance of heritability and the number of independent loci under a relaxed threshold of 1×10−5, which also has the greatest explanatory power with regard to microbial features  was low and may yielded inadequate statistical power for the detection of modest or minor correlations. Therefore, the causal relationships between microbiota and colorectal cancer could not be completely ruled out by the negative results of this study. Secondly, it had been acknowledged that the genetic factors involved in proximal and distal colorectal cancer are different  linked to constituents of the metabolome or microbiome, as well as the risk of adenoma or colorectal cancer. In addition, the examination also discovered associations between genes responsible for cholesterol metabolism and the levels of high-density lipoprotein cholesterol would affect adenoma and colorectal cancer risk  also indicated close interplay between bacteria and host .Click here for additional data file.Table S2Table S2 shows the SNPs that associated with nine microbiota taxa (P<1×10-5).Click here for additional data file.Table S3Table S3 shows the SNPs that associated with six gut microbial metabolites.Click here for additional data file.Table S4Table S4 shows the SNPs for colorectal cancer.Click here for additional data file.Table S5Table S5 shows the SNPs for adenoma and polyps.Click here for additional data file.Table S6Table S6 shows the forward MR analyses of 24 gut microbiota with the risk of colorectal cancer.Click here for additional data file.Table S7Table S7 shows the forward MR analyses of nine gut microbiota with the risk of colorectal cancer.Click here for additional data file.Table S8Table S8 shows the forward MR analyses of the six gut microbial metabolites with the risk of colorectal cancer.Click here for additional data file.Table S9Table S9 shows the reverse MR analyses of colorectal cancer, adenoma and polyps with the abundance of nine gut microbiota.Click here for additional data file.


Neurological diseases are often thought to be irreversible, including hearing loss. In this study, we found that one type of hearing loss can be reversed as long as the treatment is delivered within a critical period early in disease progression. This result is a proof of concept that hearing loss not only can be avoided but also may be reversed. This genetic approach can be used for a wide range of diseases using existing mouse resources. tm1aSpns2 mouse mutant known to show this defect. By activating Spns2 gene transcription at different ages after the onset of hearing loss, we found that an existing auditory impairment can be reversed to give close to normal thresholds for an auditory brainstem response (ABR), at least at low to mid stimulus frequencies. Delaying the activation of Spns2 led to less effective recovery of ABR thresholds, suggesting that there is a critical period for intervention. Early activation of Spns2 not only led to improvement in auditory function but also to protection of sensory hair cells from secondary degeneration. The genetic approach we have used to establish that this type of hearing loss is in principle reversible could be extended to many other diseases using available mouse resources.Hearing loss is highly heterogeneous, but one common form involves a failure to maintain the local ionic environment of the sensory hair cells reflected in a reduced endocochlear potential. We used a genetic approach to ask whether this type of pathology can be reversed, using the  Hearing impairment is very common in the population and can begin at any age. Over half of adults in their 70 s have a significant hearing loss. Hearing impairment isolates people from society, can be associated with depression and cognitive decline, and is a major predictor of dementia –4. The oOtof) sequences into the mouse inner ear at later stages leads to improved hearing in Otof mutants that would otherwise show abnormal inner hair cell (IHC) synaptic function and deafness , of around +120 mV which is essential for normal hair cell sensitivity. We have used a genetic approach in Spns2 encodes Spinster homolog 2, a sphingosine-1-phosphate (S1P) transporter. Spns2 mutant mice show a rapidly progressive hearing loss associated with a dramatic decline in EP between 2 and 3 wk after birth    to restonotyping A and C. notyping D. Entiretm1aSpns2 heterozygotes or wild types with or without Flpo; tm1aSpns2 homozygotes that did not carry Flpo showed progressive worsening of their ABR thresholds with age  measurements, and these recordings were repeated in each mouse at intervals after tamoxifen exposure until the mouse was 8 wk old, when terminal ABR and EP measurements were collected B. Controwith age F. In conwith age G, indicaSpns2 mutant homozygotes carrying Flpo , EP was severely reduced, similar to previously reported levels in these mutants  injected at P14 or P17 were higher than those of Spns2 mutants without Flpo, in some cases within the normal range  in the Spns2 mutants carrying Flpo compared with the control mice (Spns2 mutants without Flpo (red bars) showed extensive loss of hair cells in the basal turn, representing the regions most sensitive to high frequencies , many of which show abnormal phenotypes  Act of 1986 under UK Home Office licenses, and the study was approved by the King’s College London Ethical Review Committees. Mice were culled using methods approved under these licenses to minimize any possibility of suffering.tm1a(KOMP)WtsiSpns2 (tm1aSpns2) mutant mice were generated at the Wellcome Trust Sanger Institute on a C57BL/6N genetic background (tm3(CAG-flpo/ERT2)AljGt(ROSA)26Sor/J mice, also known as FlpoERR26 mice, express a tamoxifen-inducible, optimized FLPe recombinase variant called Flpo and were obtained from the Jackson Laboratory .ckground , 34. B6Nboratory . Both muSpns2 forward primer (5′CAAAACAATATGGGCTGGGG3′), an Spns2 reverse primer (5′GATGAAGGCAGGACTCAGGG3′) and a mutant-specific reverse primer (5′TCGTGGTATCGTTATGCGCC3′) (Spns2 wild-type (WT) product and 187 bp for the mutant product, as previously described  was injected intraperitoneally using a single injection at a dose of 0.2 mg/g at one of four different ages: postnatal day (P)14, P17, P21, or P28 B. ABRs wc allele C.Mice were anesthetized by intraperitoneal injection of 100 mg/kg Ketamine  and 10 mg/kg Xylazine . ABRs were measured in a sound-attenuating chamber fitted with a heating blanket as previously described , 35. SubMice were anesthetized with intraperitoneal urethane (0.1 mL/10 g body weight of a 20% w/v solution of urethane), and EP was measured as described previously , 37. A rThe organ of Corti was analyzed in mice injected with tamoxifen at P14 and P28 and then collected 2 wk after tamoxifen injection . The lat


Hand-arm vibration (HAV), which potentially causes vibration white finger (VWF), and occupational noise are serious issues in the agricultural and forestry industries. Generally, agricultural workers operate as single-family/small businesses and thus are exempted from Occupational Safety and Health Administration (OSHA) regulations/laws for noise and HAV otherwise applicable to other industries in general. The agricultural/forestry sectors are at increased risk as working hours are longer than a typical 8-h work shift putting them at greater risk of hearing loss. The study was conducted to assess the possible association between hearing sensitivity on combined exposure to noise and hand-arm vibration. A systematic literature review was conducted on exposure to noise and HAV in the agricultural/forestry sector and the resulting impacts on hearing. The peer-reviewed articles in English were searched with 14 search words in three databases of PubMed, Ergo Abstracts, and Web of Science without any filter for the year for fully available article text. The database literature search resulted in 72 articles. Forty-seven (47) articles met the search criteria based on the title. Abstracts were then reviewed for any relationship between hearing loss and hand-arm vibration/Raynaud’s phenomenon/VWF. This left 18 articles. It was found that most agricultural workers and chainsaw workers are exposed to noise and VWF. Hearing is impacted by both noise and aging. The workers exposed to HAV and noise had greater hearing loss than non-exposed workers, possibly due to the additive effect on temporary threshold shift (TTS). It was found that VWF might be associated with vasospasm in the cochlea through autonomous vascular reflexes, digital arteries narrowing, vasoconstriction in the inner ear by noise, ischemic damage to the hair cells and increased oxygen demand, which significantly affects the correlation between VWF and hearing loss. Noise-induced hearing loss is a serious problem among United States workers affecting nearly 22 million people every year . VirtualFarmers and forestry workers are prone to hearing loss due to exposure to high noise levels for long work schedules because of seasonal job demands in the agricultural and forestry sectors. Approximately 37% of the workers suffer from hazardous noise levels, as illustrated by Agriculture, Forestry, Fishing, and Hunting Statistics (AFFH) . AlthougWorkers in the agricultural and forestry sectors are exposed to noise and vibration while using various kinds of handheld tools. The exposure to vibrations may cause Raynaud’s phenomenon, which occurs when there is a reduction of blood flow to fingers which results in a reduced tactile sense. The Vibration White Finger (VWF) is a secondary and severe form of Raynaud’s phenomenon, which results in cold blanching of fingers. Working frequently for long hours and exposure to vibrations simultaneously with noise increase the susceptibility to hearing loss ,15,16. TFirst, a systematic literature review protocol was developed. The search was carried out in three different databases (a) Web of Science, (b) PubMed, and (c) Ergo abstracts. Different combinations of words were chosen using ‘AND’ and ‘OR’ operators to identify articles relevant to the study. Finally, a string of words that resulted in the maximum number of relevant articles in searched databases for the purpose of the study was: ((Hand Arm Vibration OR Hand Vibration OR Arm Vibration OR Raynaud’s OR White Finger) AND Hearing AND (Agricultur* OR cultivat* OR lumberjack OR Chain Saw OR Farm* OR Forest* OR Sawyers OR Harvest*)).An inclusion and exclusion strategy was defined. Inclusion criteria were: (a) peer-reviewed articles, (b) full text available, and (c) written in English. The exclusion criteria were: (a) articles undergoing the publishing process, (b) review papers, and (c) papers not written in English. The search was conducted without any filter for publication year. The items of interest in the title were exposure to hand-arm vibration, Raynaud’s phenomenon, VWF, and the resulting outcome of hearing loss in the agriculture sector, lumberjacks, chainsaw operators, and forestry workers. The articles that did not meet the above requirement in the title were not included in the study. After screening articles for titles, the abstracts were reviewed. The abstracts that did not present the relationship between hearing loss and hand arm vibration/Raynaud’s phenomenon/VWF were excluded. Finally, the articles meeting requirements were reviewed in full text and included in this study.The literature search was conducted up to a publication date of November 2022 in databases of Ergo Abstracts, PubMed and Web of Science using the library’s subscription of the authors’ university. It resulted in 72 articles after removing duplicates and non-English language, as presented in Nine studies were found that established the relationship between HAV and hearing loss among forestry workers. The first study was conducted by Pyykko et al., 1981 . The aimThe second study analyzed risk factors for sensory neural hearing loss during combined exposure to noise and vibration by Pyykko, Pekkarnine, and Starck in 1987 . The VWF explained a 5% variation of SNHL in forestry workers at 4000 Hz. There was an interesting observation that the combination of noise and hand-arm vibration was not more hazardous to hearing than exposure to equivalent energy of noise alone. Iki et al., 1989 studied hearing of forestry workers affected by VWF with 5-year follow-up . The noiPyykko et al., 1989  studied Iki et al., 1990  found thMurata, Araki and Aono, 1990  discoverIftime, Dumitrascu and Ciobanu, 2020  conducteThe four studies conducted by Pyykko et al., 1981 , Pyykko Another reason was suggested by Pyykko, Starck and Pekkarinen, 1986 . The autChainsaw operation causes gradual decreases in finger skin temperature with cyclic changes corresponding to each exposure and break period, as found by researchers Pyykko, Starck and Pekkarinen, 1986 . The stuThe VWF or skin temperature was found to be more significant in older persons (>50 years) in a study conducted by Iki et al., 1989  on the hThe combined effects of noise and HAV on auditory organ and peripheral circulation was studied by Miyakita, Miura, and Futatsuka, 1991 . Three eThe age and VWF exposure duration did not significantly correlate with average body sway velocity (ASV), as found by Iki, 1994  while st−2 (root means square), and the later models after 1970 had 2 to 6 ms−2 [−2, along with features of reduced weight and impulsiveness of vibration. This made it possible for workers to increase tool usage exposure time to 5 h a day [Chainsaws manufactured before 1970 caused hand-arm vibration between 10 and 20 mso 6 ms−2 . The dev h a day .−2) and front-end loader (2.53 ms−2), respectively. The highest hand-arm vibration of 10.36 ms−2 was observed for tree felling. In the x-axis, the notching stump activity resulted in the highest HAV (8.12 ms−2). In the y-axis, the tree felling task resulted in the greatest HAV (5.64 ms−2). For the z-axis, chain idling produced the most HAV (6.95 ms−2). The chainsaw had the highest HAV Aeq with 6 ms−2, 4.26 ms−2 and 5.46 ms−2 for the x, y and z axes, respectively.Neitzel and Yost  assessed−2 and 1.19–4.41 ms−2, respectively. Butkis and Vasiliauskas [−2, and 35% of the cases had 1.15 ms−2 for WBV. Air impact wrenches had the highest HAV of 8.9 ms−2, chainsaws and grinders > 5 ms−2 and impact hammers > 8 ms−2. For WBV, during cultivation unsuspended tractors generated the highest value of 2.86 ms−2 and combine harvesters with 2.19 ms−2.Monarca et al., 2009  studied liauskas  evaluateThe use of earmuffs resulted in equivalent noise levels below 85 dB when used with helmet liners . The helHearing is impacted by noise and aging. Workers with VWF had greater hearing loss compared to workers without VWF. The combined exposure to noise and VWF made subjects more prone to hearing loss. The synergistic effect of noise and vibration appears to create a greater temporary threshold shift. The proposed mechanisms behind increased hearing loss in subjects exposed to simultaneous noise and VWF exposure are: (a) decreased blood flow resulting in ischemic damage and vibration damage transmitted via bone conduction due to prolonged and strong excitation of receptor cells, (b) digital arteries narrowing which results in increased oxygen demand, (c) hyper-responsiveness of the arteries to noradrenaline (d) changes in peripheral circulation and (e) hypersensitivity to catecholamine in a local median muscular layer along with hormonal effects. The sympathetic nervous system plays a major role in the genesis of VWF. VWF also explained some variance in postural stability and osteomusculoskeletal disorders. Exposure to hand-arm vibration could cause a significant decrease in finger skin temperature as well as musculoskeletal disorders. Modern chainsaws are quieter than older models. However, exposure times with chainsaws have increased as the vibration levels of newer chainsaws were reduced, making them more comfortable to use. Engineering controls such as acoustic treatment, enclosing engines, isolating heavy equipment operator compartments, and installation of more effective mufflers can reduce both noise and HAV. Despite the progress made in improving equipment and working conditions, noise remains a problem, particularly in agricultural and forestry settings.


Background and Objectives: Hearing loss after septicemia has been found in mice; the long-term risk increased 50-fold in young adults in a previous study. Hearing loss after septicemia has not received much attention. The aim of this study was to assess the relationship between septicemia and subsequent hearing loss. Materials and Methods: Inpatient data were obtained from the Taiwan Insurance Database. We defined patients with sensorineural hearing loss and excluded patients under 18 years of age. Patients without hearing loss were selected as controls at a frequency of 1:5. The date of admission was defined as the date of diagnosis. Comorbidities in the 3 years preceding the date of diagnosis were retrieved retrospectively. Associations with hearing loss were established by multiple logistic regression and forward stepwise selection. Results: The odds ratio (OR) for the association between sepsis and hearing loss was 3.052 (95% CI: 1.583–5.884). Autoimmune disease (OR: 5.828 (95% CI: 1.906–17.816)), brain injury (OR: 2.264 (95% CI: 1.212–4.229)) and ischemic stroke (OR: 1.47 (95% CI: 1.087–1.988)) were associated with hearing loss. Conclusions: Our study shows that hearing loss occurred after septicemia. Apoptosis caused by sepsis and ischemia can lead to hair cell damage, leading to hearing loss. Clinicians should be aware of possible subsequent complications of septicemia and provide appropriate treatment and prevention strategies for complications. Septicemia survivors can experience varying degrees of disability and problems that can change their lives. The modern definition of sepsis is an abnormal host response to infection, followed by life-threatening organ dysfunction. Septicemia is a serious infectious condition that can cause cardiac events, neurologic events and mortality ,2,3,4. SCauses of hearing loss include aging, genetic effects, injury, ototoxic drugs, infection, cardiovascular and neurologic diseases, immune diseases and loud voices. In animal studies, inflammation induces apoptosis of cells in the organ of Corti and the supporting cells of the lateral wall, especially changes in type I fiber cells and inner hair cells of the spiral ligament, and stimulates glutamate overload in inner hair cells ,8. The lLimited hair cell recovery after injury in mammals results in persistent hearing impairment . CliniciThe aim of our study was to assess whether sepsis is associated with subsequent hearing loss in Taiwan. We also examined other risk factors for subsequent hearing loss. Early detection and timely treatment of complications are important to reduce hearing deficits.Taiwan has had National Health Insurance since 1995, a government-backed health care system that covers approximately 99% of Taiwan’s 23 million citizens. All healthcare providers must type computer data to pay for insurance. The Taiwan NHIRD contains all outpatient and inpatient medical insurance payment records. There are up to 5 International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) inpatient diagnosis and procedure codes and 3 outpatient ICD-9-CM diagnosis and procedure codes. The data contain each patient’s age, gender, comorbid conditions, hearing loss codes and times of admission and discharge.The dataset used in this study comes from the Taiwan Longitudinal Health Insurance Database (LHIRD), which randomly selects patients from the population. We identified patients with hearing loss diagnosis codes collected between 1 January 2014 and 31 December 2014, and we excluded patients under the age of 18 years and those who were deaf before sepsis admission. The time of admission for hearing loss was defined as the date of diagnosis in the study group. Five controls were frequency-matched to each case according to age and gender. This does not distinguish between risk factors and the order of hearing loss that occurs during hospitalization. Our aim was to identify risk factors affecting subsequent hearing loss; thus, comorbidities were retrieved before the diagnosis date of hearing loss. The flow chart is shown in We used ICD-9-CM codes to find hearing loss codes and diagnoses of comorbidities in the NHIRD. We defined transient ischemic deafness as 388.02 and sensorineural hearing loss as 389.1X in the inpatient dataset. Hearing loss comorbid disorders mapped by ICD-9-CM codes included septicemia , hypertension (401–405), diabetes mellitus (250), chronic kidney disease , hyperlipidemia (272), autoimmune disorders (710), anemia , hematological disorders including coagulopathies and platelet disorders (286–287), coronary artery disease (410–414), ischemic stroke (433–437), meningitis , head injuries  and encephalopathy .t test, while categorical variables are shown as percentages using the chi-square (X2) test. Multivariate logistic regression with forward stepwise selection was used to assess correlates of hearing loss and ischemic stroke. The statistical significance was set as p < 0.05. The statistical analysis was performed with SPSS version 21 software.Continuous variables are shown as the mean ± standard deviation and were evaluated using Student’s We retrospectively surveyed 251 hearing-impaired patients as the study group and 1255 non-hearing-impaired patients as the control group. Our study found an association between sepsis and hearing loss with an odds ratio (OR) of 3.052 : 1.583–5.884). Other factors included autoimmune disorders (OR: 5.828 (95% CI: 1.906–17.816)), brain injuries (OR: 2.264 (95% CI: 1.212–4.229)) and ischemic stroke (OR 1.47 (95% CI: 1.087–1.988)) .We also assessed ischemic stroke-related factors and revealed risk factors including septicemia (OR: 3.566 (95% CI: 1.227–10.36)), hyperlipidemia (2.437 (95% CI: 1.399–4.247)), hypertension (6.686 (95% CI: 4.649–9.616)), coronary artery disease (6.21 (95% CI: 4.34–8.884)) and hematological disorders (3.363 (95% CI: 2.159–5.24)) .The finding of our study was that sepsis is significantly associated with subsequent sensorineural hearing loss. It has been associated with hearing loss from pre-existing sepsis, ischemic stroke, autoimmune disease and brain injury. When a patient has a severe infection, healthcare providers need to pay more attention to comorbidities such as cerebrovascular attack, autoimmune disease and traumatic brain injury to prevent hearing loss.A previous study in Thailand showed a relative risk of 1.8 (95% CI: 1.0–3.2) for factors associated with hearing loss in infants, including sepsis, low birth weight, APGAR  score < 6 in 5 min, craniofacial anomalies and ototoxic exposure . Sepsis Common causes of hearing loss include noise, ototoxic drugs, sepsis, electrolyte abnormalities, dehydration and malnutrition . Sepsis Sepsis with encephalopathy may lead to microcirculation insufficiency, which reduces inner ear perfusion and leads to radial dendritic edema . FibroblAutoimmune diseases are pathological conditions caused by the immune system misrecognizing self-antigens, resulting in damage and destruction of host tissue. These diseases affect different organs and systems, including the blood, joints, skin and muscles. In autoimmune diseases, innate immune cells fail to function properly: they are either abnormally activated or physically disabled. As an important innate immune cell, neutrophils are affected by the microenvironment of different autoimmune diseases due to their short lifespan and diverse death modes. They are associated with the neutrophil death pathway; delayed or abnormal apoptosis may contribute to the development of autoimmune disease . AutoimmHead trauma and brain injury are often associated with underlying damage to the inner ear as well as blunt or penetrating head trauma and hemorrhagic lesions of the auditory cortex . TraumatPrevious studies have found that multiple risk factors, including hypertension, diabetes, dietary risk scores, current smoking status, alcohol consumption, psychosocial stress, depression and cardiac distress, contribute to stroke in multiple countries . ApoptosMen with strenuous work and noise exposure have a higher risk of brain damage and hearing loss from pneumococcal meningitis . Men (61p < 0.001) was a potential reason for the loss of importance of meningitis after multivariate adjustment. Some ototoxic drugs, such as aminoglycoside antibiotics, certain chemotherapy drugs and loop diuretics, can damage the inner ear. Meningitis in children was treated with aminoglycosides such as gentamycin, which is ototoxic and causes hearing loss in approximately 2.3% of cases [Some infectious diseases with high fever, such as meningitis, can damage the cochlea by cochlear ossification and hearing impairment . A previof cases . HoweverHyperlipidemia is associated with ischemic stroke; however, it was not related to adult deafness in our study. The reason may be that the patients with hyperlipidemia were treated appropriately according to the guidelines. The risk of hearing loss in diabetes mellitus in American and Korean women had an OR of 1.9 and 1.4, respectively . But ourTreatment can sometimes help preserve some hearing function. Prophylactic topical anti-inflammatory therapy  should be discussed in systemic inflammation to prevent sensorineural hearing loss . IdentifSensorineural hearing loss is associated with infectious and metabolic diseases and occurs primarily in patients with multisystem failure and septic shock. Unstable blood pressure in patients with sepsis can cause insufficient blood flow, which can affect hearing in intensive care units . AccordiThis study has some limitations. First, there was a lack of height, weight and noise data; family history; and severity information from audiometry and otological exams in the payment claim dataset. Patients with severely deteriorated life expectancy, bed-ridden patients or ventilation-dependent patients could not undergo hearing function tests, which may potentially underestimate the number of hearing loss patients. Second, hearing loss in people over the age of 55 is age-related. Our study group was relatively older, with a mean age of 60 years, and 43% of patients were older than 65 years. We need to survey young people to confirm our research. Third, we were unable to examine cerebrovascular status during routine hospitalization. Arterial maps from computed tomography or magnetic resonance imaging are required from registry data to determine blood flow associated with hearing loss. Fourth, the claim data included admission and discharge data, but the time from septicemia to hearing loss in intensive care was not available. A register study is needed for proof.This study explored whether sepsis is associated with subsequent hearing loss. Sepsis and ischemia-induced apoptosis are associated with hearing loss resulting from hair cell damage. Healthcare professionals must be aware of factors associated with hearing loss such as sepsis, autoimmune disease, ischemic stroke and brain injury. Hearing function must be considered in patients after hospitalization for sepsis, with early diagnosis and appropriate prevention. A prospective evaluation is needed to confirm our findings.


IntroductionNoise-induced hearing loss (NIHL) is one of the most common avoidable reasons for hearing impairment worldwide. Work-related, genetic, infectious, and environmental factors all have a part in defining the level of hearing impairment. Nevertheless, the use of personal listening devices (PLDs) is popular nowadays, particularly among younger people. Healthy behaviors are needed to prevent them from developing hearing loss. Our objective is to evaluate the knowledge level of NIHL among the people of Makkah, Saudi Arabia, and understand its association with PLDs.MethodsA cross-sectional survey was performed in December 2022 by sending an online survey on various social media applications. An electronic Arabic questionnaire with a total of 37 questions was designed to explore the participants' demographic data, history of hearing loss, risk factors, attitudes, and awareness of NIHL.ResultsAlmost 22% of the study had mild-to-severe hearing impairment. Hearing issues were especially common among male individuals. A higher incidence of hearing impairments was seen in individuals who were utilizing a sound degree of more than 80%. The causes for NIHL comprised exposure to occupational noise, duration of the listening session per day, and the level to which the sound of the television or the broadcasting was raised. Approximately 77% of the participants preferred to reduce the sound of their personal audio devices (PADs) to prevent NIHL.ConclusionAccording to this study, there is a high prevalence of hearing problems in the Saudi population. Most of the respondents understood the risk factors linked to NIHL. There is a need for more NIHL awareness campaigns to educate the Saudi population and reinforce positive, healthy listening habits. Hearing loss (HL) affects the ability of people to differentiate between sounds appropriately, making it difficult to understand basic conversations and daily life situations. Also, hearing loss in early childhood can have a considerable negative effect on both development and educational growth, adversely impacting emotional health and social well-being . HL is aA cross-sectional survey was performed in December 2022 by distributing an online questionnaire on social media platforms to collect information on participants’ demographics, history of hearing loss, risk factors, beliefs, and knowledge about NIHL as well as to assess society’s awareness of NIHL from PLDs among the general population in the Makkah region of Saudi Arabia, using a validated version of a self-administered questionnaire in the Arabic language .The sample size was decided by using a Raosoft calculator to be more than 380 subjects, with a confidence interval of 95% and a level of significance  of 5%. The questionnaire was completed by 384 people at random.We involved only participants from the Makkah region who were ≥18 years old and who agreed to participate in this survey. Partially filled questionnaire submissions were eliminated from the study.The questionnaire included a total of 37 items distributed into six categories. The initial section consisted of six items to collect personal data. The second section contained five items about medical history. The third section comprised five items about the utilization of PLDs. The fourth section similarly had five items and was designed to evaluate the symptoms of hearing impairment. The fifth section contained a total of 11 items used to assess the knowledge and beliefs regarding NIHL. The last section consisted of five items about the protective measures to stop NIHL.SPSS Statistics version 22  was utilized to analyze the data. Categorical variables are represented as frequency (percentage) comprising participants’ demographic data, history of hearing problems, risk factors, knowledge, beliefs, and practices related to hearing problems. Cross-tabulation was used to show the distribution of individuals’ hearing impairment with their different demographic data and described risk factors. The Pearson chi-square test was utilized to evaluate the significance of relationships.The Biomedical Research Ethics Committee of Umm Al-Qura University approved this study.A total of 384 individuals were surveyed: 56.5% were women, 97% were under 50 years old, 90.9% were Saudi, 44.5% had a college degree, 85.2% were nonsmokers, and 91% had no chronic diseases. Of the participants, 77.9% did not exhibit any signs of hearing impairments. However, mild, moderate, and severe hearing loss was found in nearly 13.8%, 5.7%, and 2.6% of the individuals, respectively. Furthermore, a family history of hearing impairments was described by about 51.8% (Table The risk factors for NIHL involved work-related noise (40.4%), choice of using earphones 63.5%), and a high frequency of sessions  where the individual was exposed to a loud noise sound corresponding to the following parameters: >3 h per session (31%) and a sound degree in the range of 80%-100% (23.4%). Forty-nine percent of the study participants engaged in more than 10 sessions weekly where they would listen to a noise sound for <1 h/day  and that staying in a noisy setting could also adversely impact hearing (83.9%). They also identified that a prior hearing problem could get worse by sustained exposure to loud sound 79.4%)  favored decreasing the level of several audio devices as a preventive plan, and a considerable number (81%) suggested that the manufacturer must set sound-warning features on devices Table . FurtherSubgroup evaluations relating to the recognition of independent variables implied that older age was associated with a higher number of hearing issues, though this association was not statistically significant P = 0.063). A higher percentage of males (26.3%) reported experiencing hearing problems as compared to females (18.9%). However, this was not statistically significant (P = 0.081). Additionally, the study did not find any statistically significant associations between educational level, smoking, chronic diseases, and family history (Table 3. A highThe negative impacts on human well-being due to loud sound exposure are not instantly perceivable . This stThose who describe symptoms of hearing issues, such as tinnitus and sound sensitivity, are more likely to accept protective hearing behaviors ,17. TherA study performed previously revealed that 60.6% of participants used media devices with high-sound settings on a daily basis . In agreIn the current study, 22.1% of the participants complained of hearing loss. These results were higher than the results described in a previous study , where nIn the present survey, 40.4% of the subjects were exposed to work-related noise. In contrast, a study published in Saudi Arabia revealed that 16.9% of the participants were exposed to occupational noise .In this study, 63.5% chose to use earphones. A comparable finding has been noted in a previous study, where they were utilized by 51% . In the Of the participants, 26.6% stated that sometimes the sound of their device was high enough to be heard by the individuals around them. This number is lower than that of the Saudi Arabian study, where 41% of participants reported a similar experience .Our study noticed that more than two-thirds of the participants reported difficulty in listening to others, which is a finding higher than described in the previous study .Of the participants, 87.2% understood that high sound degrees could harmfully impact their hearing. This is in agreement with the survey carried out in Saudi Arabia .This study has some limitations. First, the cross-sectional study proves only association. Second, the limit to a particular region might affect the generalization of the findings. Third, the lack of a standardized questionnaire about the attitudes and knowledge related to NIHL could have limited the comparability of the study results. Fourth, linear regression analysis was not performed.The present study has recognized that there is a high prevalence of hearing loss in Saudi society. Most of the individuals were aware that such hearing issues were avoidable. However, many of them were unaware of the minimum duration of exposure to a noise or sound or the sound degree that could lead to hearing damage. The positive attitude of the individuals regarding modifying their lifestyle suggests that there is a need for NIHL awareness campaigns to increase the educational level of society. Our recommendation for future studies is to explore the role of occupation in NIHL.


Resting metabolic rate (RMR) could represent metabolic health status. This study aims to examine the association of the predicted RMR with 1‐year poor functional outcome and all‐cause mortality in patients with ischemic stroke as a proxy of metabolic profile.A total of 15,166 patients with ischemic stroke or transient ischemic attack (TIA) from the Third China National Stroke Registry (CNSR‐III) were enrolled in this study. The Harris–Benedict equation based on sex, age, weight, and height was used to predict RMR. The primary endpoints were poor functional outcome defined as ≥3 modified Rankin Scale (mRS) score and all‐cause mortality within 1 year. The association between predicted RMR and prognosis was assessed by multivariable regression analysis. Besides that, subgroup analysis of age, sex, and body mass index (BMI) with predicted RMR was also performed.12.85% (1657) individuals had poor functional outcome and 2.87% (380) died of whatever causes within 1 year. An inverse association was found between predicted RMR with poor functional outcome and all‐cause mortality. Compared to the lowest quartile, the highest quartile was significantly associated with lower risk of poor functional outcome  0.33–0.56]) and all‐cause mortality . No significant interaction was between predicted RMR and specified subgroup.Predicted RMR by the Harris–Benedict equation seems to be an independent protective predictor of poor functional outcome and all‐cause mortality after ischemic stroke as a metabolic proxy. Predicted resting metabolic rate by equation has a reversely significant association with all‐cause mortality and poor functional outcome after is hemic stroke that indicates it seems to be a protective predictor of poor outcome of ischemic stroke as a metabolic proxy. The rationale, design, and baseline participant characteristics of the CNSR‐III had been described previously  and all participating centers. Written informed consents were signed by all participants or their legal proxies before enrolling in the study.32). The functional state was evaluated using modified Rankin Scale (mRS) score. Stroke severity at admission was assessed by trained neurologists according to the National Institutes of Health Stroke Scale (NIHSS) score. The etiology of ischemic stroke was classified according to the TOAST  criteria. Fasting blood samples were collected within 24 h of admission and were frozen in cryotube at −80°C refrigerator. Samples were sent to the central laboratory in Beijing Tiantan Hospital and measured by laboratory technicians blinded to the baseline data.Baseline data on demographic characteristics, medical and medication history, laboratory findings as well as clinical situations were collected by trained research coordinators at admission. Height and weight were measured according to standardized methods. Height was measured to the nearest 0.1 cm and weight was measured to the nearest 0.1 kg wearing only light underwear. Self‐reported height and weight were collected if the information were impossible to be collected. BMI was calculated as weight (kg) divided by height square  and Cox proportional hazards regression analysis (hazard ratio [HR] and 95% CI), respectively. Additionally, the association between ordinary mRS (7 levels with 0–6 score) and predicted RMR was also assessed with logistic regression analysis. We constructed two adjusted models to evaluate the primary endpoints: sex adjusted model and multivariable adjusted model. The latter model incorporated the following variables: sex, BMI, current smoking, hypertension, dyslipidemia, diabetes mellitus, prior stroke, prior atrial fibrillation (AF), prior coronary heart disease (CHD), NIHSS and mRS at admission, TOAST subtype, recombinant tissue plasminogen activator intravenous thrombolysis (rt‐PA IVT) treatment, antithrombotic drugs, and lipid‐lowering drugs. To vigorously assess the relationship between multivariable adjusted primary endpoints and predicted RMR on a continuous scale, we depicted restricted cubic splines with five knots . Kaplan–Meier curves associated with predicted RMR were compared using log‐rank tests by an original unadjusted model. In addition, we performed prespecified subgroup analysis to evaluate the effects of sex , age , BMI  on predicted RMR. In sensitivity analysis, we exclude the population with mRS of 4 to 5 at admission and conducted univariable and multivariable analysis in patients with the mRS of 0 to 3.Patients were dived into four groups according to predicted RMR quartiles and we chose the lowest quartile or first quartile as a reference. Continuous variables were expressed as median . Categorical variables were presented as proportions. Kruskal–Wallis test was used for comparisons of continuous variables. Categorical variables were compared with the χp value<.05 was considered significant. All of the analyses were performed with SAS software, version 9.4 A two‐sided 4In CNSR‐III, a total of 15,166 ischemic stroke or TIA patients were finally eligible and had complete information at baseline. Therein, 769 individuals not according with age of 30–80 years old limit, 45 individuals out of BMI of 16 to 40 limit, 109 individuals with reported cancer at recruitment, and 1020 individuals diagnosed TIA when discharged. Therefore, 1943 cases were excluded and the rest of 13,223 out of 15,166 individuals (87%) of ischemic stroke were eligible for analysis with median age of 62 years, 69.4% male, median predicted RMR of 1408.0 kcal/day.r ≥ .92) with those derived from the Mifflin St Jeor, WHO/FAO/UNU, and Oxford equations . Similarly, the significant association was also found when examining mRS as an ordinary variable . A 100 kcal/day increment of predicted RMR was inversely associated with poor functional outcome  (Table 12.85% (1657) participants had poor functional status and 2.87% (380) deaths occurred during 1 year. A previous survey from the Bigdata Observatory Platform for Stroke of China (BOSC) revealed that the rate of 1‐year death and disability was 6.0% (5.7%−6.3%) and 14.2% (13.8%−14.7%) respectively after first‐ever stroke in Chinese population. Although compared to the BOSC our study was with higher mortality, study cohorts and inclusion criteria like whether the first‐stroke or not and the occurrence‐to‐admission time could explain the reason  Table p < .0001) . An all‐cause mortality risk reduction of 19% was associated with each 100 kcal/day increment in predicted RMR  Table . The cump for interaction >.05; Supplemental Table The restricted cubic spline model indicated a similar associated pattern to the predicted RMR as a categorical variable both in the relationship with poor functional status and all‐cause mortality Figure . No sign5This study provided that after controlling for related confounders, predicted RMR was significantly inversely associated with poor functional status and all‐cause mortality. Furthermore, the results were consistent even after stratification for age, sex, and BMI. The results indicated that predicted RMR seemed to be an independent protective predictor for prognosis of ischemic stroke as a proxy of metabolic profile.Given that the RMR measured in current study was only based on the age, weight, and height variable by sex, so in theory, the male subjects with bigger body size (greater weight and higher) and younger age were more likely to obtain good outcome after ischemic stroke. Although it seemed to appear that outcome status was decided on the pure sum of the variables in equation, we should note that each of the variables has different weighted factors which indicted that different RMR would be obtained by changes in same unit of every variable. Owning to measurements on RMR obtained by Harris–Benedict equation  in our study may result from the common crucial variable of weight  and all‐cause mortality   (a), and all‐cause mortality (b).Table S5. Sensitivity analysis of predicted RMR, poor functional outcome, ordinary mRS, and all‐cause mortality.Click here for additional data file.


To report the configuration, risk factors, fixation methods and complication rates after repair of humeral condylar fractures (HCF) in French bulldogs, and report the presence of humeral intracondylar fissures (HIF) in this population as a possible predisposing factor.Retrospective clinical cohort study.Forty‐four elbows.The medical records of dogs referred between January 2012 and December 2021 were searched for French bulldogs presenting with HCF. Signalment, fracture configuration, stabilization method and complication occurrence were obtained. Postoperative radiographs were assessed for implant positioning, and computed tomography (CT) scans were assessed for the presence and size of HIF in the contralateral elbow.p = .01) compared to other methods. All incidences (7/7) of TCS migration were within the TCS + K‐wire group. A HIF was identified in 18/31 (58.1%) dogs. Older animals were not significantly less likely to have a HIF than younger animals (p = .129).Lateral humeral condylar fractures represented 28/44 (63.6%) of HCF in French bulldogs. Repair with a transcondylar screw (TCS) and Kirschner‐wire(s) (K‐wire) were 7.62 times more likely to result in a major complication  was associated with an increased risk of major complications and migration of the TCS. A HIF was present in the contralateral elbow of over half of the French bulldogs where CT was available.A HIF may be a predisposing factor of HCF in French bulldogs. Alternative methods of stabilization to a TCS and K‐wire(s) should be used to reduce complication risk. BCFbicondylar fracturesCWcondylar widthHCFhumeral condylar fracturesHIFhumeral intracondylar fissuresLHCFlateral humeral condylar fracturesMHCFmedial humeral condylar fracturesSDscrew core diameterTCStranscondylar screwTSAtranscondylar screw angle1The majority of distal humeral fractures in dogs involve the humeral condyle.Two possible factors are postulated to explain why LHCF are more common than BCF and MHCF. First, the lateral epicondylar region is smaller and therefore weaker than the medial region. Second, the radius articulates predominantly with the lateral part of the condyle and therefore forces from sudden impacts are predominantly directed laterally.Humeral condylar fractures are commonly diagnosed without evidence of a history of trauma. In these cases, a humeral intracondylar fissure (HIF) is probably the predisposing factor. There are two principal theories as to the formation of HIFs. A HIF may represent a failure of the medial and lateral secondary centers of ossification of the humeral condyle to fuse during skeletal development .Humeral condylar fractures are typically stabilized using internal fixation with the aim of achieving compression of the fracture fragments, anatomical reconstruction and reduction of the articular surface. The most common method employed involves the use of a transcondylar screw (TCS) along with antirotational pins or a plate, but other techniques have been described.The popularity of the French bulldog has seen an unprecedented rise in the United Kingdom over the last 10 years, with a 1417% increase in Kennel Club registrations from 2011–2020.The aim of this study was to retrospectively review cases of HCF in French bulldogs presenting to a single referral center in the United Kingdom. It was our perception that a fracture of the lateral aspect of the humeral condyle is the most common fracture configuration in French bulldogs and that the incidence of a humeral condylar fissure in the contralateral elbow is higher than previously reported. We also perceived that the complication rate was higher in dogs whose fractures were stabilized with a TCS and antirotational K‐wire. Our hypotheses were therefore (1) LHCF are more common than MHCF and BCF in French bulldogs, (2) The complication rate is higher for HCF stabilized with a TCS and antirotational K‐wire(s) (3) The presence of a HIF in the contralateral elbow is due to delayed ossification (IOHC) and therefore the incidence decreases with age.22.1Medical records (January 2012–December 2021) from a single referral hospital were retrieved for all French bulldogs that presented for surgical stabilization of HCF. Dogs that were not treated surgically, or where postoperative data was not available, were excluded from the study. The data retrieved included age, weight, sex, fracture type , etiology of fracture, stabilization method used to stabilize the fracture and whether evidence of a HIF existed in the contralateral limb on CT (if available).2.2Postoperative complications were recorded, and details noted. Complications were defined as any undesirable outcome related to the surgery as previously detailed by Cook et al.2.3For all elbows where postoperative radiographs were available (44/44), the radiographs were assessed as previously described by Morgan et al.For dogs where CT of the contralateral limb was available 31/42), images were reviewed for evidence of a HIF in the contralateral limb. As described by Moores and Moores,, images 2.4p < .05 were considered statistically significant for all tests.Commercially available statistical software program (IBM SPSS Statistics Version 28) was used to perform all statistical analysis, and graphs were produced using Microsoft Excel. Data was assessed for normality using the Shapiro–Wilk test. Nonparametric tests were used to assess data that were not normally distributed. Descriptive statistics were used to report medians and ranges. Values of t‐test, or Mann–Whitney U test were used depending on normality of distribution. The association between continuous data, such as age and fissure size were assessed using Spearman's correlation coefficient .Associations between all categorical data were assessed using Fisher's exact test or Chi squared as appropriate. For continuous data including TSA, CW:SD and weight, the independent samples 3A total of 54 French bulldogs presented with HCF during the study period. Twelve dogs were excluded as inadequate follow‐up data was available, leaving a total of 42 dogs. Two dogs suffered bilateral HCF and so each limb was treated as an individual fracture. There was therefore a total of 44 total elbows with HCF. Of the HCF, 28/44 (63.6%) were LHCF, 7/44 15.9%) MHCF and 9/44 (20.5%) BCF. The right forelimb was affected in 27/44 (61.4%) fractures, and the left in 17/44 (38.6%). There were 23 (52.3%) entire males and 21 (47.7%) entire females included. Median age at time of initial presentation was 17 weeks (range 13–56 weeks). Weight ranged from 3.8 to 15 kg (median 6.4 kg). Thirty‐one out of 44 HCFs (70.5%) occurred after a reported minor trauma, 8/44 (18.2%) had no obvious trauma reported and in 5/44 (11.4%) the cause was unknown with the dog just presenting to the owner with lameness (Table 5.9% MHCF3.1Twenty‐four out of 44 (54.5%) fractures were stabilized by placement of a TCS and supracondylar K‐wire(s), 19/44 43.2%) fractures were stabilized using a TCS plus one or more epicondylar plates, and 1/44 (2.3%) was stabilized using a 3.5 mm TCS alone (herein named as the “other” group). One fracture included in the TCS and plate group also underwent a proximal ulnar osteotomy to allow accurate articular reduction during surgery. Table % fracturWhen the TCS and K‐wire(s) group was investigated further, 14/24 (58.3%) used one K‐wire, 9/24 (37.5%) used two K‐wires and 1/24 (4.2%) used three K‐wires. Where more than one K‐wire was used, 6/10 (60%) used a transcondylar and supracondylar wire. The remaining 4/10 (40%) were placed across the supracondylar fracture line as crossed pins.3.2Follow‐up was obtained at a median time of 6 weeks postoperatively range 3–60 weeks). Twenty‐six out of 44 (59.1%) elbows experienced no complications, 5/44 (11.4%) had minor complications and 13/44 (29.5%) had major complications. No dogs suffered catastrophic complications. This resulted in an overall complication rate of 40.9%. Of the 13 dogs that experienced a major complication, 10/13 (76.9%) required surgical intervention. Further surgery was recommended in one of the 10 elbows due to implant failure, but this was declined by the owner. Three out of 13 (23.1%) required medical intervention. The mean time of major complication occurrence was 6.5 weeks post surgery (range 1–24 weeks). Individual elbows that experienced major complications are documented in Table –60 weeks3.2.1p = .022) , compared with 1/7 (14.3%) MCHF and BCF which suffered no (0/9) major complications (p = .025). Seven out of 24 (29.2%) TCS placed alongside K‐wire(s) migrated. This compares to no recorded migration of the screw when placed alongside an epicondylar plate (p = .022). Fractures stabilized using a TCS and K‐wire(s) were more likely to have any type of complication (14/24 [58.3%]) compared with fractures stabilized with a plate or single TCS (4/20 [20.0%])  (Table p = .009). Fractures that were stabilized with a TCS and K‐wire(s) were also more commonly associated with migration of the TCS (7/24 [29.2%]) compared to TCS and plate or single TCS (0/20 [0%]) . When comparing the use of one k‐wire versus multiple k‐wires within the TCS and K‐wire(s) group, no association was found between complication occurrence (p = 1.00), risk of major complication (p = .697), or migration of the TCS (p = 1.00). The positioning of the wires when multiple were used led to major complications in 3/6 (50%) when placed as a transcondylar and supracondylar wire, and 1/4 (25%) when placed as crossed supracondylar wires.Eleven out of 24 45.8%) fractures stabilized using a TCS and supracondylar K‐wire(s) encountered a major complication, compared with 2/19 (10.5%) using a TCS and epicondylar plate, and 0/1 for the “other” fixation group (Table .8% fract3.2.2p = .002), and dogs of lower weight (p = .026). Only age was associated with migration of the TCS (p = .024), with a lower age more likely to experience migration (Table p < .001) to be stabilized using a TCS+ epicondylar plate than with a TCS and K‐wire(s) . Figure R = .47) between age and percentage fissure length was found to be significant (p = .048). The correlation between CW:FW and age (R = .044) was not significant (p = .862).Thirty‐one of the 42 dogs included in the study had a CT of the contralateral limb performed at the time of presentation. Of these, 18/31 58.1%) had evidence of a HIF in the contralateral limb. The presence of a HIF was not more common in younger dogs  when compared to those associated with a plate, or when a single TCS was used. Major complications were seven times more likely to occur with a TCS and K‐wire(s) compared to all other stabilization methods. This finding agrees with our hypothesis that HCF stabilization with a TCS and antirotational K‐wire(s) results in a higher complication rate. All the incidences of TCS migration occurred with stabilization with TCS and K‐wire(s). To the authors’ knowledge this is not something specifically previously reported in the literature and is possibly attributed to the stability provided by the different adjunctive fixation modalities in addition to the TCS. The supracondylar K‐wire may not completely neutralize the rotational and shear forces that the fractured condyle must withstand during the healing period, whereas adjunctive plate fixation is biomechanically superior to supplemental K‐wire, and provides increased stiffness.The increased major complication rate seen with TCS and K‐wire(s) may be that HCF in younger dogs were significantly more likely to be stabilized using a TCS and K‐wire(s) compared to other methods. This is probably due to the size of the condyle and the difficulty in applying a plate to these smaller dogs. Dogs of lower age were significantly more likely to experience a major complication and migration of the TCS. This may be attributed to the softer bone stock of younger animals. Significant correlations have been found between pull‐out strength of implants and bone mineral density.One HCF was stabilized with a single TCS, that being a MHCF. It would therefore be unwise to make any conclusions about the efficacy and complication rate of this method without a larger sample size. In a study looking at the placement of a single 4.5 mm shaft screw, the single MHCF case in that cohort also did not encounter complications; however, both the LHCF and BCF groups did.When CT of the contralateral limb was available, 58.1% of dogs had evidence of a HIF. This is similar to that reported in a smaller case series of nine dogs in which 66.7% had evidence of HIF.A predisposition to HCF in spaniel breeds has been linked to HIF,This study was inherently limited by its retrospective nature, the most obvious being that it relied on accuracy of the medical records reviewed and the possible introduction of selection bias. There was no randomization of repair technique or prospective measurements of outcome and it was not possible to standardize surgical preparation, surgical procedure used, and surgical technique. This should be somewhat negated as dogs were from a single referral center, and so similar protocols were used. A further limitation of this study was that long‐term follow‐up was not available for all the dogs included. It is therefore difficult to make conclusions relating to the relatively predictable healing and low incidence of late implant failure in this breed compared with other breeds with documented HIF. In our experience, it is less common to see HCF in adult French bulldogs compared to Spaniel breeds which commonly present with HIF. This may reflect a difference in the underlying etiology and pathogenesis. The classification for reporting and assessing the presence of HIF is prone to error, and although we tried to standardize with a ratio‐based calculation, it is still a subjective measurement. The dogs included were all from a single referral center and so may reflect only local breed and genetic bias. This study was also limited by its small sample size, and so may be potentially underpowered for some associations. In the future, larger studies would be required before conclusions are made. It would also be beneficial to have CT images for older dogs with previously documented fissures to see if the fissures continue to persist with age, and to document whether closure occurs.There was a significant difference in complication rates between repair methods for the stabilization of HCF in French bulldogs. The use of a TCS and K‐wire(s) has an increased likelihood of major complications than a TCS and plate, and this should be considered when faced with a HCF. We also found that a HIF was present in the contralateral limb of over 50% of the dogs presenting with HCF and may suggest a possible predisposing factor in French bulldogs. Ossification in the humeral condyle of this population of French bulldogs did not appear to occur in the previously described age range of other breeds. Further studies are required to investigate the progression of these fissures.The authors declare no conflict of interest related to this report.


Cystic fibrosis (CF) patients who receive high-dose aminoglycosides can acquire inner ear damage and subsequent hearing loss. There is no current standard protocol for assessing ototoxicity in CF centers in the United States.To evaluate the cost-effectiveness of a pharmacist-implemented routine hearing screening for ototoxicity among pediatric patients using a clinically validated tablet audiometer to allow for earlier detection of hearing loss in an exploratory analysis.A Markov decision-analytic model was developed to assess the cost-effectiveness of implementing routine screening with monthly cycles over a 3-year time horizon. The model measured the difference in promptly detected hearing loss, delayed detected hearing loss, and undetected hearing loss, compared with current screening practices. Model inputs were obtained through a comprehensive literature review. Primary model outcomes included total health care costs and quality-adjusted life-years (QALYs) gained with a 3% yearly discount. One-way, two-way, and probabilistic sensitivity analyses were conducted to evaluate model uncertainty.In a hypothetical cohort of 100 patients, routine screening using a tablet audiometer increased promptly detected hearing loss by 8 patients. There was an incremental gain of 3.2 QALYs at an increased cost of $333,826 compared with current screening practices. This resulted in an incremental cost-effectiveness ratio (ICER) of $103,771 per QALY. In the 1-way sensitivity analysis, the ICER ranged between $64,345 and $258,830 per QALY.Using a tablet audiometer for routine hearing screening appears to be a cost-effective option at a $150,000 per QALY willingness-to-pay threshold when only considering the immediate benefits gained. This analysis did not examine the long-term effects of early detection in language development for pediatric patients. What is already known about this subjectCystic fibrosis patients receiving highdose intravenous aminoglycosides are at risk of developing hearing loss.Patients with hearing loss experience a long-term effect on quality of life.What this study addsThis study models the clinical and economic outcomes of a tablet-based audiometer compared with current screening practices.A tablet-based audiometer can increase earlier detection of hearing loss and is cost-effective in the short term at a willingness-to-pay threshold of $150,000.1 Bacteria associated with pulmonary exacerbations include Pseudomonas aeruginosa, a Gramnegative bacterium, methicillin-resistant Staphylococcus aureus (MRSA), and nontuberculous mycobacteria. Once established in the airways, complete eradication of these organisms is unlikely. In 2018, more than 20% of pediatric CF patients were treated with intravenous (IV) antibiotics for a pulmonary exacerbation.2 Aggressive treatment with high-dose IV aminoglycosides (AG) is often used to treat pulmonary exacerbations caused by P. aeruginosa and delay chronic infection and deterioration of lung function.3Cystic fibrosis (CF) is a genetic disorder of the cystic fibrosis transmembrane conductance regulator (CFTR) protein, which primarily affects the lungs and is characterized by chronic lung infections. Pulmonary exacerbations result in the deterioration of lung function and increased morbidity and mortality.4 Persistent use of high-dose IV AG therapies has been reported to cause ototoxicity in numerous studies, ranging from 8% to 47%.10 Hearing loss can significantly influence language and speech development in children, and earlier detection is needed to prevent long-term effects of ototoxicity. Nearly two thirds of children with permanent childhood hearing loss reported complaints of stuttering and inability to speak clearly.11 The younger a child is when he or she receives care for hearing loss, the greater effect that hearing loss interventions have on language outcomes.12Pediatric CF patients are at a high risk of AG toxicities due to altered membrane permeability and increased lean body mass, causing greater drug distribution throughout the body.14 In a 2011 survey of U.S. CF accredited care centers, 39.4% of pediatric CF centers did not perform audiology screening for ototoxicity.15 Among the centers that perform screening, there may not be a standardized approach that ensures all at-risk patients are consistently screened. A recent study conducted at the Cystic Fibrosis Care Center at Children’s Mercy Kansas City, found that a pharmacist-implemented ototoxicity monitoring protocol doubled the percentage of patients who received an audiogram after inhaled AG.16 While monitoring protocols help increase screening rates, there are still inherent limitations, since they rely on traditional screening practices.Although the American Speech-Language-Hearing Association and the American Academy of Audiology have recommended screening guidelines for ototoxic medications, adherence to monitoring during treatment varies between clinics.14 There are numerous logistical barriers to implementing a monitoring program, as audiology services may not be located in each treatment center or sufficiently staffed to provide frequent ototoxicity monitoring.17 Due to the severity of CF, patients manage a multitude of appointments, which can contribute to poor attendance to referrals. Furthermore, performing a PTA test can be burdensome and may not be necessary for all patients receiving high-dose IV AG. For these reasons, implementing a protocol using conventional screening methods may not be feasible.The lack of screening in standard practice protocols may be attributed to the time-intensive nature of frequent testing needed to adequately detect early hearing loss. Current ototoxicity screening practices involve a referral to an audiology clinic where an audiologist would perform a pure-tone audiometry (PTA) test at baseline and post-treatment.18 A previous study on the benefits of tablet-based ototoxicity monitoring for routine screening in adult CF patients showed that it increased patient accessibility and broadened the range of personnel capable of administrating screening.19 Clinical pharmacists are uniquely positioned as the medication experts to conduct ototoxicity screening as a part of medication management and drug toxicity monitoring. Pharmacists play a pivotal role in minimizing the risk of treatment-induced adverse events.20 In addition, pediatric CF patients followed by pharmacists in a therapeutic drug monitoring program achieved therapeutic drug targets more quickly.21A tablet audiometer can be used to serve as a portable and accessible solution that can be used by health care professionals outside of the audiology department.The purpose of this study was to assess the cost-effectiveness of a pharmacist-led routine audiometry screening for ototoxicity among pediatric patients using a clinically validated tablet audiometer.A Markov decision-analytic model was constructed to compare the effect of routine tablet-based audiometry screening with current screening practices on costs and utilities from the societal perspective. The model had a time horizon of 3 years, with a cycle length of 1 month.The Markov model included 8 health states as shown in 22All patients entering the model were assumed to not have had previous hearing loss or a previous bacterial lung infection. Only acute pulmonary exacerbations that required high-dose IV AG were considered in this model. The risk of death in patients with acute exacerbations was assumed to be higher than in patients who do not experience any acute exacerbations.2 The risk of developing hearing loss after the second pulmonary exacerbation was assumed to be higher than in the initial exacerbation and remained constant in future cycles.23 Patients with undetected hearing loss were screened at future exacerbations and, if detected, were categorized as delayed detected hearing loss. Transition probabilities for initial hearing loss varied by the initial and recurrent exacerbation. Due to a large range in hearing loss percentages reported in the published literature, conservative inputs were chosen from studies with more frequently reported values, and a constant ototoxicity risk was assumed after the second exacerbation.10After their initial exacerbation, patients either had promptly detected hearing loss, undetected hearing loss, or no hearing loss. Patients who did not experience hearing loss at the initial exacerbation were still at risk for future hearing loss after another acute recurrent exacerbation requiring high-dose IV AG.17 To account for the inconsistency of successful referrals, it was assumed that only 47% of patients in a center that conducts screening received baseline and follow-up screenings.All patients in the intervention strategy who experienced an exacerbation received high-dose IV AG at treatment initiation and subsequent screening from the pharmacist during routine medication monitoring. Screening occurred at treatment initiation and after completion of treatment. The intervention inputs used in this study were derived from the SHOEBOX tablet audiometer . In the no-intervention strategy for current screening practices, only a portion of patients were screened at an audiology visit using PTA after an exacerbation based on current practices and estimated screening completion rates from the literature .24 Screening frequencies of the intervention and the current screening practice model remained consistent throughout the time horizon.A larger range of current screening practice probabilities was tested in the sensitivity analysis. The PTA in the current screening practice model was assumed to have had 100% sensitivity and 100% specificity, since the tablet audiometry validation studies used PTA as the standard comparison. The sensitivity and the specificity from the validation studies were used to calculate the true positive hearing loss patients and false positive patients.26 The utility for undetected hearing loss was weighted for mild to moderate hearing loss using previously published literature, and no utility gained from using a hearing aid.28 Detected hearing loss was weighted for mild to moderate hearing loss, with 58% receiving additional utility from a hearing aid that was calculated from the literature.29 Delayed detected hearing loss was weighted for moderate to severe hearing loss, and all patients had additional utility from a hearing aid.All utilities had a decrement to adjust for having CF and experiencing pulmonary exacerbations.Intervention costs consisted of a fixed yearly cost of the tablet audiometer ; pharmacist training time; and pharmacist time spent administering the intervention. For this model, it was assumed that 5 pharmacists were trained to use the tablet audiometer (1 hour per pharmacist), and each screening took 30 minutes to complete. Screening time included testing at treatment initiation and after completion of therapy. Each exacerbation event included the episode cost of the exacerbation, as well as the additional screening time by the pharmacist. All patients in the intervention group after their first exacerbation incurred weighted costs for screening time associated with future exacerbations.New prompt or new delayed detected hearing loss costs included a confirmatory PTA test and an otoacoustic emissions (OAE) test at an audiology visit, as well as new hearing aid user costs. For the intervention and current screening practice model, it was assumed that 58% of patients in the prompt detected hearing loss required a hearing aid, whereas 100% of patients with delayed detected hearing loss would require a hearing aid. Recurring costs for prompt or delayed detected hearing loss included hearing aid user maintenance, a yearly OAE test, tympanometry, and play audiometry. Patients who were falsely diagnosed as having hearing loss using the tablet audiometer would only incur the cost of a PTA test and an audiology visit. These patients would then reenter the model in the no hearing loss state.All costs were expressed in U.S. dollars and were adjusted to 2019 dollars using the Personal Consumption Expenditure Healthcare Index. An annual discount of 3% was applied to costs and utilities.We conducted 1-way sensitivity analyses to explore each individual parameter’s uncertainty, including any relevant assumptions, and its effect on the model results. If available, the standard deviation or 95% confidence intervals from the base-case value were used as the minimum and maximum limits. Otherwise, the range for the parameter was chosen from the literature. To test for a variety of health care personnel administering the test, a range of health care salaries were considered. Two-way sensitivity analyses varied intervention specificity alongside undetected hearing loss utility to evaluate potential negative long-term effects on language development and quality of life. A probabilistic sensitivity analysis (PSA) with 1,000 Monte-Carlo simulations was performed to examine the combined uncertainty of the model inputs. For the PSA, beta and gamma distributions were used for the probabilities and costs, respectively.Because this model assumed that all patients had no previous infection, a separate analysis was completed using higher inputs to account for chronic high-dose IV AG users who were assumed to have higher probabilities for acute exacerbations and associated hearing loss. The costs and utilities were derived by reweighting the hearing loss states to include severe hearing loss.In the hypothetical cohort of 100 patients, the incremental cost of the intervention group was $333,827, with an associated increase in QALYs of 3.2. This resulted in an estimated ICER of $103,770, which is under the willingness-to-pay threshold (WTP) of $150,000 . OverallParameter estimates and assumptions were tested in the 1-way sensitivity analysis. The tornado diagram in The PSA results were plotted in a cost-effectiveness plane with WTP thresholds of $100,000 and $150,000 . In the 1,000 simulations, the mean ICER was $110,831. The intervention was cost-effective 82.5% of the time at the $150,000 threshold and 49.2% at the $100,000 threshold.In the chronic cohort scenario analysis, the ICER increased to $115,229 . This was primarily driven by increased exacerbations that increased screenings provided to each patient. With a larger proportion of patients receiving screening and acquiring hearing loss, detection would occur promptly, leading to increased costs of treatment and future audiology monitoring.6 There is currently no established screening protocol that allows for a high completion rate in CF patients. There have been reports of implementing ototoxicity monitoring programs in various institutions for other disease states, but these efforts have been met with barriers due to time constraints of audiology departments and staffing limitations.17 Using a tablet audiometer can funnel patients with suspected hearing loss to audiology services and increase the efficiency of referrals.Ototoxicity in CF patients has been increasingly reported in the literature. Numerous studies have recommended implementing targeted ototoxicity screening in standard practice.31 The 2-way sensitivity analysis showed that, with increasing utility decrement of undetected hearing loss, the intervention will remain cost-effective even if accuracy decreases.This was the first cost-effectiveness analysis of implementing a tablet audiometer to increase detection of ototoxicity. This model shows that routine screening using a tablet audiometer is a cost-effective option even when only considering the immediate utility gained. This analysis did not examine the long-term quality of life benefit of earlier detection in speech and language development. We suspect that the difference in QALYs of patients who are promptly detected and delayed detected will continue to increase as hearing loss symptoms worsen. Without timely screening, patients who self-report hearing loss symptoms will already have suffered extensive damage. In the United States, individuals with hearing loss symptoms report higher rates of unemployment and anxiety.Currently, the model is assuming that the intervention is led by a group of pharmacists as they frequently interact with patients to assess the efficacy and adverse effects of drug therapy. Pharmacists were chosen because their unique training and education allows them to be aware of patients’ exposure to medications, to consider their adverse effects, and to determine when to proactively trigger the need for screening. However, because resources and responsibilities of personnel vary between CF centers, it may not be feasible to require pharmacists for this intervention. Additional health care professionals could be trained to use the tablet audiometer if needed. The model was rerun with a range of other health care salaries, and there was only a slight decrease in the ICER, still resulting in a cost-effective solution.A strength of this model is the distinction between the initial and recurrent exacerbation effects on probabilities, as well as the incorporation of specific hearing loss states. This increases differentiation in utilities and costs associated with each health state and the time hearing loss was detected. The model was also tested using a higher risk cohort of chronic high-dose IV AG users, which allows for better generalizability, since CF centers will have a mix of new and chronic users.There are, however, several limitations to our analysis. There were numerous studies that reported different incidences of acquired hearing loss associated with high-dose IV AG. In addition, there may be a nonlinear relationship between the number of high-dose IV AG courses and the risk of ototoxicity. Therefore, conservative inputs were chosen in the base-case analysis, and a chronic user cohort was evaluated for a higher risk population.With limited literature on the utility of hearing loss, the different states of hearing loss were weighted using estimates on hearing aid use and associated utility. Utilities used in this model were measured using different instruments and may not be fully comparable. Utilities for the severity of hearing loss were also captured from caregivers and may not accurately represent the pediatric population.This analysis focused on the population level and may not accurately describe how each individual patient experiences hearing loss symptoms and what costs they incur. Indirect and nonmedical costs, such as time missed from school and caretaker burden, were not included.Finally, our time horizon does not fully capture the long-term costs and outcomes associated with ototoxicity and early or delayed hearing loss detection. Thus, the results described herein may have underestimated the cost-effectiveness of pharmacist-led audiology screening.Hearing screenings using a tablet audiometer in pediatric patients with CF at risk for ototoxicity appears to be cost-effective from a societal perspective. Decision makers should be aware of the short-term and longterm effects of hearing loss and implement measures to ensure optimal outcomes. Future investigations are needed to explore the feasibility and implementation of pharmacist-led routine hearing screening using a tablet audiometer in pediatric and adult CF centers.


Pinus massoniana Lamb.) is an important resin-producing conifer species in China. Resin yield is a highly heritable trait and varies greatly among different genotypes. However, the mechanisms regulating the resin yield of masson pine remain largely unknown. In this study, physiological, proteomic, and gene expression analysis was performed on xylem tissues of masson pine with high and low resin yield. Physiological investigation showed that the activity of terpene synthase, as well as the contents of soluble sugar, jasmonic acid (JA), methyl jasmonate (MeJA), gibberellins , indole-3-acetic acid (IAA), and abscisic acid (ABA) were significantly increased in the high yielder, whereas sucrose and salicylic acid (SA) were significantly decreased compared with the low one. A total of 2984 differentially expressed proteins (DEPs) were identified in four groups, which were mainly enriched in the biosynthesis of secondary metabolites, protein processing in the endoplasmic reticulum, carbohydrate metabolism, phytohormone biosynthesis, glutathione metabolism, and plant-pathogen interaction. Integrated physiological and proteomic analysis revealed that carbohydrate metabolism, terpenoid biosynthesis, resistance to stress, as well as JA and GA biosynthesis and signaling, play key roles in regulating resin yield. A series of proteins associated with resin yield, e.g., terpene synthase proteins (TPSs), ATP-binding cassette transporters (ABCs), glutathione S-transferase proteins (GSTs), and heat shock proteins (HSPs), were identified. Resin yield-related gene expression was also associated with resin yield. Our study unveils the implicated molecular mechanisms regulating resin yield and is of pivotal significance to breeding strategies of high resin-yielding masson pine cultivars.Masson pine ( Pinus massoniana Lamb.) is one of the most important resin-producing conifer species in China, and approximately 90% of the resin is tapped from this species , max missed cleavage set as 0. The peptide length was set as 7–25, variable modification was set as carbamidomethyl on Cys and oxidation on Met, and max variable modifications were set as 3. Transition settings: precursor charges were set as 2, 3, ion charges were set as 1, and ion types were set as b, y. The product ions were set from ion 3 to the last ion, and the ion match tolerance was set as 0.02 Da.The six independent samples of high and low resin-yielding variants in August were used for the parallel reaction monitoring (PRM) analysis. PRM was performed in a Q Exactive HF-X mass spectrometer coupled online to the UPLC (Thermo Scientific). The mass spectrometer (MS) was operated in the data-independent procedure at an electrospray voltage of 2.1 kV. The p < 0.05 and p < 0.01 were considered significant and extremely significant, respectively. All data were represented by at least three repeated means.Statistical analyses were performed with SPSS 22.0 software . The single-factor analysis of variance (ANOVA) was employed to determine the differences between sample pairs, and In this study, the mechanisms regulating resin yield were investigated at the physiological and molecular levels. Resin yield could be regulated by carbohydrate metabolism, terpenoid biosynthesis, resistance to stress, and phytohormone biosynthesis and signaling. The carbohydrate metabolism and terpenoid biosynthesis may positively regulate resin yield by promoting resin biosynthesis. Stress-related proteins may influence resin yield by regulating responses to stress. JA and GA biosynthesis and signaling may regulate resin yield by modulating terpenoid biosynthesis. Additionally, GA may regulate resin yield by promoting xylem differentiation. Auxin may regulate resin yield by participating in xylem growth and resin duct development. By further analyzing the expression levels of DEPs involved in these regulatory pathways, a set of proteins associated with resin yield were identified, including terpenoid backbone biosynthesis-related proteins , TPSs, ABCs, GSTs, HSPs, and phytohormone biosynthesis and signaling-related proteins . Relative expression analysis of resin yield-related genes suggested that these gene expressions were also associated with resin yield. Overall, our results provide new insights into the molecular mechanisms regulating resin yield, shedding light on the genetic improvement in masson pine and the utilization of valuable genetic resources .