Older adults with age-related hearing loss exhibit substantial individual differences in speech perception in adverse listening conditions. We propose that the ability to rapidly adapt to changes in the auditory environment  is among the processes contributing to these individual differences, in addition to the cognitive and sensory processes that were explored in the past. Seventy older adults with age-related hearing loss participated in this study. We assessed the relative contribution of hearing acuity, cognitive factors , rapid perceptual learning of time-compressed speech, and hearing aid use to the perception of speech presented at a natural fast rate (fast speech), speech embedded in babble noise (speech in noise), and competing speech (dichotic listening). Speech perception was modeled as a function of the other variables. For fast speech, age [odds ratio (OR) = 0.79], hearing acuity (OR = 0.62), pre-learning (baseline) perception of time-compressed speech (OR = 1.47), and rapid perceptual learning (OR = 1.36) were all significant predictors. For speech in noise, only hearing and pre-learning perception of time-compressed speech were significant predictors . Consistent with previous findings, the severity of hearing loss and auditory processing (as captured by pre-learning perception of time-compressed speech) was strong contributors to individual differences in fast speech and speech in noise perception. Furthermore, older adults with good rapid perceptual learning can use this capacity to partially offset the effects of age and hearing loss on the perception of speech presented at fast conversational rates. Our results highlight the potential contribution of dynamic processes to speech perception. Aging is often accompanied by sensorineural hearing loss (presbycusis) and poor speech perception in daily listening environments , especiaAge-related hearing loss is a primary contributor to speech perception difficulties in older adults e.g., . IndividWhen listening to connected speech  older adults with age-related hearing loss often have perceptual difficulties with rapid speech rates e.g., , in the The contribution of audiometric thresholds to speech perception tends to be larger in relatively easy conditions  than in more challenging ones  model  highlighConsistent with the ELU model, studies suggest that individual differences in cognition are associated with individual differences in the processing of speech under adverse listening conditions e.g., , 1996. FHowever, it is probably the combination of sensory and cognitive factors that affect speech perception of older adults e.g., . If listRapid perceptual learning also relates to the variability in perception of speech under challenging conditions . Rapid pPerceptual learning and speech perception are related in the sense that learning contributes to future perception . HoweverFor older adults with hearing loss, hearing aids are the most widely used rehabilitation devices. While hearing aids are unlikely to fully compensate for the auditory processing deficits of individuals with hearing impairment, they amplify sounds to improve audibility  and incoUnsurprisingly, most studies seeking to explain individual differences in aided speech perception have identified differences in hearing thresholds as the main source of variance e.g., . HoweverAccording to the literature review above, the interplay between the perception of different types of degraded speech, multiple cognitive factors, and perceptual learning is not sufficiently understood. It is also unclear whether the use of hearing aids changes the interplay among the different factors or results in plastic changes in speech perception  age 65 and above; (2) bilateral, adult-onset, symmetric, sensory hearing loss of 30–70 dB, with flat or moderately sloping audiograms, and suprathreshold word recognition scores of ≥60% and air-bone gaps ≤15 dB; (3) no known neurological or psychiatric diagnoses; (4) normal or corrected-to-normal vision; (5) high proficiency in Hebrew; (6) normal cognitive status [a score of 24 or higher on the Mini-Mental State Examination ], and one for reporting additional motor issues that could have influenced their responses on some of the tasks . Three additional participants completed the first experimental session only , and their data were thus excluded from all analyses.simr package  who met all inclusion criteria: 35 older adults with hearing loss (OHI) who did not use hearing aids and 35 older hearing-impaired adults who were experienced hearing aid users (OHI-HA). The two groups had similar ages, MMSE and cognitive scores, but hearing aid users had poorer hearing, somewhat poorer suprathreshold word recognition scores and somewhat higher education see ; Table 1 package  in R.Testing was comprised of two sessions conducted 7–14 days apart at a hearing clinic or at the participants’ home, based on each participant’s preference see . Except A questionnaire regarding education, handedness, lifestyle, and general health was used in the current study. The participants completed the questionnaire before completing further assessments.Participants were screened with a the MMSE , with a Cello and Piccolo portable audiometers and Silenta Supermax supra-aural headphones. Most comfortable levels (MCL) for speech were also assessed. The audiograms were classified based on A full pure-tone and speech audiometry (suprathreshold word recognition) was conducted in an acoustic booth, using the MAICO audiometer (model MA42) or at the participants’ home with Inventis M = 183 words/min, SD = 17); speaker 2  recorded 10 sentences at her natural fast rate  and 10 sentences at her normal, unhurried rate ; speaker 3  recorded 10 sentences at a normal rate of 88 words/min (SD = 10.30); and speaker 4  recorded 40 sentences at a normal rate of 102 words/min (SD = 12.68). To minimize the effects of sentence familiarity on performance, there was no sentence repetition within or across conditions. In addition, Speaker 4 also recorded a list containing 25 pairs of monosyllabic words, adapted from the Hebrew PB-50 test  unaided to the OHI group and (2) aided for the OHI-HA group . Stimuli were presented at each listener’s preferred level. To determine this level, a pre-recorded short passage was played and listeners determined their preferred listening level. Because some of the participants were tested at home, and others in several rooms in the clinic, achieving constant acoustic settings for sound field presentation of the speech stimuli was impossible. Thus, we decided to test all participants with headphones and play the stimuli from the computers (in line with Ten sentences (recorded by Speaker 2) were presented as time-compressed speech. Time-compressed speech was chosen because learning with this form of speech was previously documented in older adults within and across sessions e.g., . In addiBaseline recognition of time-compressed speech was defined as the proportion of correctly identified words in the two first sentences. Learning of time-compressed speech was defined as the rate of improvement in recognition over time. It was quantified as the linear slopes of the learning curves over an additional eight time-compressed speech sentences .Twenty sentences were presented (10 sentences recorded by Speaker 3 and 10 sentences recorded by Speaker 4). All sentences were embedded in a 4-talker babble noise with a fixed SNR level of +3 dB.Following previous research , 2015, wvocabulary (semantic knowledge), digit span (working memory), and block design .A battery of cognitive assessments was used to evaluate cognitive status and identify characteristics that might influence participants’ performance on the experimental tasks. This battery was administered at a comfortable auditory level that was defined by each participant to negate potential confounding effects of audibility on performance. The following subtests from the Wechsler Adult Intelligence Scale-Third Edition in Hebrew  ker test . A compuTrail making test ((RT = reaction time in ms) of the correct responses in the incongruent trials divided by the mean log RT of the correct responses in the neutral trials. A higher flanker cost (>1) means poorer selective attention. (2) ing test . Attentihttps://osf.io/sreq4).As shown in As shown in The contribution of hearing and cognition to recognition accuracy in the speech tasks was studied in the past. Therefore, our modeling here focused on the unique additional contributions of perceptual learning and hearing aid use. To this end, modeling was performed in stages: hearing and cognition were modeled first, followed by learning, and then hearing aid use. With this approach, if a later model fits the data significantly better than a previous one (with a model comparison), the predictor entered at the later stage has a unique contribution to speech recognition when all other included variables are considered. Within a given model, the coefficient of each predictor reflects its contribution while all other predictors in the model are kept constant. Since there were repeated measures for the fast speech and speech in noise, a series of generalized linear mixed models was run using the lme4 package in R . Single Five models were constructed for fast speech and for speech in noise, starting with a model that included only the random effects (Model 0). Thereafter, each subsequent model added one additional predictor over the previous model(s), with the models building upon one another sequentially . Model 1 included background variables of the participants as predictors, which included as: age, hearing, vocabulary, working memory, and attention. Model 2 included baseline recognition of time-compressed speech; Model 3 added the rapid perceptual learning slope; and Model 4 added hearing aid use . To isolate the unique contribution of each additional variable, these four increasingly complex models were compared using likelihood ratio tests with the R ANOVA function.r = 0.43 between vocabulary and working memory, r = −0.38 between hearing and learning, and r = 0.35 between learning and baseline recognition of TCS), suggesting that multicollinearity is not a serious concern. Likewise, all Variance Inflation Factors (VIF) were low (< 2), as reported below for the best fitting models.Note that in general, correlations between the different predictors were not high , age, hearing, baseline recognition of time-compressed speech, and learning were all significant predictors of fast speech recognition see  of fast The inclusion of the background variables in the model resulted in a better fit to the data than the model that included the random effects only . HoweverIn the best fitting model see . Thus, lSince there were no repeated measures , linear regression analyses were used. Four models were constructed for the dichotic listening task in two different ways: once with the dichotic sum serving as the dependent variable and once with the dichotic gap serving as the dependent variable. The models all included age, hearing, vocabulary, working memory, and attention as predictors. Thereafter, as with the models mentioned above, each subsequent model added one additional variable, with the models building upon one another sequentially. Model 2 included baseline recognition of time-compressed speech; Model 3 added the rapid learning slope; and Model 4 added hearing aids. To isolate the unique contribution of each additional variable, these four successively complex models were compared using an ANOVA Table for Comparison of Nested Model tests.Dichotic Sum as the Dependent Variable. For the dichotic listening task, with dichotic sum serving as the dependent variable, model comparisons showed that there were no contributions of variables/effects that did not appear in the first model see .For the dichotic listening task, with dichotic gap serving as the dependent variable, model comparisons showed that there were no contributions of variables/effects that did not appear in the first model see .We assessed the relative contribution of hearing acuity, cognitive factors, and rapid perceptual learning to the identification of fast speech, speech in noise, and dichotic speech in older adults with hearing loss. Hearing acuity and time-compressed speech perception uniquely contributed to the perception of both fast speech and speech in noise. Rapid perceptual learning was a significant predictor of fast speech perception even after accounting for age, hearing, and cognition. Hearing aid use had no effect on any of the speech tasks. Our findings suggest that in older adults, good rapid perceptual learning can partially offset the effects of age and hearing loss on the perception of fast speech, but not on the perception of speech in noise or dichotic speech. Determining if this is due to inherent differences between the different speech tasks or due to other differences  requires further investigation. Furthermore, the finding that time-compressed speech recognition is strongly associated with the perception of speech in noise suggests a potential link between the perception of these two types of challenging speech.In the present study, hearing acuity was the strongest predictor of both fast speech and speech in noise perception. This finding is consistent with previous work on speech perception in older adults e.g., . For exaAn interesting outcome of the current study is that the initial performance of time-compressed speech remained the second strongest predictor of perception of both fast speech and speech in noise. These findings are in line with previous results regarding the perception of fast speech  and exteAs for the association between time-compressed speech and speech in noise recognition, loss of synchrony in aging auditory systems may disrupt the fine structure cues that important for recognizing speech in noise . The finOur results indicate that the association across speech tasks is not limited to tasks that share obvious sensory characteristics. This suggests that common speech perception processes could underlie performance variability across a range of listening challenges in older adults with different levels of hearing. Consistent with this view, research on speech recognition under adverse listening conditions has shown relationships across different conditions e.g., . For exaIn contrast to previous work in older adults e.g., , in the The current finding that hearing aid use had no effect on degraded speech perception is consistent with that of https://osf.io/sreq4.The data from this study is available at Open Science Foundation; This study involves human participants. It was reviewed and approved by the ethics committee of the Faculty of Social Welfare and Health Sciences, University of Haifa. Protocol 362/18 participants provided their written informed consent to participate in this study.LL and KB designed the study, prepared the study materials, and edited the manuscript. LS recruited study participants, collected and analyzed the data, and wrote the manuscript with oversight and conceptual guidance from KB and LL. All authors approved the submitted version.This study was supported by the Israel Science Foundation (grant number 206/18).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Donnai-Barrow syndrome (DBS) is a rare autosomal recessive hereditary disorder that affects a variety of body systems. One of the most common symptoms in DBS patients is severe bilateral sensorineural hearing loss. The objective of this report is to highlight the performance of such patients after receiving cochlear implants as a management of their hearing loss. We reviewed the medical records of two cousins diagnosed with DBS before and after cochlear implantation, with a particular focus on their auditory and language performance. After receiving the cochlear implant, both patients showed substantial progress in auditory and speech perception, as well as their intelligence quotients, allowing them to join mainstream schools. In conclusion, our findings showed that cochlear implantation can be considered an ideal approach for the management of DBS patients who suffer from bilateral sensorineural hearing loss. LRP2) gene, which encodes megalin, a multiligand endocytic receptor expressed in many absorptive tissues [Donnai-Barrow syndrome (DBS)/facio-oculo-acoustico-renal (FOAR) syndrome MIM# 222448) is an extremely rare disorder that affects multiple body systems and is inherited in an autosomal recessive pattern ,2. Few s22448 is  tissues . Althoug tissues .DBS/FOAR is characterized by specific facial features such as a V-shaped point in the hairline in the middle of the forehead (Widow’s peak), large anterior fontanelle, wide metopic suture, posteriorly rotated ears, down slanted palpebral fissures, hypertelorism, enlarged globes leading to the appearance of prominent eyes, depressed nasal bridge, and short nose with broad or bifid tip ,8. AffecDue to the rarity of the disease, information on the auditory performance, speech, and language development of children with DBS are scarce. In this report, we described two cases of DBS with bilateral SNHL who underwent cochlear implantation. The objective of this report is to highlight the performance of those patients after receiving cochlear implants (CI) as a management for their hearing loss.Case 1LRP2 gene mutation, confirming the diagnosis of DBS. At the age of 18 months, her IQ test score was 75. A 14-month-old female child with a history of global developmental delay, dysmorphic features , and amblyopia was referred to our hospital, King Abdulaziz University Hospital, Riyadh, Kingdom of Saudi Arabia, due to delayed speech and language development. She was born to first-degree consanguineous parents and was diagnosed as having bilateral severe to profound SNHL and fitted with bilateral hearing aids at the age of nine months. However, no clear benefits were detected from using hearing aids on follow-ups. Magnetic resonance imaging (MRI) revealed complete corpus callosum agenesis  with no postoperative complications, and complete insertion of the electrode array was achieved. Two weeks later, the device was switched on. One year after implantation, aided audiometry revealed borderline normal to mild hearing range, whereas speech detection threshold (SDT) was 30 dB HL, and the IQ test score was 81. At the age of 46 months, the speech therapist reported overall fair performance. In June 2021, speech and language assessment revealed a LittlEARS® Auditory Questionnaire score of 35/35. This assessment tool is used to reflect the development of auditory behavior in children with CI . In addiCase 2LRP2 gene was detected. The hearing assessment revealed bilateral severe to profound SNHL. Bilateral hearing aids were fitted; however, his aided threshold after six months was moderately severe to severe hearing level range. At the age of 28 months, his IQ score was 84. Computed tomography (CT) and MRI showed bilateral normal cochlea and cochlear nerves. A male child was born in July 2015, full-term, to first-cousin parents. He was the cousin of Case 1 who was referred to our outpatient clinic as a known case of DBS for developmental, speech, and language delay. Genetic analysis confirmed the diagnosis of DBS as a homozygous missense mutation of the The patient was determined to be a candidate for bilateral implantation by the CI committee. At the age of three years and five months, bilateral simultaneous cochlear implantation  was performed. The postoperative x-ray showed that the CI arrays were fully inserted inside the cochlea Figure . Switch-Three months after the switch-on, his parents reported adequate responses at home as the patient started to imitate words and vocalize. One month later, an aided assessment was tried using narrow-band noise and the average threshold was about 40 dB HL with SDT was 40 dB HL. The patient could discriminate three out of the six Ling sounds . One year after implantation, aided conditioned play audiometry revealed bilateral mild hearing range, the speech recognition threshold (SRT) for the right ear was 25 dB HL and for the left ear was 30 dB HL. The data logging was 10 hours/day. At the age of six years (his hearing age was about 31 months), the speech therapist conducted a speech and language assessment, which revealed a LittlEARS® score of 35/35 , the perIn this report, we studied the cases of two cousins with DBS, born from consanguineous marriages. Both patients were found to have global delayed development together with severe to profound SNHL. They did not benefit from using hearing aids, and both were accepted as candidates for bilateral cochlear implantation. Two years after the implantation, they reported improvement of hearing and speech perception, which helped them to attend mainstream schools, and they had not developed sign language. This is consistent with previous reports that showed improvement in verbal communication within two years of receiving implants ,14. LPR2 gene, prenatal genetic counseling is crucial, especially with consanguineous marriage.The difference in the scores of CAP, SIR, and the integrated scale of development between the two cases can be explained by having different levels of preoperative IQ scores, the number of received implants, the presence or absence of corpus callosum agenesis, and being associated with different types of disabilities such as visual impairment . In geneOur results showed that cochlear implantation could be considered as an approach for the management of DBS patients who suffer from bilateral SNHL. CI helped the two cases to restore hearing and to start to acquire language. The present data of the two reported cases provide new insights into the audiological management of DBS as a rare clinical disorder. Early detection and providing multidisciplinary care for those patients could help to provide them a better quality of life.


Objectives: The purpose of this study was to investigate the relationship between speech-frequency hearing loss (SFHL), high-frequency hearing loss (HFHL), and cognitive impairment (CI). Then to determine whether there are any differences in gender among older community dwellers in China. Methods: This study involved 1,012 adults aged ≥60 years . The participants had their hearing and cognition measured using pure tone audiometry and Mini Mental State Examination (MMSE), respectively. We used the audiometric definition of hearing loss (HL) adopted by the World Health Organization (WHO). Speech-frequencies were measured as 0.5 kHz, 1 kHz, 2 kHz, and 4 kHz; high-frequencies were measured as 4 kHz and 8 kHz. Pure tone average (PTA) was measured as hearing sensitivity. Results: Our studies demonstrated a 37.6% prevalence of HL in males and a 36.0% prevalence of HL in females. Adjusted for confounding variables, the results from a multivariate analysis showed that SFHL was associated with CI in females  and males . However, HFHL was associated with CI only in females . HL was associated with poorer cognitive scores (P<0.05). “Registration” (P<0.05) in MMSE was associated with speech and high-frequency hearing sensitivity. Conclusion: The associations between HL and CI varied according to gender in older community-dwellers, suggesting that different mechanisms are involved in the etiology of HL. Moreover, hearing sensitivity was negatively associated with cognition scores; therefore, early screening for HL and CI among older community-dwelling adults is advised.


Association of hearing loss has been found with a couple of febrile illnesses. Dengue fever is an arboviral febrile illness that is transmitted by Aedes mosquito. A case of sensorineural hearing was documented in the literature recently in dengue haemorrhagic fever. We are aiming to find if hearing loss occurs in dengue patients.We assessed the hearing of ten patients diagnosed with Dengue fever from August 2018 to October 2018, prospectively. Patients who had a prior history of hearing loss or chronic suppurative otitis media were excluded from the study. Brief history, clinical examination and audiological assessment were made for all patients. All patients were followed up for three months with repeat audiological evaluation.Two patients complained of hearing loss after the onset of fever. They had a bilateral mild sensorineural hearing loss on audiological evaluation. One other patient was found to have bilateral high-frequency hearing loss although there was no complaint of hearing impairment. On three months follow up, both patients had bilateral mild sensorineural hearing loss with no improvement.Hearing loss in dengue fever, even though being mild in nature is irreversible. The cause of hearing loss in dengue is yet to be found. For the definitive association of hearing loss in dengue fever further studies are required. Dengue is an important arboviral infection affecting humans which results in high morbidity and mortality. It is estimated that 50 million infections per year occur worldwide, across approximately 100 countries . Dengue In Dengue Haemorrhagic fever, the initial symptoms are the same but generally present with worsening of signs on the third or fourth day. Patient presents with agitation, lethargy, tachycardia, hypotension, spontaneous bleeding manifestations, cyanosis and hypothermia ,2,6.Detection of non-structural protein 1(NS1 Antigen) by enzyme-linked immunosorbent assay (ELISA) is sufficient for confirmatory diagnosis . The genA study done in Boston revealed that hearing loss was detected in 63% of patients who were diagnosed to have antibodies against rubella, mumps, varicella-zoster virus, CMV, or influenza. In another Greek study of 262 patients with unilateral sudden hearing loss, only in 27% of patients, there were antibodies against Epstein–Barr virus (EBV), herpes simplex (HSV) type I and II virus, or CMV.There is no definite association of hearing loss proved with dengue in the medical literature. There is only one case report of sensorineural hearing loss associated with dengue haemorrhagic fever in which hearing loss is reported. Association of hearing loss with dengue is an enigma. This paper aims to explore the association of dengue with hearing loss.A prospective study of 10 patients diagnosed with dengue fever was done. Institute ethics committee clearance was obtained prior to start of this study (No. AIIMS/IEC/2018/1423). The patient presented in Department of Medicine with NS1 antigen-positive dengue fever were included in the study from September 2018 to October 2018. After October 2018, due to change in weather we did not get any NS1 antigen positive dengue fever patient. All patients from age 16 to 65 years were included in the study. Patients who had a prior history of chronic otitis media or hearing loss were excluded from the study. We excluded the patients with hypothyroidism, diabetes mellitus and neurological diseases. We also excluded patients with a history of exposure to noise and ototoxic drugs. A brief history, along with clinical examination, including otoscopy and tuning fork test were done as soon as the patients were diagnosed with dengue. A complete audiological evaluation was done, including pure tone audiometry with average of 500Hz, 1000Hz, 2000Hz, Tympanometry, Brainstem evoked response audiometry, and Steady-state auditory response. Baseline evaluation of fever was also done simultaneously, including complete hemogram, serology workup for other febrile illnesses including malaria, chicken guinea, typhoid, scrub typhus etc. Patients who had hearing loss were treated as per standard protocol. Patients were followed up to 3 months with repeat audiological evaluation. The patients were re-evaluated at three months, to confirm hearing loss and to assess the reversibility.Ten patients were included in the study and were assessed prospectively. Following confirmation of dengue with NS1 antigen positivity, patients were analyzed clinically and with the audiological test. The Majority of patients were male (8 out of 10). The mean age of patients was 29 years. The Mean platelet count of patients (lowest) was 50960 per cubic millimetre. The Mean Haemoglobin of patients was 13.6 g/dL. The Mean haematocrit value was 42.35 %. The following table shows the characteristics of patients who were included in the study. Two patient’s complained about hearing loss 2 to 3 days following the onset of fever. On audiological evaluation, both patients had bilateral mild sensorineural hearing loss. Another patient aged 65 years had bilateral high-frequency hearing loss with complaints of tinnitus too. All these findings are overlapping with presbycusis. We may not consider this hearing loss is caused by dengue fever. All other patients had normal hearing sensitivity. All patients had normal tympanometry. Two patients with hearing loss had otoacoustic emissions referred. All patients had normal BERA waveforms. ASSR also corresponded to the findings. Patients who had hearing loss are being summarised belowCase 1The patient was a 50-year-old female who was brought to medicine emergency department with complaints of fever with chills and rigors. The patient was admitted and evaluated and was found to be NS1 antigen positive. She did not give any history suggestive of bleeding manifestations. On serial hemograms, the patient was found to have low platelet counts falling as low as 70000. She complained of bilateral impairment of hearing, two days after the onset of fever. On audiological evaluation, she had mild sensorineural hearing loss both ears. She was treated on high dose steroids in line with sudden sensorineural hearing loss. For dengue fever, she was managed conservatively. On three months follow up, repeat pure tone audiogram was done, which showed no improvement.Case 2The patient was a 30-year-old female who was brought to medicine emergency with complaints of fever for seven days which was associated with chills, rigors, myalgia and headache. She was found to be NS1 antigen positive. She did not complain about any bleeding manifestation but had low platelet counts, as low as 25000. She complained of hearing loss, three days after the onset of fever. On further evaluation, she also had bilateral mild sensorineural hearing loss. She was also treated as per standard protocol for sudden sensorineural hearing loss. On three months follow up, repeat audiogram was done which showed no improvement.Case 3The patient was a 65-year-old male who was brought to medicine emergency with complaints of fever for five days associated with chills, rigors, myalgia and headache. On further evaluation, the patient was found to be NS1 antigen positive. He did not have any prior history of hearing loss before the episode of fever. The patient had low platelet counts, lowest being 65000. On Pure Tone Audiogram, patient was found to have bilateral high-frequency hearing loss. On follow up after three months, repeat pure tone audiogram showed no improvements.Patients with hearing loss had fewer platelet counts as compared to patients without hearing loss. We couldn’t find any relation with temperature/haemoglobin/platelet counts/haematocrit.Patients with mild sensorineural hearing loss were started on neurotropic drugs. On three months of follow up, repeat audiological evaluation showed a similar picture.We could find only one case report, reporting a case of sensorineural hearing loss associated with dengue haemorrhagic fever in literature . Two patThe hearing loss following the onset of dengue fever cannot be ignored. We searched all causes of hearing loss, but only correlated factor was the dengue fever. As our sample size is small, a definite association of hearing loss with dengue fever cannot be confirmed. This study may enlighten further research to clarify the association between hearing loss and dengue fever. As the age range of patients in our study is wide, the possibility of asymptomatic presbycusis cannot be ruled out in two patients. Still, we had one young patient in our study who had hearing loss. Moreover, all three patients complaint about new-onset hearing loss following the onset of fever.We repeated the hearing assessment after three months with a pure tone audiogram in all cases to identify any delayed onset nature of hearing in all patients and if hearing loss is reversible in patients who had hearing loss.There are few viral infections which can lead to hearing loss, for example, mumps and cytomegalovirus. Hearing loss has also been sporadically reported in diseases with flaviviruses, including West Nile virus, Zika virus -12. Scrub typhus is also said to be associated with hearing loss . The heaThe symptoms of dengue haemorrhagic fever are generally non-specific. Patients typically present with high-grade fever with features suggestive of upper respiratory infection. Patients may also present with frontal headache, retro-orbital pain or bleeding manifestation, which may be associated with low platelet count. It seems that symptoms like ear pain 36.6%), vertigo (20%) and tinnitus (6%) may appear in dengue patients .6%, vert. One of The mechanism of hearing loss by different viruses vary. The most popular hypothesis is by direct damage or immune-mediated damage to inner ear structures . The virPatients with hearing loss had low platelet counts too. But still, we cannot establish any correlation based on just two cases. We could not find any relationship with other haematological parameters.We used a battery of investigations to identify the type of hearing loss and to compare and confirm our findings. We considered doing ASSR as it will be beneficial for assessing patients with profound hearing loss .We need to analyze a large sample of dengue patients with a longer follow up to establish the association of hearing loss and dengue and the reason for hearing loss in dengue patients.A couple of febrile illnesses are associated with hearing loss. Dengue is an arboviral febrile illness which may also lead to hearing loss. As we have two patients with dengue who had objective and subjective hearing loss. Still, further studies and long term follow up is required to prove the association of dengue fever with sensorineural hearing. The reason for hearing loss in dengue fever is also unknown and need to be investigated. The patients in our study had no improvement on follow up with pure tone audiogram. It may indicate that the hearing loss in dengue patients may be irreversible. Large sample size has to be analyzed and had to be followed up for a more extended period to establish the same.


Hearing and vision impairments and the use of audio-visual aids are associated with cognitive decline in community-dwelling older people, but effects in long-term care facilities (LFCF) are unclear. We hypothesize that visual and hearing impairment are associated with cognitive decline and these relationships are mediated by using visual and hearing aids.Secondary data analysis of a longitudinal study was conducted in the 7 government-subsidized LTCF operated by one of the largest non-governmental organizations in Hong Kong using data between 2005 and 2016. Eligible residents were ≥ 60 years of age without severe cognitive impairment at baseline who had stayed in the facilities for more than 3 years. All variables were measured by using the Minimum Data Set-Resident Assessment Instrument Version 2.0, Hong Kong version. The outcome was cognitive decline. Predictors were visual and hearing impairments. Mediators were the use of visual and hearing aids. General linear models were employed to test the hypotheses.p = 0.004) and hearing impairments (p = 0.022) had a higher risk of cognitive decline. Using hearing aids  positively mediates the effect of hearing impairment on cognitive decline. Using visual aids  negatively mediates the effects of visual impairment on cognitive decline.Results for 2,233 residents were analyzed, with a mean age of 82.1 ± 8.2 years and a mean follow-up period of 4.4 ± 0.8 years. Results showed that those who had visual impairment (In LTCF, hearing and visual impairments are associated with a higher risk of cognitive decline. Hearing aids often-users were associated with a higher risk of cognitive decline. LTCF residents with visual impairment did not use visual aids. Use of visual aids demonstrated potential effects in slowing cognitive decline. A future study with a larger and more diverse sample with attention to quality of devices is proposed to confirm its effects. Cognitive decline refers to a longitudinal decline in cognitive function . CognitiHearing impairment refers to a reduction in hearing sensitivity that causes difficulty in daily living . It is cHearing aids are common instruments available to older people to improve their audibility, thereby boosting their social interactions and improving their quality of life . HoweverLiterature indicates that hearing impairment significantly predicts cognitive decline, mild cognitive impairment and Alzheimer’s dementia in prospective cohort studies –27; visuAlthough links between cognitive decline, hearing and vision impairment, and hearing aid use were reported in studies, some important knowledge is still missing. First, observations of the promising effect of hearing aids on cognitive function were mostly for community-dwelling older adults. One recent article reported on hearing loss and its impact on residents in LTCFs; however, investigators only reported the effects of cerumen removal on cognitive function . TherefoSensory impairment is associated with cognitive decline, andThe use of audio-visual aids mediates the effect of the sensory impairment on cognitive decline.The objectives of this study are to examine 1) the association between sensory impairment and cognitive decline and 2) the mediation effect of the use of audio-visual aids between sensory impairment and cognitive decline in LTCFs. We hypothesize that:This was a secondary data analysis from the Hong Kong Longitudinal Study on Long-Term Care Facility Residents, in which all residents in 7 LTCFs were repeatedly assessed. The exact period between two repeated assessments could not be precisely controlled because of the availability of the residents  and the availability of certified assessors. The period of two repeated assessments of each resident varied but ranged from 6 to 12 months. In that project, health data were routinely collected from a cohort of Chinese long-term care residents in Hong Kong to review and improve clinical practices in LTCFs. The data were collected between January 2005 and December 2016.The advantage of using regularly collected clinical data for analysis is that it allows dynamic relationships between variables to be examined over time. Secondary data analysis refers to an analysis of data that are collected by someone else for another primary purpose . We follThe study was conducted in the 7 government-subsidized LTCFs, also known as Residential Care Services for the Elderly, operated by one of the largest non-governmental organizations in Hong Kong. Their services include residential care, meals, personal care and limited nursing care for elders who suffer from poor health or physical/mild mental disabilities with a deficiency in daily living activities but who are mentally suitable for a communal living .Only residents in the dataset who fulfilled the following eligibility criteria were selected for analysis:Older people as defined by WHO at age ≥ 60 years at baseline ,Those who had no follow-up data,Those whose baseline cognitive impairment is severe, as defined by a Cognitive Performance Scale score of ≥ 5  , as therThose who have resided in the LTCF for less than 3 years, because the extent of the cognitive decline in 3 years in people without dementia and with early dementia is relatively small  . The Cogρ = 0.85) [r = -0.863, p < 0.001) good criterion validity with MMSE to identify cognitive impairment  [The Minimum Data Set-Resident Assessment Instrument Version 2.0 (MDS-RAI 2.0), Hong Kong version, was utilized as the measurement tool , 47. The = 0.85) , as well85–0.95) .The Vision and Hearing scale have good accuracy to identify hearing loss  and vision loss  compared against performance-based measures , as wellAge, gender, cognitive function at baseline, follow-up year, and related comorbidities were collected to describe residents’ demographic and clinical profiles.Hearing impairment was measured by the item entitled “Hearing” in the section on Hearing Patterns in the MDS-RAI 2.0. Residents’ hearing impairment was quantified to a score ranging from 0 to 3, which was in turn re-coded as a dichotomous variable. No Impairment described being able to adequately hear normal talk, TV, and phone ; Impairment  ranged from having minimal difficulty hearing  to being highly impaired .Visual impairment was measured by the item entitled “Vision” in the section on Vision Patterns in the MDS-RAI 2.0. Residents’ visual impairment was quantified to a score ranging from 0 to 4, which was then re-coded as a dichotomous variable. No Impairment  referred to seeing fine details adequately, including regular or large print in newspapers or books. Impairment  either indicated moderately impaired vision  or severe impairment .Dual sensory impairment was measured by combining the re-coded hearing impairment and visual impairment scores. Residents were categorized as follows: 1) no impairment , 2) one sensory impairment , and 3) dual impairment .The hearing aid use pattern was measured by the item entitled “Communication Devices” in the section on Hearing Patterns in the MDS-RAI 2.0. Residents’ use of hearing aids fell into one of these four categories: a) hearing aid present and used, b) hearing aid present and not used regularly, c) other receptive communication techniques used, and d) none of the above. The use of hearing aids was re-coded into a 3-point categorical variable: 1) hearing aid present and used , 2) hearing aid present and not used regularly , and 3) having no / not using hearing aids .Visual aid use was measured by the item entitled “Visual Appliances” in the section on Visual Patterns in the MDS-RAI 2.0. It is a dichotomous variable. Visual aid use denoted the use of glasses, contact lenses, or magnifying glasses. Not using visual aids referred to not observed with those devices.Cognitive decline was captured by the change in cognitive function from baseline to the last time point of observation . A higher score indicates more severe cognitive decline.Residents’ age and gender were measured at baseline in the database. Cognitive function at baseline, which is associated with the subsequent cognitive decline , and co-IBM SPSS Statistics 25 was utilized to conduct the statistical analysis. Mean with standard deviation and frequency with percentage were used to describe residents’ profiles and related variables in this study. To test hypothesis #1, a univariate general linear model was employed, where cognitive decline served as the dependent variable and hearing impairment, visual impairment, and dual sensory impairment served as the independent variables. To test hypothesis #2, the test of linear moderated mediation using PROCESS macro for SPSS was employed . The depThe authors are team members of the “Well-being and Associated Factors of Vulnerable Populations in Long-term Care in Hong Kong” project, entailing our direct access to the database. After extracting data according to the eligibility criteria, we excluded participants with missing data in any variables involved in this analysis.n = 3,992), had severe cognitive impairment at baseline , had stayed in the facilities for less than 3 years , or were younger than 60 (n = 5). After the exclusion of non-eligible residents, 2,233 were left. All these residents had complete data on every variable in our analysis.As shown in Fig. n = 1,530, 68.5%). The mean Cognitive Performance Scale score at baseline was 1.5 (SD = 1.2); the mean follow-up year was 4.4 (SD = 0.8) years. Most co-morbidities, except hypertension , characterized only a small number of people, including dementia , stroke , and diabetes . A relatively smaller portion of residents had hearing impairment , visual impairment , or dual sensory impairment . Most residents used no hearing aids  and most residents were not using visual aids  at baseline. The mean decline in the Cognitive Performance Scale score from T0 to T1 was 0.4 (SD = 0.8).As shown in Table n = 333, 14.9%) than those who were using visual aids . Residents with hearing impairment, the majority of them were not using hearing aids , a small group of them used hearing aids , and another small group of them had hearing aids but they did not use regularly .As shown in Table p = 0.004). Compared with those who had hearing impairment, those who did not have hearing impairment had less cognitive decline . Compared with those who had a dual sensory impairment, those who had single sensory impairment  and those who had no sensory impairment  had a lower level of cognitive decline.For hypothesis #1, as shown in Table For hypothesis #2, as shown in Table To the authors’ best knowledge, this is one of the very few studies demonstrating the protective effect of visual aids on cognitive decline in LTCFs. It is also among the very few to illustrate the effect of hearing aid use patterns on cognitive decline in LTCFs. In terms of strength, the data in this study were collected by highly trained and accredited healthcare professional assessors in multiple sites in Hong Kong, and there were no missing data for any variable. The key findings of this study are multiple. First, hearing impairment is associated with a higher risk of cognitive decline and the hearing aids users have the worst hearing impairment and higher risk of cognitive decline. Second, visual impairment is associated with a higher risk of cognitive decline and visual aids users have a reduced risk of cognitive decline. We further explained the findings below.th decade of life becomes much more significant  [Residents who often used hearing aids had the most severe hearing impairment. This pattern conveys that in the group of residents who used hearing aids often may still have not adequate restoration of hearing function. This could be because the hearing impairment in this group is caused by central hearing loss which could not be improved with peripheral amplification, such as hearing aids . Anotherer year) . Withouter year) . TherefoIn the literature, reported hearing aids use was associated with slowing down the cognitive decline of older people with hearing impairment in community settings . A heariVisual impairment is associated with an increased risk of cognitive decline and the use of visual aids has the potential to protect residents from cognitive decline. This finding is consistent with previous literature . The senDual sensory impairment is regarded as a risk factor of cognitive impairment . CompareThere are several limitations to this study. First, sensory function was assessed by allowing the residents to see or hear with the aids that they commonly used. Therefore, this measurement did not reflect their capacity. Instead, it was the performance after considering their pattern of utilization of sensory aids. Second, sampling bias was probable since the median length of stay in the LTCF was only 73.4 weeks  . TherefoTo prevent cognitive decline, this study highlighted the importance of providing regular screenings for visual impairment with subsequent visual aids prescription and monitoring of use and function. To ensure hearing aids could improve hearing function, regular objective audibility tests with and without hearing aids and regular hearing aid fitting should be conducted among LTCF residents. Further studies should incorporate hearing aid fitting and objectively assessed hearing function to examine whether hearing aids could restore residents’ audibility adequately. Also, further studies should examine why the LTCF residents with visual impairment did not use visual aids. Routine screening and monitoring of visual and auditory impairment and resident function might potentially change their quality of life and caregiver burden.


This ability for mlh3 alleles to complement the loss of Pms1 suggests that an ancestral Pms1/Mlh3 protein was capable of performing both MMR and crossover functions. Our strategy for analyzing MLH pathway specificity provides an approach to understand how paralogs have evolved to support distinct cellular processes.Baker’s yeast contains a large number of duplicated genes; some function redundantly, whereas others have more specialized roles. We used the MLH family of DNA mismatch repair (MMR) proteins as a model to better understand the steps that lead to gene specialization following a gene duplication event. We focused on two highly conserved yeast MLH proteins, Pms1 and Mlh3, with Pms1 having a major role in the repair of misincorporation events during DNA replication and Mlh3 acting to resolve recombination intermediates in meiosis to form crossovers. The baker’s yeast Mlh3 and Pms1 proteins are significantly diverged , suggesting that an extensive number of evolutionary steps, some major, others involving subtle refinements, took place to diversify the MLH proteins. Using phylogenetic and molecular approaches, we provide evidence that all three domains  in the MLH protein family are critical for conferring pathway specificity. Importantly,  Gene duplications, occurring through events such as polyploidization or unequal crossing over, can create new gene families that play important roles in adaptive evolution . In bakeMMR is a highly conserved mechanism that reduces the genome mutation rate through the action of MutS homolog (MSH) proteins that bind to base–base and insertion/deletion mismatches that form as the result of DNA replication errors . MSH recognition of mismatches results in the recruitment of the Mlh1-Pms1/PMS2  endonuclease, which is activated through interactions with MSH proteins and the DNA replication processivity factor PCNA to nick the newly replicated daughter strand, leading to excision and resynthesis steps that maintain the original template information  formation? Crossing over of parental homologs during meiotic prophase facilitates their segregation during the Meiosis I division. In the absence of at least one crossover event per homolog pair, nondisjunction events occur at high frequency, leading to the formation of aneuploid gametes . In bakeMLH3 that expanded its MMR specificity without disrupting its role in meiotic crossing over. This combination of approaches provides a strategy to understand how organisms have evolved paralog complexes with distinct cellular functions.We asked if regions of Pms1 and Mlh3 could be identified that confer their functional specificities and if this information could be used to alter Mlh3 to make it a more robust MMR factor. Our work is based on a phylogenetic analysis indicating that Mlh1 homologs initially diverged from an MLH ancestor, followed by a splitting into Pms1 and Mlh3 sister groups. As described below, these efforts provided evidence that all three functional domains of the MLH proteins  have evolved for gene specialization. Importantly, a small number of mutations were created in Saccharomyces cerevisiae SK1 and S288c strains were grown at 30°C in either yeast extract-peptone-dextrose media or minimal selective media  of constructs was confirmed by Sanger DNA sequencing (Cornell BioResource Center). Oligonucleotides and sequences of plasmids are available upon request.SK1MLH3 and SK1PMS1 sequences were derived from pEAI254, a 7.8 kb SK1MLH3::KanMX integrating vector . The Block mutation vectors were derived from pEAM168, a 10.7 kb SK1MLH3::KanMX 2µ vector, fragments of which were isolated to integrate mlh3 alleles . The MLH3 and PMS1 boundaries in the chimera plasmids were chosen based on structural and homology model analyses of MLH proteins that yielded three distinct regions; an ATP-binding domain, a linker region, and C-terminal endonuclease/MLH interaction domain . For Mlh3, these domains were: ATP binding, aa 1 to 375; linker, 376 to 488; C-terminal endonuclease, 489 to 715. For Pms1, the domains were: ATP binding, aa 1 to 361; linker, 362 to 638; C-terminal endonuclease, 639 to 877 (SK1). The chimera constructs were assigned the following abbreviations: PMM [Pms1(1-361)-Mlh3(376-488)-Mlh3(489-715)]; MMP [Mlh3(1-375)-Mlh3(376-488)-Pms1 (639-877)]; PPM [Pms1(1-361)-Pms1(362-638)-Mlh3(489-715)]; MPP [Mlh3(1-375)-Pms1(362-638)-Pms1(639-877)]; PMP [Pms1(1-361)-Mlh3(376-488)-Pms1(639-877)]; MPM [Mlh3(1-375)-Pms1(362-638)-Mlh3(489-715)].Mlh3/Pms1 chimera integration vectors containing mlh3 Block mutations were constructed using NEB HiFi DNA Assembly cloning and/or Q5 site-directed mutagenesis kits . The integration plasmids were digested with BamHI and SalI prior to transformation into EAY3255 using methods described by MLH3/PMS1 chimera and Block mutation alleles (SK1 background) were also expressed from the native MLH3 promoter on 2µ LEU2 plasmids or on ARS-CEN HIS3 plasmids. pEAI254 (SK1::KanMXMLH3), pEAM168 , pEAM65 , and pEAA636  were the parental plasmids for these constructs. These plasmids were tested for complementation of MMR defects in the S288c strain EAY3097 .14lys2::insE-A allele to measure mutation rate (wild type), EAY3255/EAY3486 (mlh3Δ) and EAY3255::mlh3 alleles/EAY3486 diploids contain spore-autonomous fluorescence markers to measure meiotic crossing over in the CEN8-THR1 interval  was used to determine if mlh3 alleles (SK1 background) expressed on 2µ and ARS-CEN vectors could restore MMR functions in pms1Δ strains (mlh3Δ) was used to show that the SK1 derived MLH3 gene fully complemented the MMR defects seen in the strain.The SK1 strains EAY3252, EAY3255, and EAY3486 and indicated derivatives were used to measure Mlh3-dependent meiotic crossing over and MMR functions (Supplementary Table S2). EAY3255 and derivatives contain the  strains . The S2814lys2-A reversion assay  where f is the reversion frequency and N is the total number of revertant in the culture ]. Two to three independent transformants were measured per allele on at least two different days to prevent batch effects. In this assay, wild-type SK1 S. cerevisiae strains gave single crossover events at 37.1% frequency, whereas mlh3 null strains gave single crossover events at 18.3% frequency (http://vassarstats.net/) was used to test statistical significance to classify each allele as exhibiting a wild type, intermediate, or null phenotype. We applied a Benjamini–Hochberg correction at a 5% false discovery rate to minimize α inflation due to multiple comparisons .Diploids in the EAY3252/EAY3486 background (Supplementary Table S2) were used for analysis of meiotic crossing over phenotypes. These diploids contain a spore-autonomous fluorescent protein marker (CFP) linked to requency . A PearsHomo sapiens, Coprinopsis cinerea, Arabidopsis thaliana, S. cerevisiae, and Dictyostelium discoideum . Escherichia coli MutS and B. subtilis MutL were used to potentially root the tree. Twenty-nine Mlh3, 34 Pms1, 18 Mlh2, and 33 Mlh1 proteins were analyzed in the tree analysis. A gene missing from a particular species does not necessarily indicate gene loss in that species but could reflect incomplete genome sequencing or other bioinformatic difficulty in locating the orthologous sequence. To decipher relationships between MutL homologs, amino acid sequences from the entire open reading frames of the Mlh1, Mlh2, Pms1, and Mlh3 proteins were aligned in SeaView .The 18 species included for the evolutionary rate covariation (ERC) analysis were: parately . ERC valparately  with modB. subtilis MutL and a subset of MLH homologs  were used for multi-Harmony analysis  were repeated on at least two separate days. The Supplementary figures and tables can be found in the GSA Figshare portal: https://doi.org/10.25387/g3.14367533.Strains and plasmids are available upon request. Supporting information contains all detailed descriptions of Supplemental files. All experiments presented , Opisthokonts (fungi/metazoa), and Amoebozoa. Note that although the MLH families were well resolved, the branching order of the taxonomic lineages was not well resolved within each family because of insufficient alignable sequence in the paralogs.To better understand how the Mlh3 and Pms1 proteins diverged, we performed two phylogenetic tree analyses of homologs of the MLH paralogs. The first was performed with a diverse set of eukaryotic lineages , with the goal of estimating when Materials and Methods; Kluyveromyces and Saccharomyces clades. The identification of Mlh1, Mlh2, Mlh3, and Pms1 homologs in both clades confirms that Mlh1, Mlh2, Mlh3, and Pms1 predated the whole-genome duplication event , because outside of the genus Saccharomyces the synonymous sites are saturated. The data also suggest that Mlh1 remains under stronger constraint relative to Mlh3, which is curious because Mlh1 and Mlh3 are hypothesized to be coevolving as measured by ERC analysis  and Mlh3 (resolving recombination intermediates into crossovers) to act in meiotic recombination is an alternative explanation. It is difficult to make a definitive conclusion on this point because the events are ancient. Estimating selective pressure during that ancient divergence is challenging . With this new method, we see similarly significant ERC signals between Mlh1 and Mlh3, and Mlh1 and Pms1 (P < 0.05). Elevated ERC signals (P ≤ 0.03) were seen between the individual Mlh3 domains as well as between the three Mlh3 domains and the Pms1 linker. They were also seen between the Mlh1 N-terminal and the Mlh3 N-terminal, Mlh3 C-terminal, and Pms1 linker domains. Finally, an elevated ERC signal was seen between the Pms1 N-terminal and Pms1-C-terminal domains. These observations do not show a specific pattern of signals between specific domains of MLH proteins but are consistent with structural studies indicating that ATP-dependent conformational rearrangements involving the linker regions of the MLH proteins are important for the positioning of the two N-terminal MLH domains and bound DNA near the endonuclease active site in the C-terminus , linker, and endonuclease/MLH interaction  domains of Mlh1, Mlh3, and Pms1 using 18 yeast species . We measured meiotic crossing over using a spore-autonomous fluorescence assay to measure percent tetratype at the CEN8-THR1 interval  and assessed for their ability to complement Mlh3’s major function in crossing over and minor function in MMR . The endunctions  and 2. AMLH3 that affected its MMR and meiotic crossing over functions. Such substitutions might also allow Mlh3 to partially replace Pms1 MMR functions (see below). We performed this analysis recognizing that the divergence of Mlh3 and Pms1 is an ancient event, and any changes in specificity would be informative as refinement of protein function would likely require large numbers of changes over a long evolutionary time scale.Our inability to identify domains in the MLH proteins that conferred functional specificity encouraged us to perform a more targeted approach. Because Mlh3 plays a minor role in MMR, and Pms1 does not act in dHJ resolution, we thought that our best opportunity to study the specificity of the MLH proteins was to make substitution mutations in Materials and Methods; We used multi-Harmony analysis as a targeted approach to identify residues in Mlh3 and Pms1 required for MMR function. Multi-Harmony uses multiple sequence alignments between subfamilies of proteins, homology models, and multi-Relief and sequence-Harmony algorithms to identify amino acids that may suggest functional specificity  allele conferred an intermediate phenotype in the mutation rate assay (2.20-fold higher than wild type) but did not affect meiotic crossing over.The mlh3-Block2 (Mlh1 interaction) alleles conferred intermediate phenotypes in both the mutation rate assay (1.68- to 3.68-fold higher than wild type) and meiotic crossing over , but with one allele (mlh3-K502G) conferring a more severe defect in the meiotic crossover assay.The mlh3-Block3, 5, 6 (Mlh3 endonuclease motifs) alleles conferred intermediate to severe phenotypes in both mutation rate and meiotic crossover assays, with some alleles conferring a more severe defect in one assay vs the other. It was interesting to see a more severe defect for the Block 3 mlh3-R530K, R532N double mutation compared to the single mutations , indicating important roles for the two residues in Mlh3 function.mlh3-Block4 mutant alleles were created. mlh3-Block4-PIP1 contains the yeast Pms1 PIP motif (QKLIIP) and mlh3-Block4-PIP2 contains just the three critical consensus residues (QTFIAP), with the other residues derived from Mlh3 . The mlh3-Block4-PIP2 mutation complemented Mlh3 functions in both MMR and meiotic crossing over, whereas mlh3-Block4-PIP1 conferred an intermediate defect in both assays . These observations encouraged us to perform the detailed analysis of the PIP motif described below.Two Our observations confirmed that regions of high conservation specific to the Mlh3 family were critical for Mlh3 function; every Block substitution group conferred defects in MMR and meiotic crossing over, though with different phenotypic strengths. Also, the finding that some Block mutations differentially affected Mlh3 MMR and meiotic functions is consistent with the previous identification of Mlh3 separation of function mutations that may disrupt interactions with specific pathway components .mlh3-Block1-6 alleles could complement Pms1 MMR functions . As shown in mlh3-PIP1 and PIP2 alleles expressed on an ARS-CEN vector could complement the pms1Δ mutator phenotype. As shown in mlh3 allele complemented the pms1Δ mutator phenotype.The studies presented in unctions . We firsmlh3-PIP1 and -PIP2 alleles to complement the pms1Δ mutator phenotype encouraged us to express mlh3 alleles through the MLH3 promoter on a high copy 2µ LEU2 pRS derived vector. We were encouraged to overexpress the mutant proteins because an analysis of multiple protein abundance data sets , but this rate was still significantly lower than seen in pms1Δ strains (6320-fold). This was not a surprise as we had shown previously that robust overexpression of MLH3 through a GAL10 promoter conferred mutation rates in a wild-type strain similar to that seen in pms1Δ, most likely by sequestering Mlh1 from interacting with Pms1 , whereas mlh3-Block2, 3, 5, 6 alleles and the six chimera constructs did not. The failure of the mlh3-Block4-PIP1 allele, which contained the complete PIP consensus, to suppress the pms1Δ MMR defect suggested that the suppression seen with mlh3-Block4-PIP2 was not due to Mlh3 being able to interact with PCNA in MMR. To better understand if a canonical PIP motif was important for this improved complementation, we made a total of nine substitutions in the Mlh3 GTFVAR sequence . The finding that mlh3-PIP5 (QTFIAR) and mlh3-PIP9 (QTFVAR) strains  maintained modest complementation (2.1- to 2.7-fold lower mutation rates) whereas the mlh3-PIP1 strain did not, provided the most relevant data suggesting that the improved MMR functions in the mlh3-PIP2 strain were unlikely due to the creation of a PCNA interaction. The other substitutions, which were focused on introducing one, two, or three conserved PIP residues into the Mlh3 GTFVAR sequence were not especially informative because none of them improved MLH3 MMR functions . Together, these findings suggest that the addition of a functional PIP motif was unlikely to explain the improved MMR phenotype seen in mlh3-Block4-PIP2, -PIP3, and -PIP5. In addition, they do not address whether the mlh3-PIP proteins are directly interacting with PCNA, or if a structural change induced by the insertion of this motif alters its endonuclease activity in vivo to be more similar to that seen with Mlh1-Pms1.As shown in mlh3-Block1 and mlh3-Block4-PIP2 alleles could be enhanced or maintained in combination with other mlh3 alleles. As shown in mlh3-Block1, Block4-PIP2 double mutation complemented the pms1Δ MMR defect as well, if not slightly better than the mlh3-Block1 or mlh3-Block4-PIP2 mutations alone. Double-mutant combinations that included mlh3-Block4-PIP2 and alleles that did not, or only weakly affected MLH3 function  displayed mutation rates similar to the mlh3-Block4-PIP2 mutant alone. However, other hypomorph mlh3 alleles , disrupted the ability of mlh3-Block4-PIP2 to suppress the pms1Δ MMR defect. It was interesting to see that the severe mlh3-R530K, R532N and mlh3-Block6 mutations disrupted mlh3-Block4-PIP2 complementation, consistent with the idea that Block mutations that could not complement mlh3Δ and pms1Δ functions were deleterious for all MLH functions. Together, these observations indicate that multi-Harmony is a valuable approach to identify residues outside of consensus motifs that are critical for specificity of subsets of protein family members. The finding that substitutions located in both the ATP-binding and endonuclease domains of Mlh3 and Pms1 could alter Mlh3 specificity supports ERC analysis indicating that multiple domains across the MLH proteins are co-evolving to provide specificity. It is also of interest because the N-terminal domains of Mlh1 and Pms1 were shown to independently bind to double-stranded and single-stranded DNA  displayed partial complementation of Pms1 MMR functions yet maintained Mlh3 meiotic crossover functions (MLH genes resolves conflicts seen for an ancestral gene that performs both functions. However, our findings suggesting that the specialization of Mlh3 functions could be partially reversed appears less consistent with the DDC model, which proposes that neutral degenerative mutations occur in each duplicated gene that complement each other.Two models were presented in the unctions , suggestunctions . Our obsin vivo as was seen for the modest complementation that we observed for the mlh3 Block 1 and 4 alleles. Our work complements a recent study, which examined the evolution of factors that act in vegetative and meiotic functions. In baker’s yeast, the Rad51 and Dmc1 strand exchange proteins, which share ∼50% amino acid identity and are thought to evolve from a single-gene duplication of an ancestral recombination protein, play critical roles in promoting homologous recombination [reviewed in mlh3 alleles with significantly improved functions in the PMS1 MMR pathway. When we started this work, we recognized that making mlh3 alleles with altered specificity would be challenging because Mlh3 and Pms1 work with a multitude of other proteins in their respective meiotic and MMR pathways [reviewed in MLH3 by only making a small number of amino acids changes. More extensive changes could be made, for example, by using advanced computational modeling approaches. Such methods could be used to identify an ancestral state of Mlh3 capable of acting more efficiently in MMR (see reviews by mlh3 alleles that counter a strong selection such as conferring viability in pms1Δ pol3-01 haploids that are inviable due to high mutational load (REC8 and in other genes that conferred viability in vegetative growth when the meiotic kleisin Rec8 was expressed in the absence of the vegetative paralog Scc1.Our study raises the question of whether it would be possible to identify


Pulmonary mucormycosis caused by Mucorales is a highly lethal invasive fungal infection usually found in immunocompromised patients. Isolated pulmonary mucormycosis in immunocompetent patients is very rare. Here, we present a case of a 32-year-old male who developed pulmonary mucormycosis without any known immunodeficiency.Absidia. His symptoms were relieved with the use of amphotericin B, and he eventually recovered. We also provide a systematic review of relevant literature to summarize the characteristics of pulmonary mucormycosis in immunocompetent patients.The patient presented to our hospital because of cough and chest pain along with blood in the sputum. He was first treated for community-acquired pneumonia until bronchoalveolar lavage fluid culture confirmed the growth of Pulmonary mucormycosis has variable clinical presentations and is difficult to identify. Due to its high fatality rate, clinicians should make judgements regarding suspected cases correctly and in a timely manner to avoid misdiagnosis and delayed treatment. Absidia, Rhizopus, Rhizomucor, Mucor, and Cunninghamella, among others, fungi that can invade the nose, sinuses, brain, gastrointestinal tract, skin, and lung or even disseminate throughout the body [Absidia, Rhizopus, and Rhizomucor are the most common types of Mucorales isolated from patients with mucormycosis. Mucorales species are ubiquitous saprophytes, and soil is believed to be the main habitat of most of these fungi. The sporangiospores released by Mucorales range from 3 to 11 µm in diameter and can be aerosolized to disperse in the environment, leading to an airborne infection in the upper or lower airways [Mucormycosis is an opportunistic infection caused by Mucorales, including the body . Absidia airways .Pulmonary mucormycosis is the third most common presentation of mucormycosis and is known for its aggressive clinical course, with a mortality rate of over 50% . This hiAbsidia  is most likely to affect the skin and subcutaneous tissue. Absidia can also invade the lung, causing pathological alterations characterized by vascular invasion, thrombosis, and tissue necrosis [Absidia in an adult male with no known immunodeficiency and provide a systematic review of the relevant literature to summarize the characteristics of pulmonary mucormycosis. We hope that this case will help clinicians identify pulmonary mucormycoses as early as possible, especially in immunocompetent patients, to improve therapeutic efficacy and prognosis.As one of the most common pathogens of mucormycosis, necrosis . Herein,A 32-year-old male presented to our hospital in January 2018 because of cough and chest pain along with blood in the sputum. His chest pain was on the right side and was significantly aggravated by deep breathing. The above symptoms started after he became chilled 5 days prior and were exacerbated without obvious inducements 2 days prior. After receiving anti-infection treatment in the outpatient department for 2 days with little improvement, he was admitted to our hospital for further diagnosis and treatment.9/L ; neutrophil%: 87.1% (RI: 40.0–75.0%); lymphocyte%: 10.2% (RI: 20.0–50.0%); hypersensitive C-reactive protein: 92.9 mg/L (RI: < 1 mg/L); D-dimer: 1.37 µg/ml (RI: < 0.5 µg/ml). Influenza and parainfluenza IgM antibodies were tested, and the results were negative. No obvious abnormalities were found on an electrocardiogram or for the rheumatic immune system, routine urine and liver function, electrolyte or renal function. Fibreoptic bronchoscopy and sputum smear did not show any abnormalities. Chest CT imaging suggested pulmonary infection with pleural effusion  using the following search terms: ("Rhizopus" OR "Rhizomucor" OR "Lichtheimia" OR "Absidia" OR "Mucor" OR "Mucormycosis" OR "Zygomycosis") AND ("pulmonary” OR “lung"). Only studies published in English between 1 January 2010 and 10 October 2020 were reviewed as primary screening. We included studies reporting patients diagnosed with pulmonary mucormycosis based on EORTC/MSG criteria 2018 ; studiesFourteen articles describing 15 patients were eventually included and analysed –22. The Almost all cases were diagnosed through bronchoalveolar lavage culture 50%, 6/12) or histopathologic examination of biopsy ; the remaining case was confirmed by autopsy. All confirmed patients with fungal infection received antifungal drugs, with an overall mortality rate of approximately 43% (6/14). Almost all patients  were treated with amphotericin B. A total of 12 patients received amphotericin B alone, with a mortality rate of 50% (6/12). In two cases, amphotericin B along with caspofungin or voriconazole achieved remarkable antifungal efficacy. Additionally, one patient received oral posaconazole alone as antifungal therapy; however, he eventually died of respiratory failure. We also found that two patients who underwent surgery both had encouraging outcomes, with symptom the alleviation. The mortality rate of pulmonary mucormycosis in our review  was lower than that reported previously  [2 or histNotably, two of the patients included in the review experienced liver failure with decompensated disease: one had acute liver failure, and the other had hepatic cirrhosis. Acute liver failure (ALF) shares similarities with septic shock and has the characteristics of systemic inflammation and functional immunoparesis . The perMucormycosis is an acute, progressive, and fatal disease that can affect people of almost all ages. Host immunosuppression appears to be the most critical risk factor for susceptibility to mucormycosis. Diabetes is also considered to be an important risk factor, as it will significantly reduce immune system function and increase the risk of various infections , 25. CliAbsidia. A continuously rising D-dimer level and CT image presentation hinted at pulmonary embolism of unknown cause in this case. The manifestation of pulmonary embolisms caused by Rhizopus infection has also been reported by autopsy in a previous case [Our patient was a 32-year-old man with symptoms of cough, chest pain, and haemoptysis. Considering that he did not have any of the afore-mentioned risk factors, we initially suspected that he may have community-acquired pneumonia or tuberculosis until bronchoalveolar lavage fluid culture confirmed the growth of ous case . In routous case . Nonetheous case . Remarkaous case . TherefoWe speculate that our patient became infected by inhaling dust carrying spores due to his job as a warehouse keeper and his dust exposure history. Similarly, a previously reported patient from the United Kingdom who was a civil engineer with occupational exposure to soil and decaying plant matter developed rhinofacial mucormycosis. In fact, very few cases can be accurately traced back to the source of infection and the route of transmission due to widespread nature of saprophytes and their spores . NeverthIn general, non-specific symptoms such as fever, cough, dyspnoea, haemoptysis and chest pain are the most common clinical manifestations in patients with pulmonary mucormycosis. The variable presentations make it difficult for doctors to distinguish pulmonary mucormycosis from other pulmonary diseases. Furthermore, fiberoptic bronchoscopy and sputum smear were prone to miss the detection of fungal infection. The definitive diagnosis of pulmonary mucormycosis should rely on the identification of typical hyphae through bronchoalveolar lavage culture, needle biopsy, and resected lung tissue biopsy . HoweverAbove all, pulmonary mucormycosis is an opportunistic infection caused by Mucorales. Such fungal infection mainly occurs in patients with immune system deficiency, though it can rarely attack immunocompetent patients. Due to its high fatality rate, clinicians should make judgements on suspected cases correctly and in a timely manner to avoid misdiagnosis and delayed treatment. Early diagnosis of pulmonary mucormycosis remains a clinical challenge due to the lack of specific clinical manifestations. First, it is essential for clinicians to keep in mind that pulmonary mucormycosis might occur in patients with normal immune function, especially when routine anti-infective treatments fail. Second, clinicians should be cautious with the occurrence of pulmonary embolism in patients with signs of lung infection. Third, it is important to carefully review the exposure history. Here, we present an immunocompetent case and summarize the characteristics of patients with pulmonary mucormycosis with normal immune function in the literature. We aim to provide a wide range of ideas for clinicians during diagnosis and to prevent delayed diagnosis and treatment or even misdiagnosis for such immunocompetent cases to ultimately improve the prognosis and decrease the risk of death.


Conclusion: This study shows that aminoglycoside therapy for tuberculosis may contribute to hearing impairment among tuberculosis patients in Ghana. Audiological management of these patients should therefore be an essential part of their therapeutic treatment plan.Background: Hearing impairment (HI) is a major problem in Ghana; however, the few attempts at shedding light on its causes appear to overlook the adverse effects of some medications—a gap that this study sought to fill. Aminoglycoside therapy for tuberculosis (TB) treatment is one of these medications. Aim: The aim of this study was to establish the potential of aminoglycoside as a cause of hearing impairment among patients on anti-TB treatment. Method: This was a case–control study, involving patients receiving treatment for TB with aminoglycoside at the chest clinic of the Tema General Hospital and a control group of age- and gender-matched healthy volunteers. A structured questionnaire was administered to obtain the demographic data and case history of the participants. The hearing sensitivity of the participants was assessed using conventional pure tone audiometry and transient evoked otoacoustic emission tests. Results: A hearing loss prevalence of 20% (12/60) was found among patients receiving treatment for TB, with the intensity of impairment ranging from mild to severe. Hearing thresholds of patients receiving anti-TB medications were significantly elevated ( Hearing impairment (HI) is one of the notable disabling conditions of significant global health concern that can have a detrimental effect on a country’s socio-economic development, if not addressed properly. According to the World Health Organization (WHO) , unless This is evident in Ghana, where a report from Komfo Anokye Teaching hospital (KATH) showed that there is an overall increase in the number of patients with hearing loss who visited the hospital between 1999 and 2004 . In AccrEven though HI is unquestionably a public health problem, there appears to be little effort to investigate it in Ghana. There are currently no comprehensive studies on the genetic and environmental etiologies, classification, and burden of HI on Ghana, with only little evidence existing on HI in patients receiving ototoxic treatments in Ghana. For example, in a community-based survey among children in peri-urban Kumasi, Larsen-Reindorf et al.  concludeRecent studies in the field of HI in Ghana, which tried to identify malaria and sickle cell disease as possible causes of HI in children, suggested that sickle cell disease is not a likely cause of HI or delay in speech in children . Severe The World Health Organization (WHO) reports that, globally, an estimated 10.4 million people acquired tuberculosis (TB) in 2016 , with GhThe treatment of TB and MDR-TB is largely dependent on the simultaneous administration of multiple antibiotics, including aminoglycosides such as streptomycin and rifampicin. For decades aminoglycosides have been added to other antibiotics for TB therapy because they have been found to be effective. Like most drugs, however, aminoglycosides have been on record to have ototoxic effect on users, which leads to hearing impairment ,12,13. OThis side effect has been reported to influence non-compliance and non-adherence to TB therapy ,15. ThisIn many jurisdictions, the effect of aminoglycosides on hearing has been well documented ,12,13, aIt is critical, therefore, that this study was conducted, to help identify and document the prevalence of aminoglycoside-associated hearing impairment in study patients who had previously demonstrated no indications of hearing loss before the treatment. It was therefore hypothesized that there will be a significant difference between the hearing thresholds of patients receiving treatment and those not on therapy in the high frequencies. Secondly, it was hypothesized that there will be a significant association between TB therapy and elevated hearing thresholds.This was a case–control study  design involving 60 consenting patients receiving aminoglycoside treatment therapy (streptomycin and rifampicin) for TB at the chest clinic of the Tema General Hospital (case) and a control group of 60 age- and gender-matched uninfected volunteers.Patients on TB treatment for less than a month, those presenting with ear infections, and those with history of ototoxic medications within the last 3 months were excluded from the study. The study was conducted at the Chest and Otolaryngology  clinics of the Tema General Hospital. Only participants who consented to partake after extensive explanation concerning the objectives and significance of the study were enrolled. A structured questionnaire was administered to gather key patient information such as the demographics and clinical histories, including case history information and HIV–AIDS comorbidity.Participants had their ears preliminarily assessed for abnormalities such as for signs and presence of foreign bodies, tympanic membrane perforation, impacted wax, obstructions in the external ear canal, and collapsed ear canals.Using a calibrated Otovation Amplitude T3 Diagnostic PC-based audiometer with EAR 5A inserts and Radiocar B-71 bone conductor, the conventional (250–8000 Hz) Puretone Audiometry (PTA) was conducted on all participants who underwent and passed otoscopic examination. Functional inspection, daily biological calibration, and performance checks were done on the audiometer. With the appropriate insert ear tip size, study participants were fitted with the insert earphone. Testing began in the better hearing ear (according to the participants’ account) at 30 dBHL at 1000 Hz, using an ascending approach. Next, 2000 Hz, 3000 Hz, 4000 Hz, 6000 Hz, 8000 Hz, 500 Hz, and 250 Hz were tested in that order. To validate the threshold, testing was redone at 1000 Hz. The contralateral ear was tested using the same order except that 1000 Hz was not retested to validate the thresholds.The tests were conducted using standard audiometric procedures . With boThe degrees of hearing loss across subjects were determined using the pure-tone average of the air conduction thresholds of subjects at 500 Hz, 1000 Hz, and 2000 Hz. They were classified using the commonly used modification of the combination of the Goodman (1965) and Clark (1981) classifications . Normal The status of the hair cells in the cochlea of participants was assessed using the Echo-screen TS SET transient-evoked otoacoustic emissions (TEOAE) test. In brief, a probe with a miniature loudspeaker and a microphone was inserted into the ears of the participant. A click or tone burst stimulus was applied to the participant’s ears via the loudspeaker in the probe. The cochlea then responds to the acoustic stimulus by generating sound waves that are then picked up, measured, recorded, and analyzed by the microphone in the probe. The outcomes were categorized into “pass” or “refer” depending on the integrity of the cochlea, based on the criteria described in p < 0.05. All statistical analyses were conducted using Statistical Package for Social Sciences (SPSS), version 20.Data from study were preliminarily described as percentages and frequencies to determine the prevalence of the condition. A Chi-square test was performed to reveal any association between the exposure to TB medications and the auditory thresholds between the two groups. Statistical significance was defined as This study enrolled TB-infected individuals and TB is known to be highly infectious; thus, this study adhered to stringent safety measures, as recommended by Kemp and Bankaitis , to curbA total of 120 study participants was enrolled in the study. This was made up of the treatment group (n = 60) and control group (n = 60), aged between 18 and 50 years with mean ages of 37.97 years and 34.17, respectively. The minimum age of the participants enrolled in the study was 18 years whilst with the maximum was 50 years. Participants within the age range of 40–50 years were the most prevalent in the treatment group , whilst the least prevalent  was the age bracket of 18–29 years . For theIn the treatment group, new cases of TB were the most prevalent  compared to retreatment cases  . The lasIndividual audiograms for participants are presented as spaghetti plots for the right and left ears in The OAE results for the participants in the treatment and control groups are displayed in p < 0.05) from the control group with respect to the mean hearing thresholds at the high frequencies  in the two ears. The mean hearing threshold of the treatment group was greater than that of the control group at the 0.05 level of significance. The breakdown of the independent t-test on the mean differences between the treatment and control groups is presented in Differences in the means of the treatment and control groups were tested using an independent t-test. Statistically, the treatment group differed significantly , as presented in For the association between the audiometry findings and exposure to TB medications, a Chi-square test was performed. The results revealed a statistically significant association between abnormal audiometry findings and exposure to TB medications (χDespite hearing impairment (HI) clearly being a public health issue, there seems to be just some modest effort to study its causes in Ghana. Contrary to the situation in Ghana, in many jurisdictions, the effect of aminoglycosides on hearing has been well documented ,12,13, aThe present study showed a hearing impairment prevalence of 20% among patients on aminoglycosides treatment. The proportion of patients who had their hearing affected in this study is consistent with the findings reported in other studies conducted all over the world. These included findings such as 18.75% reported by Duggal and Sarkar ; 36.83% The occurrence of hearing impairment among patients on aminoglycosides treatment is backed by studies that have described evidence of the presence of aminoglycosides in the inner ear ,30,31. AThe high prevalence of hearing loss reported among TB patients undergoing treatment in this study can be attributed to the fact that 50% of the patients presented with hearing loss were also TB–HIV co-infected. This finding is consistent with findings from a study by Harris et al. , who estA significant proportion of the patients who initiated TB treatment presented with poor hearing thresholds in this study. This finding is consistent with works by Törün et al. , Gülbay The poor thresholds reported in this study were all bilateral and evident in the high frequencies, which is consistent with findings by Sagwa et al. , NizamudThe poorest hearing thresholds in this study were recorded by patients on an anti-TB regimen since the mean and standard deviations of the AC thresholds of the treatment group were higher than in the controls. This result is consistent with findings from a study conducted by Brits et al. , who comHigher hearing threshold differences were recorded in the higher frequencies than in the lower frequencies between the treatment and control groups. Aminoglycoside-induced hearing loss has been observed with a distinct pattern, which shows the high frequencies (4000–8000 Hz) being affected first with the lower frequencies affected later . In thisIt was hypothesized that there will be a significant difference between the hearing thresholds of patients receiving treatment and those not on therapy in the high frequencies. This hypothesis was supported by the data collected. Differences with respect to hearing thresholds in the group means were noted in all frequency categories. However, the differences that were statistically significant were found between the treatment and control groups in the high frequencies. This hypothesis is consistent with the findings from a study conducted by Brits et al. , who repThe study also revealed a significant elevation in the hearing thresholds of the single and multiple treatment groups compared to those of the controls. However, there were no significant differences in the mean hearing threshold of TB patients on treatment and uninfected persons in the low frequency categories. In addition, Brits et al.  also repp < 0.05) between the treatment group and OAE referral. All the patients referred in the OAE and who also demonstrated hearing loss of varying degrees were found to be in the treatment group and also undergoing therapy. Another test of association conducted to explore the association between the audiometry findings and exposure to TB medications also reported a statistically significant association between the abnormal audiometry findings and exposure to TB medications. The second hypothesis stated that there will be a significant association between aminoglycosides therapy and elevated hearing thresholds. This was also supported by the data collected. A test of association between hearing status and the two group revealed a statistically significant association (These results are consistent with findings from studies conducted by Duggal and Sarkar , Sagwa eThis study has shown that aminoglycoside therapy for tuberculosis may play a role in HI in Ghanaian patients. The study revealed elevated hearing thresholds among the patient’s receiving treatment for TB as compared to the controls. The patients presented with various degrees of hearing losses and this finding is consistent with findings from studies that have been conducted in other parts of the world. This study based on outcomes obtained concluded that patients on aminoglycoside therapy are more likely to end up with significant hearing impairment due to the side effects of the treatment regimen. Audiological management of these patients should therefore be an essential part of their therapeutic treatment plan, to minimize the socio-economic effect they suffer just because of their willingness to get treated.Although some limitations can be identified in the study, this did not significantly affect the outcome and interpretations. These limitations included the use of a small sample size, the inability to perform tympanometry, extended high frequency audiometry and diagnostics DPOAE, and the inability to conduct pretreatment measurements and ascertain treatment compliance. Furthermore, no secondary analysis was conducted to account for patients treated with antiretroviral drugs for HIV, even though there is some preclinical data to suggest that these medications may also lead to ototoxicity, possibly disturbing the picture of only tuberculosis treatment being the reason for hearing damage. Additionally, the definition of PTA used in this study can be considered old, even though that is what is commonly used in Ghana and as such was applied in the current study in order to give a better representation of the situation in the country. Nonetheless, the outcomes from this study underscore the need for the auditory monitoring of patients initiated on anti-TB therapy because of ototoxicity concerns.