Background: In many countries, neonatal hearing screening programs (NHS) have been available for many years; however, because of the presence of hearing loss at late onset, early hearing detection programs (EHDP) have been implemented. The aim of this study was to evaluate all cases of infantile hearing loss under the care of two different provinces of a regional health service since the introduction of NHS. Methods: Clinical data  were retrospectively collected during the period from 1 January 2012 to 31 December 2018, starting from the IT management system used in all of the regional neuropsychiatric services. Results: In total, 124 children were included—116 cases failed the screening, 1 case had an untraceable result, and 7 cases (5.6%) had hearing screening that passed. Most of the children were placed under the care of a neuropsychiatric infantile and adolescence (NPIA) service within the first year of life. The main differences across the two provinces concerned the percentages of audiological risk factors and the number of unilateral hearing loss cases. Conclusion: In order to plan and manage hearing rehabilitation programs for children in the best way, it is very important to know the local clinical-epidemiological features of the population. Hearing loss is one of the most frequent congenital diseases in children, with a reported prevalence of 1–3:1000 in the healthy baby population, and a major prevalence, with variable results, in the neonatal intensive care unit (NICU) population . As it hNHS programs are available, but they do not identify hearing loss at late onset, and some cases may be missed. The Emilia Romagna region approved a document that introduced the newborn hearing screening (NHS) on 1 January 2012, and also guaranteed early intervention programs , introduNeuropsychiatrist infantile and adolescent services (NPIA) represent an important resource in the territory, and are provided according to geographical areas and the number of inhabitants. Each NPIA service has a local HDT, and they refer to the regional HDT, which has the role of coordination. The treatments provided by NPIA services are speech therapy, clinical monitoring, and intervention dedicated to school integration.This study evaluates all cases of infantile hearing loss being treated in NPIA in two different provinces of a regional health service. The main aims were to know how many children participated in an EHDP, as well as the time they were placed in the care of NPIA.This was a retrospective study, using clinical records. Patients’ data were collected during the period from 1 January 2012 to 31 December 2018, starting from the IT management system used in all of the regional neuropsychiatric services, named ELEA, and searching ICD-10 codes related to hearing loss. In one province, the search was also conducted, using a hospital IT management system named SAP. The data collected included the date and place of birth, gender, presence of audiological risk factors, entity of hearing loss, age of first evaluation by the NPIA service, use of hearing aid/cochlear implant, and exposure to bilingualism.County 1 had approximately 705,000 inhabitants and it was divided into seven health districts over the territory. County 2 had approximately 343,000 inhabitants and it was divided into three health districts over the territory. For both provinces, each district had its own NPIA service, and families were assigned to the district based on residence. In each county there was a NICU, with five birth facilities in county 1 and two birth facilities in county 2.Concerning the NHS program, our region adopted a two-stage protocol, differentiating healthy babies from NICU babies. All healthy babies underwent otoacustic emission (OAEs) tests in the birth facilities, and had a re-test within 14 days if there was no clear response. NICU babies were tested by OAEs and by clinical ABR/aABR, because of their increased risk of sensorineural hearing loss and auditory neuropathy . All chiDiagnostic hearing testing was conducted by audiologists/otorhynolaryngologists with experience in infantile hearing loss, and normally was completed in the first 3–4 months of age, also depending on the child’s general clinical conditions . A full family history was always taken and several other tests could be performed, including tympanometry, visual reinforces audiometry, or play audiometry, depending on the patient’s age and ability to cooperate.The severity of hearing loss was defined according to the WHO classification, as follows: normal hearing (0–15 db), as well as slight (16–25 db), mild (≥26 to <40 dB), moderate (≥41 to <55 dB), moderate severe ≥56 to <70 dB), severe (≥71 to <90 dB), and profound hearing loss (>90 dB) [0 dB, sevThe prevalence of hearing loss was calculated for each county by comparing the number of affected subjects with the total number of newborns in the period of the study. Demographic data were obtained from the Regional Health Agency.Globally, 124 children were enrolled in the study. In county 1, 84 children were enrolled in total, of which 75 were born in the region (69 in the province), 7 out of the region, and 2 abroad, and 56 were males and 28 were females.In total, 79 cases of bilateral hearing loss were identified—14 (17.8%) cases were affected by profound hearing loss, 10 (12.6%) by severe hearing loss, 10 (12.6%) by mild hearing loss (6 were conductive), 22 (27.8%) by moderate hearing loss, and 23 (29.2%) by moderate/severe hearing loss. Five were unilateral cases  did not receive any hearing rehabilitation. Thirty-nine (46.4%) children were exposed to bilingualism.Most of the children (65%) were placed under the care of NPIA within the first year of life, in particular 25% (21 cases) by the fifth month, 25% (21 cases) by the ninth month, and 15% (13 cases) by the first year. Ten cases (12%), affected by mild/moderate hearing loss, were placed under the care of the NPIA service after three years of age see also .In county 2, 40 children were enrolled in the study. Two children were born out of the province but moved soon after birth, and three children started the intervention program and then moved. Sixteen were males and twenty-four were female. Thirty-three (82.5%) children were affected by bilateral hearing loss. Of these see also , 8 casesTwenty- nine cases received hearing aids, seven cases affected by slight or mild hearing loss did not receive any hearing rehabilitation, and eight babies received a cochlear implant. Fourteen (35%) children were exposed to bilingualism.Twenty babies (50%) were placed under the care of NPIA, mostly by the eighteenth month of life, while the rest of the babies, affected by slight/moderate  hearing loss, were discharged after NPIA service evaluation. In particular, eight children rehabilitated by CI were followed directly by the hospital service, while those with unilateral hearing loss were discharged after the first evaluation see also .When analysing the NHS results, in county 1, 77 cases failed the screening , in 1 case the result was not traceable, and in 6 cases the screening was passed. In county 2, all except one failed the hearing screening at birth. “Pass” cases at NHS represent 5.6% globally .In county 1, only one was due to progressive hearing loss with hereditary factors, two were mild with associated disabilities, one was a cCMV infection, and one was moderate due to a cleft palate. In county 2, the only case that was passed on by NHS received a diagnosis of hearing loss by a clinical ABR, performed since the presence of familiarity for hearing impairment.This study provides a picture of the clinical-epidemiological features of infantile hearing loss treated by territorial services after the introduction of the newborn hearing screening, as well as its implementation through early intervention programs. As evidenced by the data analyzed, almost all children enrolled were identified by the NHS, which achieved optimal coverage in both provinces. Regional health legislation played an important role for achieving these results, underlining the importance of programs receiving strong support from healthcare administrators .Since the analysis of data started by the NPIA IT management system, it has demonstrated that hospital and territorial services have worked concretely in synergy. In particular, children affected by profound bilateral hearing loss have been diagnosed and treated in a timely way, according to the principle that the earlier the intervention, the better the audiological and linguistic outcomes are achieved . The preThe prevalence of congenital hearing loss had comparable percentages between the two counties. In the literature ,2,10, moIn this study, the prevalence of congenital hearing loss was calculated based on the number of cases placed in the care of the NPIA service, and does not include young children who directly receive care in hospital or those who receive NPIA care when they attend primary school. Moreover, a few children with slight or mild hearing loss, identified later, are probably treated in private practice.The number of patients suffering unilateral hearing loss was found to be significantly different between the provinces, and they were mostly discharged from NPIA after the first evaluation. It is known that, in the past, the impact of unilateral hearing loss was underestimated, and because a child has normal oral language development, the family is likely to assume the absence of implications for child development related to hearing and linguistic abilities.The results did not reveal particular discrepancies concerning structural abnormalities of the temporal bones and other syndromic clinical pictures, which are amongst the most common causes of permanent congenital sensorineural and mixed hearing loss ,13. SimiThe main differences across the two provinces was the percentages of prematurity and familiarity for hearing loss, which seemed inversely proportional between the two cohorts. The incidence of hearing loss increased with prematurity ; this isThe presence of bilingualism was slightly different across the examined provinces, also because of the different socioeconomic factors, such as number of inhabitants and the geographic conformation of the two areas. Bilingualism can imply different rehabilitation strategies, mainly when parents are also not skilled in the adoptive language.Our findings can have implications for the management of available resources in the examined areas and for the organization of the education services specifically oriented to families of those with infantile hearing loss . Indeed,The major drawback of this study is the relatively small sample size analyzed.The implementation of newborn hearing screening programs represents a very useful tool, both in order to achieve an early diagnosis of hearing loss in children, and in order to establish a timely treatment/rehabilitative protocol. Furthermore, the presence of early hearing detection and intervention programs is crucial in order to treat infantile hearing loss adequately, and this is confirmed in our experience.


Rhizopus arrhizus is the most common etiological agent of mucormycosis in this country, infections due to Rhizopus microsporus, Rhizopus homothallicus, and Apophysomyces variabilis are rising. Occasionally, Saksenaea erythrospora, Mucor irregularis, and Thamnostylum lucknowense are isolated. Though awareness of the disease has increased among treating physicians, disease-associated morbidity and mortality are still high, as patients seek medical attention late in the disease process and given the low affordability for therapy. In conclusion, the rise in the number of cases, the emergence of new risk factors and causative agents, and the challenges in managing the disease are important concerns with mucormycosis in India.Mucormycosis is an angioinvasive disease caused by saprophytic fungi of the order Mucorales. The exact incidence of mucormycosis in India is unknown due to the lack of population-based studies. The estimated prevalence of mucormycosis is around 70 times higher in India than that in global data. Diabetes mellitus is the most common risk factor, followed by haematological malignancy and solid-organ transplant. Patients with postpulmonary tuberculosis and chronic kidney disease are at additional risk of developing mucormycosis in this country. Trauma is a risk factor for cutaneous mucormycosis. Isolated renal mucormycosis in an immunocompetent host is a unique entity in India. Though  Mucormycosis is an angioinvasive disease that is characterised by tissue infarction and necrosis . The cliUncontrolled diabetes mellitus is the most common underlying disease associated with mucormycosis in India ,6,8, in Rhizopus arrhizus is the commonest cause of mucormycosis [Apophysomyces species ranks second in India compared to the Lichtheimia species in developed countries [Rhizopus microsporus and Rhizopus homothallicus are rising in India [The pathogens associated with mucormycosis varies considerably between India and developed countries . Globallrmycosis ,12. The in India ,6,13. InThe annual incidence of mucormycosis reported from different case series in India is shown in Diabetes mellitus was reported in 54–76% of cases . Of thosDue to the lack of regular health check-ups in the Indian population, the diagnosis of mucormycosis unmasked diabetes in 43% of patients from North India , 40% in Haematological malignancy (HM) is a risk factor in 1–9% of mucormycosis patients in India , compareSolid-organ transplantation (SOT) is a risk factor in 2.6–11% of mucormycosis cases from India , compareIn India, 3–26% of mucormycosis cases are recorded from the immunocompetent host , compareOther predisposing factors associated with mucormycosis in India are chronic kidney disease (CKD), steroid therapy, pulmonary tuberculosis, and chronic obstructive pulmonary disease (COPD) ,6. CKD iOn the basis of the anatomical site of involvement, the clinical form of mucormycosis reported in various case series from India is shown in Diabetes mellitus is a common predisposing factor for the ROCM type of disease. A recent multicentre study from India reported that 77% of ROCM cases were in the diabetic population . DifferePulmonary mucormycosis is commonly associated with SOT recipients 37–44%), haematological malignancy 10–26%), and diabetes mellitus (10–14%) in Indian patients . These f6%, and d7–44%, haThe cutaneous type is seen in 10–31% of patients with mucormycosis after trauma following road traffic accidents, burn wounds, intramuscular injection, intravenous catheters, adhesive tapes, and surgical-site infections ,22,61. IGastrointestinal mucormycosis accounts for 2–8% of cases from India . About 6Renal mucormycosis in an immunocompetent host is a unique clinical entity in India. Different case series from India reported that 33–100% of renal mucormycosis cases were in an immunocompetent host . PrakashRhizopus, Lichtheimia, Cunninghamella, Rhizomucor, and Apophysomyces [Mucorales are thermotolerant saprophytic fungi found in decaying organic matter and soil samples ,67. An eysomyces . Similarysomyces ,68. TablRhizopus arrhizus is the most common agent causing mucormycosis in India and globally. However, the spectrum of agents causing this disease in India is considerably large. Recent studies reported a rise in mucormycosis cases due to Rhizopus microsporus and Rhizopus homothallicus [Rhizopus species are associated with ROCM mucormycosis [Rhizopus species in soil and air samples [Apophysomyces variabilis is the second commonly isolated agent. India accounts for approximately 60% of reported cases in the literature due to Apophysomyces species [of Apophysomyces species in air samples, which may explain the source in ROCM mucormycosis [Apophysomyces species were nosocomial in origin [hallicus ,6,13,69.rmycosis ,6, and t samples ,67. Apop species ,70, and  species ,6,70. Th species . Rarely, species ,38,71. ALichtheimia species contribute 0.5% to 13% of cases from India. Chander et al. reported that most of the cases in India are due to L. ramosa [Rhizomucor pusillus, Cunninghamella species, Mucor species, Syncephalastrum species, and Saksenaea species (Saksenaea erythrospora, Mucor irregularis, and Thamnostylum lucknowense are also reported [. ramosa . Other M species . Mucormyreported ,72,73,74The treatment and outcome of mucormycosis in Indian patients are depicted in Rhizopus arrhizus is the most common causative agent isolated in all clinical forms of mucormycosis. However, the spectrum of agents causing the disease is considerably large in India. Apophysomyces and Saksenaea species are common agents causing cutaneous mucormycosis. Newer species like Rhizopus homothallicus, Rhizopus microsporus, Mucor irregularis, Thamnostylum lucknowense, and Saksenaea erythrospora are emerging in India and require expertise in laboratory identification. The broad spectrum of agents emphasises the need to improve routine clinical laboratory facilities to identify rare Mucorales associated with mucormycosis. Mortality associated with mucormycosis in India is considerably high due to delays in seeking medical attention and diagnosing the disease, and challenges in managing the advanced stage of infection. It is necessary to conduct population-based studies in India to determine the exact prevalence of mucormycosis in diverse at-risk populations, which would help draw stakeholder attention to the early diagnosis and managing the disease. Though AmB is routinely used in the treatment of mucormycosis, it is important to study the role of newer antifungal agents such as isavuconazole in the treatment of mucormycosis in the Indian population.The exact prevalence of mucormycosis in India is unknown, though the estimated prevalence is much higher than that in developed countries. The possible reason for the high prevalence is the abundant presence of Mucorales in the community and hospital environment, large number of susceptible hosts especially diabetics, and the neglect for regular health check-ups of Indian population. A considerable number of patients are ignorant of diabetes status till they acquire mucormycosis. Though uncontrolled diabetes is a common risk factor in all types of mucormycosis, it is significantly associated with ROCM type. Other emerging risk factors of mucormycosis are pulmonary tuberculosis, chronic kidney disease, and critically ill patients. Isolated renal mucormycosis in an immunocompetent host is a unique clinical entity and requires more studies on pathogenesis. Like in the global data,


Parabens (PBs) and triclosan (TCS) are generally used as antimicrobials mostly in personal care products. Their wide prevalence in daily products raised an acute need for the biomonitoring of these contaminants and the investigation of possible health impacts.In this study we aimed to quantitatively determine PBs and TCS levels in urine and amniotic fluid samples using a liquid chromatography – mass spectrometry system (LC–MS). Ninety nine (99) pregnant women took part in this research. The samples were collected during the amniocentesis in the early second trimester of their pregnancy. Women of all ages, education, household income and profession were selected. The exposure and the burden of pregnant women and their infants were also evaluated.The most prevalent compound in urine, among the analyzed, was TCS with 74.7 % positive samples while in amniotic fluid methyl paraben (MePB) with 21.2 % positive samples. MePB was detected at higher concentrations in urine (mean: 378.5 ng/mL) followed by TCS (mean: 55.3 ng/mL), ethyl paraben (EtPB) (mean: 23.2 ng/mL) and butyl paraben (BuPB) (mean: 2.3 ng/mL) while benzyl paraben (BePB) was not detected in any urine sample. Concentrations in amniotic fluid samples were much lower. In particular, the mean concentrations were 6.6 ng/mL for MePB, 9.2 ng/mL for EtPB, 0.4 ng/mL for BuPB, 0.6 ng/mL for BePB and 1.8 ng/mL for TCS. The detected levels of all analytes in urine were correlated with those in amniotic fluid but no statistically significant results arose (p >n0.05). Negative associations were observed between amniotic fluid levels of MePB and maternal age (p = 0.05) while both urinary and amniotic levels of TCS were correlated with maternal BMI (p = 0.04). Somatometric characteristics of the infants showed no statistical significant associations with the detected levels of PBs and TCS.This study indicated a strong/possible association between exposure of pregnant women to TCS and higher/lower maternal body weight gain during pregnancy. The same trend was observed between amniotic fluid MePB levels and maternal age. However, no statistically significant associations were observed between neonatal somatometric characteristics or health status and PBs and TCS levels. The main route of human exposure is personal care products (PCPs), such as deodorants, shower gels, shampoos, body creams and lotions . PBs areEuropean Union has notified specific guidelines regarding the presence of PBs and TCS in consumer products. In particular, the maximum permissible concentration of TCS in cosmetics is 0.3 % , while tDespite the limitations, the widespread use of PBs and TCS has resulted in the long-termhuman exposure which has raised concerns about the possible health impacts in the human body. PBs and TCS have been characterized as endocrine disruptors (EDs) as several studies have indicated that they affect the proper action of hormones and therefore the proper function of the endocrine system, leading to several health problems. Until now, studies indicate that exposure to PBs is correlated with male (even to the descendants) and female reproductive problems, breast cancer, increased chance of developing obesity, potential genotoxicity, increased sensitivity to allergens and neurotoxic effects . SimilarThe burden of general population usually is estimated by hair analysis . The las22.1Escherichia coli from Roche Diagnostics . Ultrapure water was produced by Merck’s Direct-Q 3UVwater purification system .MePB, EtPB, BuPB, BePB, ethylacetate (High Pressure Liquid Chromatography (HPLC) grade), hydrochloric acid (≥37 %), ammonium acetate  and solid phase extraction (SPE) cartridges C18 (100 mg) were purchased by Sigma – Aldrich . TCS (100 %) was obtained by Honeywell–Fluka , methanol (LC-MSgrade) and acetonitrile (Liquid Chromatography - Mass Spectrometry (LC–MS) grade) by Honeywell–RiedeldeHaën  and phenobarbital-d5 used for internal standard by Isotec Inc. . Phosphate buffer saline was purchased from FlukaBiochemika  and β-glucuronidase enzyme from 2.2Sampling took place at the “Mitera” Maternity Hospital in Heraklion, Crete. Maternal urine and amniotic fluid samples were collected from ninety nine (99) pregnant women during the amniocentesis in early second trimester of their pregnancy. The amniocentesis procedure was scheduled by the doctor due to one (or more) of the following reasons; the maternal age, the maternal medical/obstetric history and the health condition of both mother and fetus. In specific, in Greece, it is almost obligatory to conduct amniocentesis on pregnant women over the age of 35. Also, in case that the mother, or fetus, had presented any health problem  either in previous or the current pregnancy, amniocentesis was necessary to ensure the health of both mother and fetus.Before sampling procedure, all participating women were informed about the research and asked to sign participation consent. Samples were collected in screw glass tubes and stored at −20 °C until analysis. This study was approved by the ethics committee of the University of Crete (43/22.11.2018).2.3During the sampling, the participants were asked to complete questionnaires about maternal demographic  and somatometric characteristics ) before and during pregnancy, nutritional  and lifestyle habits , medical and obstetrical history and the frequency of personal care products. Six to twelve months after childbirth, additional information was collected regarding infants’ development ) and health condition as well as birth type .2.41 mL of each amniotic fluid sample was placed in glass screw tubes, since the samples had been centrifuged. Subsequently, 10 μl of β-glucuronidase enzyme was added to each sample to hydrolyze the conjugated (glucuronidized) compounds and 250 μl of 0.1 M phosphate buffer pH 6.5 to create the appropriate environment for the enzyme to act. The samples were incubated in a water bath at 37 °C for 12 h. After incubation, 100 μl of 2 M hydrochloric acid were added, followed by extraction with 2 mL of ethyl acetate. The samples were shaken for 20 min and then the extract, that is the organic phase, was transferred to glass evaporation tubes. This process was repeated twice, followed by evaporation to dryness under nitrogen flow, reconstitution of the evaporation residue in 100 μl of methanol and transfer to 2 mL vials (inside inserts) for LC–MS analysis.2.5Similar procedure was followed for urine samples. 1 mL of each sample was placed (after centrifugation) in glass screw tubes and 10 μl of β-glucuronidase enzyme and 250 μl of 0.1 M phosphate buffer pH 6.5 were added. After overnight incubation at 37 °C, 100 μl of 2 M hydrochloric acid were added, followed by extraction with 2 mL of ethyl acetate three times. At this stage of the experimental procedure, an extra clean step was added using SPE cartridges. In particular, the extracts were evaporated to dryness and then reconstituted in 1 mL of buffer solution pH = 2. The cartridges were cleaned and activated using 2 mL of acetonitrile, 2 mL of acetorintrile:water 1:1 and 2 mL of water. Then, the samples were loaded and washed with 2 mL of water. After cartridges had been dried up, the analytes were extracted using 2 mL of acetorinitrile : ethyl acetate 1:1. Finally, the extracts were collected, evaporated to dryness under nitrogen flow, reconstituted in 100 μl of methanol and analyzed with LC–MS.2.6m/z of each analyte are given.A Shimadzu  liquid chromatography – mass spectrometry system (LC–MS 2010 EV model) equipped with an autosampler was used. Separation of the analytes was achieved using a Supelco Discovery column C18 (25 cm)  at 30 °C stable oven temperature. A gradient of 5 mM ammonium acetate (solvent A) and acetonitrile (solvent B) were chosen for the analysis of PBs and TCS. The flow of chromatography was 0.6 mL/min and the total duration of the run for each sample was 25 min. Atmospheric pressure chemical ionization (APCI) combined with a quadrupole mass filter in a selected ion monitoring (SIM) negative mode were used for monitoring the aforementioned substances. In 2.7Measures of central tendency  and measures of dispersion  were used according to the data normality for the continuous variables. Counts, percentages and proportions were applied for discrete data. The correlation of discrete variables was tested using Pearson's χ2 test, changes to paired measurements of discrete data were tested using McNemar for 2 × 2 tables or Mc Nemar-Bowker test for nxn tables. Pearson’s rho coefficient was used to estimate correlation of continuous and ordinal variables. Boxplots were used for representing ordinal and discrete data and scatterplots were used for examining correlation between continuous variables. IBM SPSS Statistics 24.0 was used for data analysis and a level of acceptance was set at p = 0.05 level.33.12) was >0.99 for all compounds in both matrices. Linearity obtained from spiked samples at concentrations 0, 5, 10, 25, 50 and 100 ng/mL was similar with that of standard solutions (R2>0.99).Analytical parameters of the applied methods were checked and evaluated for the target compounds. Standard solutions were prepared at concentrations 0, 25, 50, 100, 250 and 500 ng/mL and the obtained calibration curves showed that linearity (RRecovery (%), accuracy (%) and inter day precision (%) were also calculated for both urine  and amniotic fluid  and found to be within the accepted values.Limits of detection (LOD) were calculated using the signal to noise ratio (S/N); S/N > 3 for LOD. The calculated values were 0.07 ng/mL for MePB, 0.31 ng/mL for EtPB, 0.12 ng/mL for BuPB, 0.17 ng/mL for BePB and 0.73 ng/mL for TCS.3.2A total of 99 women participated in the study and the mean age was 35.2 ± 5.8 years ranging from 18.0 to 44.0 years. Reported BMI before pregnancy was 24.4 ± 5.6 Kg/m2 (range 16.0–45.4) and the corresponding at the time of amniocentesis was 25.9 ± 5.3 Kg/m2 (range 17.2–46.3) showing a statistically significant increase (p < 0.001) (mean DBMI: −1.5 ± 1.4).Medical history of the participating women showed that thyroid problems were the most common (32.3 %), followed of allergic disorders/diseases (29.3 %), gynecological (24.2 %) and respiratory problems (7.1 %). Eighty-five mothers accepted to give additional information about infants’ development (6months – one year after birth) and possible health issues. Female neonates were 44 (51.7 %) and only 7 female neonates were born pre-term (<37 gestation weeks). Frequency of pre-term gestation did not differ between male and female neonates (p = 0.663). Female neonates presented a mean weight at birth 3048 ± 559 g which do not differ significantly from male neonates 2981 ± 670 g (p = 0.621). Similar findings were found for neonates’ length vs neonates’ gender (p = 0.790) with a mean length of 50.2 ± 2.9 cm and for neonates’ head circumference vs gender (p = 0.949) with a mean HC of 34.7 ± 1.5 cm. A total of 12 newborns 14.1 % suffered from a disease/disorder. The most common reported health issues were allergic disorders (10.6 %) followed by respiratory problems (2.4 %) and genital abnormalities (1.2 %) .Table 2S3.3Descriptive statistics of measured PBs  and triclosan (TCS) are given in Urinary levels ranged from 5.3 to 3501.3 ng/mL (mean: 378.5 ng/mL) for MePB, from 0.8 to 81.7 ng/mL (mean: 23.2 ng/mL) for EtPB, from 1.2 to 7.6 (mean: 2.3 ng/mL) for BuPB and from 0.7 to 615.5. ng/mL (mean: 55.3 ng/mL) for TCS. The big range of MePB and TCS is attributed to the fact that these two substances are the most common used antimicrobials in personal care products. Similar ranges have been observed in previous studies and other biological matrices, too . In amniDue to the small prevalence of positive samples for PBs and TCS, correlation between them was examined only for MePB and the estimated rs was 0.711 (p < 0.001) .Fig. 1Co3.4Detected levels of PBs and TCS in urine and amniotic fluid were correlated with the somatometric characteristics of women. Correlation results are shown in 4In the current study we aimed to determine PBs and TCS levels in urine and amniotic fluid samples from pregnant women. Maternal and fetal exposure as evaluated from biomonitoring data in urine and amniotic fluid, respectively, were associated with maternal demographic and somatometric characteristics as well as daily habits and medical history. Infants’ somatometric characteristics and health condition were also correlated with the found levels.The target compounds were mostly present in urine samples with % positivity ranging from 8.1 to 74.7 % for urine samples and from 1.0 to 21.2 % for amniotic fluid samples. MePB had the higher detection frequency (21.2 %) and mean concentration level (6.6 ng/mL) among the detected compounds in amniotic fluid. MePB presented also high detection frequency (64.6 %) in urine samples but TCS frequency was even higher (74.7 %). The higher concentration levels in urine were observed for MePB with mean value 378.5 ng/mL followed by TCS with mean concentration 55.3 ng/mL. BePB was not detected in urine while in amniotic fluid there was only one positive sample (0.6 ng/mL). Additionally, EtPB and BuPB presented very low detection rates in amniotic fluid . This high difference of detection rates and concentration levels supports existing views that PBs and TCS has lower biotransformation/metabolism in amniotic fluid than in urine which leads to insignificant accumulation potential ,28.Until now there are only three published studies on biomonitoring of PBs and TCS in amniotic fluid. The detected concentrations in the present study are similar with the levels reported in the literature . On the Philippat and co-authors correlated the levels of PBs and TCS in maternal urine with those in amniotic fluids, and found that urine and amniotic fluid followed the same trend. For instance, women with high urinary MePB and TCS concentrations presented also high levels in amniotic fluid . AlthougAccording to the literature, urinary PBs levels generally show the following trend MePB > EtPB > BuPB > BePB. The same distribution/order is observed in our study, too, and the respective mean concentrations are 378.5 ng/mL for MePB, 23.2 ng/mL for EtPB, and 2.3 ng/mL for BuPB, while BePB was not detected in any sample. Shekhar and co-authors reported a similar trend for amniotic fluids, specifically MePB > TCS > EtPB > BuPB, which is also observed in our results . This faCorrelation of maternal demographic characteristics with the detected levels showed no statistically significant results except for maternal age which was negatively correlated with MePB levels in amniotic fluid. There is no such association reported in literature however Ashrap and co-authors found that urinary PBs levels were higher in elderly pregnant women . The samIn the current study, urinary TCS levels were higher when small BMI alteration during pregnancy was observed. Li and co-authors also indicated that BMI is possibly associated with TCS . AdditioInfants’ somatometric characteristics have been previously correlated with both TCS and PBs. Previous studies have indicated that birth length, weight and head circumference tend to be smaller when TCS levels are high ,41,42 whOne of the most debatable issues of PBs and TCS exposure is the risk that may arise for both the mother and the infant. There are animal studies that claim preterm birth or miscarriage after animals’ exposure to PBs and/or TCS ,47. AlthThere are several studies that correlate children exposure to PBs and TCS with allergies and asthma incidents. However, when it comes to maternal exposure and infants’ burden only PBs are correlated with increased asthma rates . The inc5To the best of our knowledge, the current study is one of the very few, that aimed to correlate maternal and fetal burden to PBs and TCS. Also, this is of the very few studies that tried to assess the exposure of Greek women to these substances. The importance of this study lies in the fact that PBs and TCS are endocrine disruptors strongly correlated with fetus developmental problems and subsequent postnatal problems in growth. The study population consisted of women residents of Crete; a big Greek island which lands away from the mainland. The participants originated from all social layers with different incomes, education and professions. This way, we tried to simulate the exposure of Greek women using a sample size of 99 women. Although urine and amniotic fluid levels of PBs and TCS were not associated, significant associations arose between the detected levels and both maternal age and BMI. The correlation between urine – amniotic fluid levels and neonatal somatometric characteristics as well as neonatal health status did not result in statistically significant conclusions. This fact may be attributed to the low prevalence of the target compounds in the analyzed samples. Nevertheless, the detection of these compounds in maternal urine and amniotic fluid raises concerns about the real risk to both mothers and fetuses; hence further studies must be conducted in order to elucidate it. One fact that must be taken into consideration is the combined exposure to these substances and their potential synergistic toxicity  as this Vasiliki Karzi: Investigation, Formal analysis, Writing-review & editing; Manolis M. Tzatzarakis: Conceptualization, Supervision, Methodology; Eleftheria Hatzidaki: Resources, Validation; Ioanna Katsikantami: Investigation; Athanasios Alegakis: Formal analysis, Data curation; Elena Vakonaki: Methodology; Alexandra Kalogeraki: Resources; Elisavet Kouvidi: Resources; Pelagia Xezonaki: Resources; Stavros Sifakis: Resources, Validation; Apostolos K. Rizos: Conceptualization, Supervision.The authors report no declarations of interest.


Scientific Reports 10.1038/s41598-020-78571-0, published online 11 December 2020Correction to: This Article contains a typographical error in the first paragraph of the Results section, where“The data of 89 participants are presented, of which 39 had tinnitus and hearing loss (THL group), 21 participants had hearing loss but no tinnitus (HL group), and 39 controls with neither tinnitus and no or minimal hearing loss (CO group).”should read:“The data of 99 participants are presented, of which 39 had tinnitus and hearing loss (THL group), 21 participants had hearing loss but no tinnitus (HL group), and 39 controls with neither tinnitus and no or minimal hearing loss (CO group).”


The absence of best practice guidelines on informational counselling, has caused lack of clarity regarding the information audiologists should provide to parents and caregivers following the diagnosis of a hearing loss. Research shows that informational counselling provided by audiologists is limited and often biased, with little evidence of how parents experience this service.To explore the nature and practice of informational counselling by audiologists.This study was descriptive in nature and adopted a survey design to obtain information on the current practices of informational counselling from the perspective of parents and primary caregivers. Ninety-seven face-to-face semi-structured interviews were conducted across KwaZulu-Natal province of South Africa. Descriptive statistics and thematic analysis using Nvivo software were conducted.The majority of the parents reported receiving some form of informational counselling. However, the information provided by audiologists was considered to be biased as it included a favoured communication option, school and rehabilitative technology. There was a lack of information related to aural rehabilitation and family-centred intervention. The provision of all communication options, school options and rehabilitative technology were identified as gaps that contribute to an unfavourable decision-making process.There are inefficiencies experienced by families of deaf and hard of hearing children during informational counselling. However, this understanding, together with the identified gaps by parents, can help address the professional response to caring for families with deaf and hard of hearing children. It is reported that 90% – 92% of children who are deaf are born to hearing parents who have little or no experience of deafness  province in South Africa in the past 5 years, identifying gaps in informational counselling and exploring contextually relevant factors that audiologists need to consider during informational counselling with parents and primary caregivers of children who are deaf or hard of hearing.The study was descriptive in nature with both qualitative and quantitative components. A descriptive survey was conducted using face-to-face interviews. An interview schedule with open-ended questions was used.The participants were hearing parents and primary caregivers of children who are deaf or hard of hearing residing in KZN province. This was done to facilitate homogeneity of the participants looking at the region. The parents and primary caregivers were accessed from 31 hospitals within all 10 districts representative of KZN providing paediatric audiology services.To recruit the participants, random sampling was employed. Patient files were accessed from the public hospitals and contact numbers were retrieved. Participants who met the selection criteria were contacted telephonically and were addressed in English or isiZulu by the researcher who is a first language isiZulu speaker. For participants who were non-literate, the study was verbally explained to them. The participants were contacted to provide details regarding the study, and to schedule a convenient date, time and place to conduct interviews. Private audiologists made contact with potential participants regarding the study. Interested participants contacted the researcher. The researcher randomly selected parents and primary caregivers from all public hospitals (80) and private clinics or hospitals (17) using the KwaZulu-Natal Department of Health database. Limited participation from some private facilities was attributed to paediatric audiology services not being offered and some audiologists withholding access to potential participants on their caseload.A statistician was hired to ascertain the sample size. A sample size of 97 randomly selected parents produced a two-sided 95% confidence interval with a width equal to 0.20 or 20% (i.e. ± 10%) when the sample proportion is 0.50 or 50%   father, 40 (41%) mothers and 56 (58%) primary caregivers . A total of seven (14%) parents were first language English speakers, with the remainder being first language isiZulu speakers. The age range of participants was between 18 and 62 years. The level of education of the participants ranged between grade 2 and an honours degree. All participants had children who were deaf or hard of hearing diagnosed within the past 5 years in 31 public hospitals and three private clinics within KZN and had an age range between 8 months and 9 years.The data collection instrument, that is, interview schedule, was derived from the literature taking into consideration the research question. The interview schedule comprised a demographic section and open-ended questions related to the age of diagnosis, type of counselling received, the content areas covered during informational counselling, grieving process, identified gaps in informational counselling, factors audiologists need to consider when providing informational counselling, family-centred intervention, the decision-making process and views on the informational counselling received. Face-to-face semi-structured interviews were conducted by the researcher in either English or isiZulu. The duration of the interviews ranged from 10 min to 37 min and the interviews were audio recorded.A pilot study was conducted on 12 participants and data obtained during this process were not used in the main study. Changes were made to the revised interview schedule. The interviews were audio recorded using the Olympus digital voice recorder DM-650, Olympus Audio SA and transcribed by a professional transcribing company. Thematic analysis using Nvivo 12 was conducted to process and analyse the data. All interviews in isiZulu were transcribed into English and then backtranslated by a professional company. These were then verified by the researcher before being uploaded into Nvivo for analysis.All ethical considerations were adhered to in this study. Issues related to informed consent, voluntary participation, withdrawal and anonymity were addressed. Ethical clearance was obtained from Biomedical Research Ethics Committee of the University of KwaZulu-Natal .Of the 97 participants interviewed, six (6%) participants reported that they did not receive any informational counselling from the audiologist or any other health professional, whilst two (2%) could not recall if they had received any informational counselling. The remaining 89 (92%) participants reported to have received some form of informational counselling; however, the content areas addressed and the manner in which the information was provided during these sessions varied for all participants.One participant stated:‘No, we were never counselled, she just got tested and they diagnosed her with hearing loss and they said she will get a hearing aid and they made an appointment for us to come and get the hearing aid.’ n = 89).All 89 (100%) participants who were counselled reported to have received information about hearing aids and South African Sign Language as the only communication option mentioned. Only nine parents of the 89 who received counselling (10%) reported that the audiologist counselled them about all the available communication options, such as total communication, oralism and bilingual–bicultural, and only four (4%) reported to be informed about more than one education methodology. Two parents (2%) reported receiving information about communication strategies and only one (1%) parent was reported to be informed about cochlear implants as an available rehabilitative technology. A total of 76 (85%) of the 89 parents or primary caregivers reported that the parent advisors from a national non-profit organisation offering a home-based care programme provided detailed information; however, this information was only on Sign Language and the bilingual bicultural education methodology. These parents reported that although the information was extensive, they would have preferred extensive information on other communication options as well. These parents also reported to have benefitted from the basic Sign Language lessons provided by the representative from the home-based care programme, as evident in the following quotes:‘They gave me the information based on their views.’ ‘There is nothing else they explained to us, they just explained about the sign language.’ The majority,  of these parents or primary caregivers reported to be informed about the availability of a disability grant, whilst almost the same number  reported to have been informed about one education methodology, that is, bilingual–bicultural school for the deaf. Whilst 46 (47%) parents or primary caregivers reported information about the diagnostic results, only 29 (30%) reported counselling about aural rehabilitation and the significance of family-centred intervention and the implications of the hearing loss in terms of communication.The identified gaps represented information that parents deemed critical for intervention decision-making, which was either absent, limited and/or biased during the informational counselling they received. These content areas are presented in More than 50% of the participants reported that informational counselling needs to include aetiology of the hearing loss, all education methodologies, parent-to-parent support groups, all communication options, family communication strategies and Sign Language classes. About 30% – 45% of the participants in the study reported that there are gaps in information related to implications of the hearing loss, diagnostic results and hearing aid benefits. The remaining content areas identified as gaps were considered by less than 30% of the participants.The number of participants in relation to the content areas identified as gaps was based on the information that each participant deemed critical based on whether they did or did not receive it. A total of 64% of participants reported that audiologists need to provide information on the cause of the hearing loss, as shown in the following quotes:‘I can say at the hospital, we got information, but something we never got was what the cause was for her hearing loss. That it was natural or what.’ ‘The only suggestion I have is that as a mother of the child, I was all alone and the father left me after finding out that the child has a hearing loss. They were supposed to tell me what the reason is, what the reason for my child losing her hearing was this and that.’ A total of 77% of participants reported that not all education methodologies were provided. The majority of these participants were reported to be informed of one education methodology and only later found out about other education methodologies, as clear from the following quote:‘They advised me about special schools only, they never spoke, explained the results. No they didn’t explain in detail and the cause you see?’ Parent-to-parent support groups were reported as a gap during informational counselling by 72% of the parents and primary caregivers:‘I wanted to know from other people that how did they react to it when it happened to their kids.’ A total of 62% of parents or primary caregivers reported that the provision of all communication options was a gap. A total of 88% of parents or primary caregivers reported gaps in the provision of information about communication intervention strategies, whilst 71% of these parents or primary caregivers reported Sign Language classes as a gap during informational counselling. The impact of the hearing loss on speech and language development was reported as a gap by 44% of the parents or primary caregivers. Amongst other reported gaps by participants were care pathways (1%), hearing aid benefits (31%) and troubleshooting (9%), websites (19%), support systems (21%), environmental modifications (1%) and all available rehabilitative technologies (28%).Some parents and caregivers reported that for informational counselling to be relevant and influence compliance for follow-up sessions, various aspects need to be considered and evident during informational counselling. Twenty-one (22%) parents and primary caregivers reported that when providing informational counselling, audiologists need to factor in their cultural beliefs only, whilst 28 (29%) parents and caregivers stated that a combination of spiritual beliefs and cultural beliefs needed to be considered during informational counselling. Interestingly, 48 (49%) parents and caregivers reported that audiologists had to factor in their spiritual beliefs as opposed to culture when providing informational counselling. All parents (100%) in the study reported the significance of considering the socio-economic status during informational counselling. As the majority of the parents were first language isiZulu speakers, 67 (69%) proposed that audiologists consider the language used during the provision of informational counselling. Furthermore, 63 (65%) parents reported the significance of considering family dynamics in the provision of informational counselling.This study revealed that the majority of parents were only informed about hearing aids and the bilingual–bicultural communication option during informational counselling. These findings concur with the study by Duldulao and Ramsey , who repIn this study, a great number of parents and caregivers were exposed to information regarding the disability grant. Whilst it is commendable that audiologists are providing these families with the opportunity to access these funds for the benefit of the child with the disability, audiologists should not lose sight of the ethical benefits of this grant and their role in the rehabilitation process to ensure independent individuals in the future. This grant should not be used as a substitute for rehabilitation; however, it should be used in conjunction with rehabilitation to assist families and children who are deaf or hard of hearing to be independent, employable South African citizens. This notion does not disregard the socio-economic status of the majority of these families and the role of the disability grant; however, it supports focus on these children being rehabilitated. Interestingly, the majority of parents were not informed about aural rehabilitation. This questions our stance as rehabilitation specialists, the availability and accessibility of these services and our perceptions of our role as audiologists. These results question the difference between our scope of practice and that of other hearing service providers such as acousticians. The audiologist’s role goes beyond that of diagnosis and extends to that of rehabilitation; however, the results of this study contradict this role in some contexts within KZN province. According to the HPCSA (2012), audiologists are expected to provide aural rehabilitation. Duldulao and Ramsey  reportedIn this study, the participants reported that there was a lack of information regarding the cause of the hearing loss. The lack of providing the cause of the hearing loss by audiologists could be attributed to uncertainty and limitations in the scope of practice as ear, nose and throat (ENT) specialists are expected to provide this information. The fact that some parents blame themselves or are blamed by their spouses when the child is diagnosed with a hearing loss makes the aetiology pertinent for these caregivers. It is when the cause of the hearing loss is known that some parents can deal with the emotions that are aroused by the confirmation of the hearing loss. This also contributes to how parents address and manage the implications of the hearing loss thereafter in relation to traditional beliefs.N = 73) reported to have participated in some kind of parent support group. The common theme identified in this study was the desire for the parents to have access to a parent-to-parent support network. This was a similar finding in this study. Engaging with ‘similar others’ created a sense of belonging for new parents of children who were deaf or hard of hearing and also reduced anxiety that comes as a result of the diagnosis of hearing impairment  (De Andrade, Another aspect was the parents of children who are deaf or hard of hearing being counselled by audiologists who spoke a language different from theirs. The profession of Audiology and Speech Language Therapy is dominated by white therapists who speak English and Afrikaans, whilst the client base is dominated by black individuals who adopt African languages (eds. Moonsamy & Kathard, The sample size was a strength of this study as it allowed the researcher to obtain in-depth information that allows for generalisability within the region. The disproportion in the number of participants accessed from the public and private sectors was a limitation of the study.This study highlighted contextually relevant factors that need to be considered during the facilitation of informational counselling that contributes to the relevance and decision-making process. Future research may explore the outcome of including contextually relevant factors and how this facilitation may contribute to the decision-making process of parents and caregivers.As a result of the controversies and conflicting views on education methodologies, communication options, medical treatment and sensory devices, parents need to be appropriately counselled so that they can be equipped to make informed decisions about the controversial issues that surround intervention for a deaf or hard of hearing child. The information provided for these families through counselling needs to be balanced and at the proficiency level and rate at which family members can absorb the information whilst coping with their emotional reactions. This study highlighted the inefficiencies and lack of service experienced by families of deaf and hard of hearing children. The participants identified informational counselling needs to include the cause of the hearing loss, all available communication options, educational methodologies, rehabilitative technologies and available parent support groups. Audiologists also needed to consider the socio-economic status of the family, cultural and spiritual beliefs and language during the facilitation of informational counselling. This will influence the relevance of informational counselling offered. An understanding of the scope of counselling by audiologists, together with the identified gaps by parents themselves, can help to address the professional response to caring for families with deaf and hard of hearing children, as well as promote parents as advocates for their children.


Presbycusis or age-related hearing loss is a prevalent condition in the elderly population, which affects oral communication, especially in background noise, and has been associated with social isolation, depression, and cognitive decline. However, the mechanisms that relate hearing loss with cognition are complex and still elusive. Importantly, recent studies show that the use of hearing aids in presbycusis, which is its standard management, can induce neuroplasticity and modify performance in cognitive tests. As the majority of the previous studies on audition and cognition obtained their results from a mixed sample of subjects, including presbycusis individuals fitted and not fitted with hearing aids, here, we revisited the associations between hearing loss and cognition in a controlled sample of unaided presbycusis. We performed a cross-sectional study in 116 non-demented Chilean volunteers aged ≥65 years from the Auditory and Dementia study cohort. Specifically, we explored associations between bilateral sensorineural hearing loss, suprathreshold auditory brain stem responses, auditory processing (AP), and cognition with a comprehensive neuropsychological examination. The AP assessment included speech perception in noise (SIN), dichotic listening (dichotic digits and staggered spondaic words), and temporal processing [frequency pattern (FP) and gap-in-noise detection]. The neuropsychological evaluations included attention, memory, language, processing speed, executive function, and visuospatial abilities. We performed an exploratory factor analysis that yielded four composite factors, namely, hearing loss, auditory nerve, midbrain, and cognition. These four factors were used for generalized multiple linear regression models. We found significant models showing that hearing loss is associated with bilateral SIN performance, while dichotic listening was associated with cognition. We concluded that the comprehension of the auditory message in unaided presbycusis is a complex process that relies on audition and cognition. In unaided presbycusis with mild hearing loss (<40 dB HL), speech perception of monosyllabic words in background noise is associated with hearing levels, while cognition is associated with dichotic listening and FP. Age-related hearing loss (ARHL), or presbycusis, affects one of every three persons aged more than 65 years, with an estimated worldwide prevalence of ∼430 million people . PresbycThere are several publications that explore the relationship between cognition and auditory processes in aged populations, with conflicting results. For example, Another important variable that could have a role in modifying the interactions between cognitive and auditory functions is the neuroplasticity derived from the use of hearing aids in subjects with hearing loss. In this line, recent reports show that the use of hearing aid devices can induce neuroplasticity and modify the performance in cognitive tests . These rIn this study, we proposed that to better understand the interactions between cognition and hearing functions, these should be studied in a controlled group of individuals, without the influence of neuroplasticity induced by hearing aids. Therefore, in this study, we aimed to examine the associations between auditory and cognitive functions in non-demented subjects (≥65 years) without previous use of hearing aids. We studied audiogram hearing thresholds; suprathreshold auditory brain stem responses (ABR); speech perception in noise (SIN); dichotic listening [dichotic digits and staggered spondaic words (SSW)]; temporal processing [frequency pattern (FP) and gap-in-noise (GIN) detection]; and cognitive skills including attention, memory, language, processing speed, executive function, and visuospatial abilities.A total of 134 volunteers (≥65 years), with a Mini-Mental State Examination (MMSE) score > 24, were prospectively involved (between 2016 and 2018) in the Auditory and Dementia study (ANDES) cohort. They were all Chileans, belonging to the Recoleta and Independencia districts from Santiago, Chile, and spoke Spanish as their native language. Thirteen subjects did not complete the audiological evaluation, and two patients had missing data. In addition, following the recommendations of the ®, Middelfart, Denmark), DD45 headphones, and B-71 bone oscillator, according to the clinical standards of ANSI S3.6, 2010. The average hearing threshold for frequencies 0.5, 1, 2, and 4 kHz (PTA) was calculated and used for subsequent analysis.We recorded air and bone conduction thresholds for octaves between 125 and 8,000 Hz for all subjects with an AC40 audiometer  with cingulate cortex atrophy , showing®, Middelfart, Denmark) to elicit ABR. The stimuli were broadband clicks delivered through E-A-RTONE™ 3A inserts earphones, with an intensity of 80 dB nHL, and a duration of 100 μs. We used high pass 100 Hz filters and low pass 3,000 Hz filters. Responses were recorded using active electrodes placed on both mastoids and on the forehead (reference or non-inverting), and a ground electrode was secured over the right brow. Waves I to V were identified from two averages of 2,000 repetitions. The amplitudes of waves I and V were defined from the peaks of the respective waves and the negative troughs that followed, and latency from peaks. Amplitude and latency of wave V were measurable in all subjects, while wave I was identified in 109/116 (93.9%) of the cases. When waves I were missing (with detectable wave V), they were imputed with the lower observed value for the amplitude of wave I and the greater observed value for the latency of wave I , delivered to the participant through the AC40 audiometer and DD45 headphones. Before testing each person, we calibrated the audiometer output following the instructions of the manufacturer using a 1 kHz pure tone. According to the availability of evaluations in Spanish, we included the following tests.The battery chosen for the evaluation of AP was developed considering the recommendations of the Lists of 25 monosyllabic words were presented monaurally to each ear with a white noise background at a 10 dB SNR. The result for each ear was the total number of correct answers expressed as a percentage. The sound level presentation was 40 dB above audiogram thresholds .Following a binaural presentation of 20 sequences of digit pairs, subjects had to repeat the four-number sequence . The result for each ear was the total number of correct repetitions for the digits presented to each ear expressed as a percentage. The sound level presentation was 50 dB above PTA .Participants were exposed to 40 sequences of four words binaurally. The result for each ear was the sum of errors for the competing and non-competing performance, that is, the total number of errors for the right and left ears. The level of presentation was 50 dB above PTA . To miniWe used the beta adult version of the Adaptive Test of Temporal Resolution©, with the across channel modality . BrieflyThree tones were presented monaurally and randomly in a set of 30 sequences, with either high  or low pitch (880 Hz) . ParticiCognitive performance was assessed by an experienced psychologist in cognitive tests that were blind to auditory evaluations. Instructions were given orally and visually using a desktop computer. The battery included the Trail Making Test Part A (TMT-A) for processing speed and Part B (TMT-B) for executive functions , WechsleU test and ear differences for auditory processes using the Wilcoxon rank-sum test.For descriptive analysis, we used the median and interquartile range (IQR) of demographic variables. We also explored gender differences using the Mann-Whitney We performed exploratory factor analyses for hearing loss, auditory brain stem, and cognitive domains, allowing us to build composite scores that represented the main aspects of the auditory processes analyzed. To define how many scores were produced by each of these elements, we used the parallel analysis method . Factors•Hearing loss: PTA and DPOAE of both ears.•Suprathreshold ABR: latency and amplitude of waves I and V of both ears.•Cognitive domains: forward and backward digit span, digit symbol, TMT-A, TMT-B, Rey figure, total recall of the FCSRT, and Boston naming test.R-squared value. To estimate pseudo-R-squared values, we used a variance function-based method , median education of 11 years (IQR: 6 years), and a median hearing threshold of 27.5 dB HL (IQR: 17.2 dB HL) for the right ear and 26.3 dB HL (IQR: 21.3 dB HL) for the left ear. Women (62% of the sample) were younger, had better hearing (both PTA and DPOAE), had larger amplitude and shorter latency of wave I of the left ear, shorter latency of wave V for both ears, performed better in SSW for both ears and FP of the right ear, and performed worse in digit symbol and total recall tests . Due to The majority of the subjects had either normal hearing, defined as PTA less than 25 dB HL (49.1%), or mild hearing loss, defined as PTA between 25 and 40 dB HL (36.2%). Only 14.7% of subjects had PTA greater than 40 dB HL. The audiometric profile for both ears was a descending sensorineural hearing loss . The lefThe EFA yielded four composite scores. One factor for hearing loss (DPAOE and PTA) with a Cronbach’s alpha of 0.94. Suprathreshold ABR EFA produced two factors: amplitude and latency of wave I of both ears  and amplitude and latency of wave V of both ears . These were nominated waves I (auditory nerve) and V (midbrain), respectively. Cognitive EFA had only one factor, Cronbach’s alpha of 0.79.R-squared values (<0.15).Next, we fitted models including the variables age, sex, and schooling, and the four factors found with EFA  as independent variables for each of the auditory processes evaluated, included as dependent variables . HearingIn this study, we explored the associations between several abilities of AP with cognition and physiological measures of hearing function in presbycusis without dementia. All the associations and interactions were obtained in subjects older than 65 years of age, without dementia, and with no previous use of hearing aids. Therefore, we excluded any neuroplasticity cofounding factor. Some functions, such as speech recognition in background noise, correlated preferably with hearing thresholds, while other skills such as dichotic listening were mainly associated with cognition.In our study, the performance variability in the SIN task correlated with hearing thresholds and age in both ears but had no interaction with cognition. These results differed from the report by Our study is in agreement with other reports that used word recognition tests in elderly subjects that have also been unable to identify a correlation with cognitive domains. For instance, It is important to highlight that the test we used to assess speech discrimination in background noise is the only validated test for clinical assessments in our country. It has a +10 dB SNR and was easily performed by our volunteers, which could explain possible ceiling effects in SIN performance . We propAnother important factor to consider for SIN performance is hearing loss severity. In our study, we involved adults older than 65 years of age, without previous use of hearing aids. As, in Chile, hearing aids are guaranteed for individuals with hearing loss greater than 40 dB HL, it is relatively difficult to find presbycusis patients with more than 40 dB HL of hearing loss not using hearing aids. In addition, as we followed the recommendations of the R-squared values were near the cut-off value of 0.15 that we used, showing that other variables not included in our study could be important. Previous reports have described a correlation between dichotic digits and cognition. Gates evaluated a group of 313 adults aged between 71 and 96 years . The model including cognition had a pseudo-Our volunteers were mostly women. An effort was made to control gender bias by including gender as a variable in our models. Inclusion criteria required normal hearing or mild to moderate presbycusis participants that could execute tests for AP, thus our results cannot be extended to severe hearing loss. We selected AP tests that were available in Spanish and previously validated in our population . With thIn a population of elderly subjects with normal hearing levels, or mild to moderate presbycusis (<40 dB HL), the comprehension of the auditory message relied differently on the hearing levels and cognition. Speech perception of monosyllabic words in background noise was associated with hearing levels, while cognition was associated with dichotic listening and FP. Importantly, these findings were not related to neuroplasticity, since none of the subjects had previous use of hearing aids.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Ethics Committee of the Clinical Hospital of the University of Chile, permission number: OAIC752/15. The patients/participants provided their written informed consent to participate in this study.PD and CD: conceptualization and funding acquisition. MT, AL, CB, and BM: data curation. MT, FM-G, CB, and SS: formal analysis. MT, RV, FM-G, CB, AL, SS, BM, CD, and PD: investigation. FM-G and RV: methodology. PD: project administration. BM, FM-G, and RV: software. CD, MT, and PD: supervision. MT, RV, FM-G, CD, and PD: visualization. MT: writing – original draft. MT, RV, FM-G, CB, AL, SS, BM, CD, and PD: writing – review and editing, contributed to the article, and approved the submitted version.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.


To detect the carrier rates of deafness gene variants in populations in Ningbo and analyze the risk of hereditary hearing loss through concurrent hearing and genetic screening tests.  Two thousand one hundred and seventy-four newborns were enrolled from November 2018 to August 2019. All subjects underwent hearing screening and newborn deafness genetic screening with 15 variants in 4 genes, and the positive sites were simultaneously verified by sequencing. GJB2 c.235delC was the variant with the highest prevalence (2.12%), approximately accounting for 48.9% of the total carrier frequency. The carrier frequency of SLC26A4 c.919-2A>G was 0.87%, while the most common variant in mitochondrial DNA (mtDNA) MT-RNR1 gene was m.1555A>G, and its carrier frequency was 0.184%. In the OAE testing, 92 newborns passing hearing screening were tested positively for variants in 4 genes, and 2 of 42 newborns who failed in the first hearing test were found to mutate in 4 genes.  The total carrier rate of genetic variants in Ningbo reached 4.32%, when  Herein, the results concerning the carrier rates for deafness gene mutations of Ningbo population are reported. Our study is beneficial to the insight into the deafness genomic epidemiology for deafness genes in Ningbo population and provides the reference for healthcare in Ningbo. Hearing loss has become a popular illness worldwide that severely endangers people's life quality. In the last few decades, 27.8 million cases of hearing loss, making up a proportion of 33.5% of the total disability, have been reported in China –3. FurthGJB2, SLC26A4, mitochondrial genes, and GJB3 as well as other genes constitute the most prevalent deafness genes of China [Heredity is the biggest cause of hearing loss, and more than 60% of hearing loss patients are related to hereditary deafness genes . Since 2Universal newborn hearing screening is one of the important strategies for early detection and diagnosis of hearing impairment, but it has its own limitations. As for delayed hearing loss, drug-induced hearing loss and other newborns who do not show hearing loss at birth, they cannot be timely detected and predicted. Therefore, the combined screening of hearing and genetic deafness genes in neonates is a scientific means for early detection and intervention of delayed hearing loss and drug-induced hearing loss.In our study, the leading mutation type and rate of four common deafness genes among the newborn in Ningbo were reported, and at the same time, the significance of concurrent hearing testing and genetic screening in a large-scale manner was presented.Totally, 2174 newborns were enrolled from November 2018 to August 2019 in Mingzhou Hospital of Zhejiang University. And the selected cases were all Han Chinese neonates from Ningbo who were to be born in our hospital. The otoacoustic emission (OAE) test and genetic screening were concurrently performed in infants. Besides, all parents had been inquired for a full history and presented a written informed consent prior to the research, while doctors and genetic counselors took charge of explaining screening outcomes and then raising feasible intervening measures for mutation carriers. Here, it should be noted that the research had obtained approval from the institutional review board at Mingzhou Hospital of Zhejiang University.μl, and DNA purity (OD 260/280) reached 1.7–2.0.Three blood spots with the diameter of no less than 8 mm were gathered from the heel venous blood in the newborn within 3 days after birth. Then, they were naturally dried and stocked in preparation. Apart from that, the whole blood genomic DNA extraction system kit  was adopted, while DNA concentration was 3–25 ng/GJB2, GJB3, SLC26A4, and MT-RNR1) was made by adopting DNA microarray technology, when their mutations are c.35delG, c.176_191del16, c.235delC, c.299_300delAT; c.IVS7-2A>G, c.2168A>G, c.1174A>T, c.1226G>A,c.IVS15+5G>A, c.1975G>C, c.2027T>A, c.1229C>T; c.538C>T; and m.1555A>G, m.1494C>T. According to the protocol, 15 amplicons in the four genes were augmented using multiplex PCR technology. Then, the PCR reaction mixture had hybridization with specific tag probes fixed onto the microarray chip. Finally, chip signals were scanned and imaged using LuxScan Microarray Scanner and the detection system.CapitalBio Gene Chip array kit (No. 300068) in deafness gene mutation detection, with approval from the National Medical Products Administration, was used in the study. Besides, simultaneous screening on the 4 genes .The OAE screening was performed using Madsen AccuScreen within 48-72 hours after neonatal birth. Then, newborns having abnormal OAE were tested repeatedly 42 days later, and hearing loss was verified through conducting brain auditory-evoked potential (BAEP) and further audiological diagnosis examinations by audiologists of the superior hospital, if the newborn still does not pass the second screening.χ2 or Fisher's exact test was performed in rate analysis, and p < 0.05 was statistically significant.The statistical analysis was made by IBM SPSS Statistics 20 statistical software. The GJB2 gene, accounting for 2.53% in the tested newborns, while there were 3, 31, and 4 mutations detected from GJB3, SLC26A4, and MT-RNR1 genes, respectively, with corresponding mutation rates of 0.18%, 1.43%, and 0.18%, accordingly , accounting for approximately 48.9% of the total carrier frequency, while the carrier frequency of SLC26A4 c.919-2A>G was 0.87%. In addition, the most frequent variant in MT-RNR1 gene was m.1555A>G, and its carrier frequency was 0.184%.The total mutation frequency of the research was 4.32%. Mutations detected from 94 newborn samples were also verified by direct sequencing . The resGJB2 c.299_300delAT heterozygous variant and one case for SLC26A4 c.2168A>G heterozygous mutation , followed by c. 2168A> G, which is the same as the results in domestic literature [SLC26A4 gene. For the Iranian population, SLC26A4 c.1334T > G is the most common mutation, accounting for 10% of the study population [ing loss . SLC26A4ing loss . Thus, pterature . Furtherpulation . In addiIn this study, 4 cases of m.1555A>G homoplasmic mutation were detected. All of these cases passed the newborn hearing screening, but genetic screening results clearly indicated their sensitivity to aminoglycoside antibiotics. Thus, newborns with this gene mutation should avoid ototoxic antibiotics for their entire life. Moreover, the early research reported that the m.1555A>G homoplasmic mutation is among the major reasons of aminoglycoside-caused and nonsyndromic hearing loss .The results suggested 92 of the 94 patients passed hearing screening tests, but they were tested positive for mutation screening. Patients experiencing mutations did not undergo hearing loss when they were young, but abnormal hearing might occur in their late life . In addiGJB2 gene but also warn of large vestibular aqueduct syndrome caused by SLC26A4 gene and drug-induced deafness caused by MT-RNR1 gene, aiming to effectively prevent the occurrence of delayed deafness and drug-induced deafness.The joint genetic screening of neonatal hearing and hereditary deafness provides a scientific means for early detection and intervention of delayed and drug-induced deafness. Universal newborn hearing screening is one of the effective strategies for early detection and diagnosis of hearing impairment. However, newborns who do not show hearing loss at birth, such as delayed and drug-induced deafness, cannot be detected and predicted in time, resulting in the omission. Neonatal deafness gene screening can not only detect children with congenital deafness caused by MT-RNR1, while the next-generation sequencing cannot reach [In the research, the gene chip array was applied for approximately 5 h in every test. Thus, with cost-effective and rapid turnaround, the screening of large populations is feasible. Here, it should be noticed that the next-generation sequencing provides a stronger solution , 14,wherot reach , 15.In conclusion, our research helps understand the deafness genomic epidemiology in Ningbo population and provides insight and evidence on healthcare in Ningbo. However, there are also some limitations. First, there is no enough large sample number of newborns with concurrent genetic and hearing screening. Second, although the hearing screening is passed, long-term follow-up is still required. Third, human cytomegalovirus (HCMV) infection is not planned in our research. HCMV screening might improve the detection for newborns with hearing loss risk but passing newborn hearing screening .