Triclosan (TCS) and triclocarban (TCC) are antimicrobial agents that have been used in personal care and consumer products in the past decades. In this study, influent, effluent, and sludge samples collected in selected wastewater treatment plants across the Durban metropolis were qualitatively and quantitatively investigated. It was revealed that the concentration of TCS ranged from 1.906 to 73.462 µg/L, from 1.732 to 6.980 µg/L, and from 0.138 to 2.455 µg/kg in influent, effluent, and sludge samples, respectively. The concentrations of TCC were found to be between 0.320 and 45.261 µg/L, <LOQ–1.103 µg/L, and from 0.107 to 8.827 µg/kg in the influent, effluent, and sludge samples, respectively. Higher concentrations of TCS as compared with TCC were observed in the aqueous samples. However, the concentrations of TCC in the sludge samples were significantly higher than the level of TCS. More water solubility of TCS could be responsible for the observed trend in the influent and effluent samples, while the trend observed in the sludge could be due to the more hydrophobicity character of TCC. The results of this study indicated that substantial amounts of TCS and TCC are been removed during the treatment process which could be a major reason for the decline in the levels recorded in the effluent samples, therefore, reducing the amount of the TCS and TCC that would eventually end up in the surface rivers. Qualitative analyses of the samples indicated the presence of caffeine, tert-butylhydroquinone, chloroxylenol, phenol, 4-, and dimethyl-bisphenol A. Further investigative ecological risk assessment studies are crucial due to the potential threat the contaminants may pose to aquatic lives and humans. Wastewater systems are the primary source of pollution via which pollutants find their way into surface water systems. The pollution associated with wastewater channels is mostly of anthropogenic origin that could result from domestic, industrial, agrochemical, and pharmaceutical sources or a combination of those, which form a major point source of surface or underground water pollution ,2. It isN′- urea) (TCC) (w/w) and 2% (w/w) of TCS and TCC, respectively [Triclosan (5-chloro-2-[2.4-dichloro-phenoxy]-phenol (TCS) and triclocarban (N-(4-chlorophenyl)-a) (TCC) a,b, are ectively ,12,13,14ectively ,12,15. Tectively ,17. The ectively . Similarectively . Researcectively . Triclosectively . In thisectively ,21,22. Sectively  reportedectively , and Traectively  at levelThe potential health risks of TCS and TCC to human and animal health have been documented ,27,28. RApart from personal care products that constitute a threat to aquatic bodies, inorganic pollutants such as the excessive release of nutrients including ammonia, phosphate, chlorides, and nitrous oxide, as well as heavy metals are also inimical to the survival of aquatic biotas. Regrettably, the public is unaware of the associated hazards. Human activities have contributed significantly to the pollution loads of surface waters, which are the main sources of water for larger populations within their catchment areas. The overbearing effects of surface water pollution due to human activities have led to water stress and have contributed significantly to the inadequate supply of water for aesthetic use. This could also have direct impacts on the ecological and corresponding health effects on aquatic lives and humans. Therefore, to protect aquatic ecosystems, as well as drinking water supplies, it is important to examine the fate of TCC, TCS, nutrient concentrations, and other wastewater physicochemical parameters following release to the environment, which was the aim of this study. The main objectives of this study were: to evaluate the levels of nutrients and other physicochemical properties in the influent and effluent samples collected across the Durban metropolis; to quantify the levels of TCS and TCC in the influent, effluent, and sludge samples; to qualitatively determine other contaminants of concern present in the wastewater samples.The data generated and the results of this study would provide the much-needed information that could be useful for the relevant agencies on the levels and fate of targeted pollutants. Due to the crucial nature of this study’s subject matter, the results should propel further studies to identify the best possible remediation approach for targeted and other potential emerging contaminants in wastewater, and therefore, to safeguard the receiver surface water along with the point of their discharge.®, South Africa; anhydrous sodium sulfate, organic solvents HPLC grade dichloromethane, and acetone (organic solvent) were supplied by DLD Scientific, South Africa. Glass fiber filters  were used. Sample interference is a problem in an analytical analysis and, as such, could jeopardize the integrity of the process. The glassware was soaked in an acid bath with tap water for a 24 h duration; the use of detergent or soap was carefully avoided because these could introduce the targeted analytes (TCS and TCC) into the samples, thereby, leading to an overestimation of the TCS and TCC. The glassware was removed from the acid bath, rinsed with running tap water, and then with deionized water; the glassware was finally rinsed with acetone and placed on a rack to dry. The dried glassware was placed in an oven set at 135 ℃ overnight for further sterilization prior to use. This was done to eliminate any possible carryover effect and contaminations during sample preparations.Triclosan and Triclocarban standards were purchased from Sigma-AldrichThe study areas were: the Isipingo Wastewater Treatment Works (29°59′24.936″ S 30°54′21.78″ E), Southern Wastewater Treatment Works (29°55′51.456″ S 30°59′53.268″ E), Northern Wastewater Treatment Works (29°48′49.356″ S 30°52′23.7″ E), and New Germany Wastewater Treatment Works which is known as an innovative water treatment (29°47′43.44″ S 30°59′53.268″ E). The global positioning system (GPS) was used to supply accurate sampling position sites. The map of the sampling locations is presented in This research explored four WWTPs in the Durban metropolis, KwaZulu-Natal, South Africa. The WWTPs where samples were collected were Isipingo WWTP, Southern WWTW, New Germany WWTP, and Northern WWTP. Influent, effluent, and sludge samples were collected from each of these WWTPs. Raw wastewater (influent), sludge, and final effluent samples were collected at three different points at varying time periods from each WWTPs to ensure a fair mixed representation of the samples. A composite sample was obtained by mixing the samples from the three points. The sampling campaign was done from 15 to 21 September 2021 between 8:15 to 10:35 a.m.; 250 mL influent and effluent samples were collected from each point to make approximately 750 mL after mixing per sampling point. Water samples for TCS and TCC were collected using an amber glass bottle to avoid leaching of phthalate esters that could introduce an extraneous material and interfere with the analytes of interest. Water physicochemical parameters such as pH, electrical conductivity, total dissolved solids (TDS), and salt were measured on-site using a portable multi-parameter meter . Samples were kept cool in a cooler box and transported safely to the laboratory. Upon transport to the laboratory, the influent and effluent samples were filtered through joint suction filtration glass Buchner funnel conical flask filters, and stored in a refrigerator at 4 °C prior to further analyses at the Department of Chemical Engineering, Mangosuthu University of Technology, UmLazi. Sludge samples are dewatered using centrifugation, as described by Lozano et al. , at 450 Filtered wastewater samples were subjected to liquid–liquid extraction as reported by Lehutso et al. , but witNutrients such as ammonium, nitrate, nitrite, phosphate, and total chloride were determined in wastewater samples using a nutrient analyzer .2 = 0.9996, respectively.The use of solid and liquid soap and antibacterial-coated papers were carefully avoided as much as possible for cleaning any of the glassware during sample preparation. All the sample preparations were done within 72 h. Laboratory blanks were prepared alongside the real sample in the case of external influence, which could introduce the analytes of interest into the samples, thereby, leading to overestimation of a result. The purities of 99.7%, 99.5%, and 95% HPLC grade of DCM, acetone, and n-hexane, respectively, were used in this study. To evaluate the effectiveness of the method for the sample preparation procedure, recovery studies were undertaken. The recovery methods were done by spiking a 5 µg/mL containing TCS and TCC solution in 250 mL distilled water. The solution mixtures were equilibrated overnight and treated as performed for the real wastewater samples. The percentage recoveries were found to be 92%, and 85%. The limit of detection and quantifications were evaluated using three (3) and ten (10) times the standard deviation of the blank with a slope of the regression line respectively. The obtained values were 0.0442 and 0.142 µg/L for TCS and 0.134 and 0.430 µg/L for TCC, respectively. During each analysis in this study, freshly calibration standards were prepared for each set analysis and the regression equation and relative response values were y = 415,949x – 51,010 and RIn this study, an ecological risk assessment was determined. The risk quotient (RQ) and hazard index (RI) were adopted  to asses to be 3 .The wastewater physicochemical parameters and nutrient composition of the influent and effluent samples collected across the Durban metropolis are presented in Ammonia, chloride, and phosphate ions are among the nutrients evaluated in this study. Notably, the amount of ammonia recorded in this study ranged between 29.10 and 36.86 mg/L and between 3.93 and 40.80 mg/L for influent and effluent samples, respectively. The primary sources of ammonia in wastewater are raw domestic, industrial sewage, or agricultural runoff . ElevateDue to their frequent usage, the environmental implication to aquatic life, and the health-associated effects of TCS and TCC on humans, it is crucial to evaluate the levels of TCS and TCC from raw sewage and effluent that finally end up in surface water. Four selected WWTPs across the Durban metropolis were sampled in this study. These WWTPs receive their raw sewage from domestic sources and a few receive from both domestic and industrial sources. Raw wastewater and effluent were both evaluated for contaminants of concern in this study; the results are presented in On the one hand, the concentrations of TCS in the influent and effluent ranged from 1.91 to 73.50 µg/L and from 1.732 to 6.980 µg/L, respectively. On the other hand, concentrations of TCC in the influent and effluent ranged from 0.589 to 45.30 µg/L and from 0.344 to 1.103 µg/L, respectively. The results indicated that substantial amounts of TCS and TCC are present in the samples. Based on the distributions of TCS and TCC across the sampling point, it was noted that the contaminants of concern were present at levels above the detection and quantification limits (LOD and LOQ) of 0.177 µg/L and 0.536 µg/L, except for the TCC in the SWW1 that received its waste from both domestic and industrial sources. At this point, the concentration of TCC in the domestic influent was 0.321 µg/L, which was below the LOQ. TCC at the Isipingo, New Germany, and Northern wastewater effluent samples had concentrations of 0.344 µg/L, 0.372 µg/L, and 0.348 µg/L, respectively, which were well below the LOQ. Among the waste treatment plants, the Isipingo plant was noticed to have the highest levels of both TCS and TCC in its influent sample followed by New Germany, which also recorded a reasonable level of TCC in its sewage influent sample 5.554 µg/L). The possible scenario for this observation could be that the treatment plants received a higher volume of waste from personal care and consumer products (PCPs) that contain higher percentages of these contaminants than other WWTPs. In addition, the consumption patterns of PCPs with TCS and TCC formulation among the residents within their respective locations or catchments could be responsible for the elevated concentrations observed at these locations. Other important factors for the increase in the concentration at these plants could be variations in the consumption patterns, types, volume and composition of waste streams being received, treatment technologies, and effectiveness of the WWTPs adopted  µg/L. Th also repow). These properties typically enable TCC to have substantially higher antimicrobial concentrations in wastewater sludge as compared with TCS. TCS has high water solubility (10.0 mg/L) with a pKa of 7.9 and is prone to microbial degradation, preferentially being converted into its metabolites through biotic and abiotic processes and mechanisms within organisms and WWTPs as well as in the environment [The levels of TCS and TCC found in the sludge samples collected across the selected WWTPs in this study are presented in ironment ,56,57. Wironment ,22, althironment .The concentrations of TCS and TCC in sludge samples were both generally higher than those found in filtered influent samples. This could primarily be due to their sorption capacity and relatively high hydrophobic character ,58,59,60The ecological risks of TCS and TCC in influent and effluent samples collected from four different wastewater treatment plants across the Durban metropolis using RQ were evaluated. It is important to know the risks the discharge of the final effluent could pose when the pollutants are not efficiently removed during the treatment processes from wastewater plants. The values of RQ are presented in According to the risk ranking criteria, RQ < 0.01, 0.01 < RQ < 0.1, 0.1 < RQ < 1, and RQ > 1 indicated minimal risk, low risk, medium risk, and high risk, respectively ,67,68. TA similar observation was recorded by Musee  where th8H10N4O2), tert butylhydroquinone (C10H14O2), chloroxylenol (C8H9OCl), phenol, 4- (C14H22O), and dimethyl-bisphenol A (C17H20O2). The details of these compounds in terms of their properties, sources, and application, as well as environmental and health impacts are well documented in In this study, extracted filtered wastewater samples were qualitatively analyzed for any possible contaminants of concern (CECs) using GC-MS. The notable compounds qualitatively identified are presented in The findings of this study are important due to the crucial nature of the health-related issues of TCS and TCC to aquatic environments and human health. TCS and TCC enter the aquatic environment through wastewater and effluent discharge pathways. In this study, influent, effluent, and sludge samples collected in selected wastewater treatment plants across the Durban metropolis were quantitatively investigated to determine the concentration levels of TCS and TCC. In addition, samples were qualitatively analyzed to identify any possible contaminants of concern. The results of this study revealed that TCS and TCC were present in the samples analyzed. It was observed that the concentrations of TCS ranged from 1.906 to 73.462 µg/L, from 1.732 to 6.980 µg/L, and from 0.138 to 2.455 µg/kg in influent, effluent, and sludge samples, respectively. The concentrations of TCC were found to be between 0.320 and 45.261 µg/L, <LOQ–1.103 µg/L, and from 0.107 to 8.827 µg/kg in the influent, effluent, and sludge samples, respectively. The concentrations of TCS were found to be higher in the aqueous samples as compared with those recorded for TCC in the same medium. However, the concentrations of TCC in the sludge samples were significantly higher than the levels recorded for TCS. The trend observed could be due to the higher aqueous solubility of TCS and more hydrophobicity character of TCC. Another possibility could be that TCS is more frequently applied as an antimicrobial agent in personal care and consumer products. Generally, the mean concentrations of TCS and TCC in influent and sludge samples were both higher than those found in the effluent samples across the treatment plants investigated. In addition, the risk quotient was evaluated in the influent and effluent samples. The RQ values in the influent samples were generally lower than those found in the effluent samples. The RQ value reported for TCS was found to be significantly higher than TCC; therefore, TCS could pose a greater threat to organisms in contact with aquatic environments than TCC. It could be assumed that the treatment processes adopted by the treatment plants were able to remove substantial amounts of TCS and TCC from the raw sewage waste before being discharged to nearby surface rivers, thereby, reducing the ecological risk that could be associated with TCS and TCC in the environment. The qualitative investigation revealed that some endocrine xenobiotic compounds such as caffeine, tert butylhydroquinone, chloroxylenol, phenol, 4-, and dimethyl-bisphenol A were also present. To safeguard aquatic environments and the health of people depending on the receiving rivers across the catchment areas, it is important for frequent monitoring of the levels of these contaminants of concern and to identify the most effective treatment methods to remove these xenobiotics and endocrine-disrupting compounds in raw sewage wastewater before being discharged. There is also a need for proper and quantitative investigations of the levels of caffeine, tert butylhydroquinone, chloroxylenol, phenol, 4-, and dimethyl-bisphenol A in raw sewage and effluent samples, as these compound are more toxic and pose serious health-related issues for humans and aquatic environments.It is believed that the data generated and the outcomes of this study would provide the much-needed information that could be useful for the relevant agencies on the levels and fate of the targeted pollutants. Due to the crucial nature of this study’s subject matter, the outcomes of this study should propel further studies for the best possible remediation approach for the targeted and other potential emerging contaminants in wastewater for safeguarding the receiver surface water along with the point of their discharge.


The Speech, Spatial and Qualities of Hearing Scale has been widely used to assess the subjective sense of auditory ability, functional hearing loss and the resulting benefit of the hearing correction strategy.To translate and culturally adapt the Speech, Spatial and Qualities of Hearing Scale to the Colombian Spanish from Brazilian Portuguese by means of a final version that demonstrates an understanding percentage greater than 85%.The study was divided into three phases: in the first one the translation was done, the retro translation and the modifications were defined by the evaluation team, and in the other two, two pilot tests were made to 50 participants: in the first one the understanding of each of the statements that made up the Speech, Spatial and Qualities of Hearing Scale was examined in 25 people and adjustments were made, and in the second, the same procedure was carried out in 25 other individuals but the document was not changed.It was observed that during the pilot test 1, there was difficulty in questions number 2 of Part 1 (56% understanding), and in 8, 9, 10, 12, 16 and 17 of Part 3 (75%) of understanding), while in others, the degree of understanding was higher than 85%. However, in pilot test 2, understanding was above 85% in all questions. In addition, Cronbach's alpha (0.93) indicated that the items from which the test was constituted measured the same construct and were reliable.The method used allowed obtaining the version of the Speech, Spatial and Qualities of Hearing Scale in Colombian Spanish with an understanding percentage greater than 85%. Hearing is one of the most important senses for the human being, not only because it allows one to remain alert in case of any eventuality, but because on a personal level, it grants access to a constant auditory stimulation that generates different sensations, such as those caused by the sound of birds or a stream of water.The above facilitates the use of hearing in the real world, which includes monitoring the ambient sound, recognizing and locating auditory events, analyzing and controlling one's voice, taking advantage of auditory experiences, and most importantly, perceiving the speech of others and communicating effectively orally.When auditory decreases occur, changes in the quality of life of people develops,Also, in 2004 Stuart Gatehouse and William Noble developed the Speech, Spatial and Qualities of Hearing Scale (SSQ), that is currently made up of three parts with 49 questions, the first enquiries about hearing for language (14 questions), the second one enquiries about spatial hearing (17 questions), and the third one, emphasizing the qualities of hearing (18 questions).The SSQ analyzes the skills to segregate sounds and attend to simultaneous voice flows, as well as the naturalness and clarity in listening yyo or identifying different speakers, pieces, musical instruments and familiar sounds. It is designed to calculate a range of auditory disabilities in several domains, such as language in complex competitive environments, and directional components of distance and movement of spatial hearing.It has been widely used to assess the subjective sense of auditory ability, functional hearing loss and the resulting benefit of the hearing correction strategy.Since its creation in English, it has been applied and adapted to other languages, such as Dutch,On the other hand, in its adaptation to Brazilian PortugueseTherefore, the objective of this study is to translate and culturally adapt the SSQ of adults from the Brazilian Portuguese to Colombian Spanish, by means of a final version that demonstrates an understanding percentage greater than 85%, as established by Miranda and Almeida in 2015, in the adaptation they made of the same questionnaire to Brazilian Portuguese.The design was quantitative, descriptive and transversal. This study was approved by the Ethics Committee with the number 14226719.2.0000.0030.The team was formed by two native Spanish speakers with a Certificate of Proficiency in Portuguese Language (CELPE-BRAS), granted to foreigners with satisfactory performance,In total 50 people over 18 and under 50 years old, participated. 25 women and 25 men, of Colombian nationality, literate in Spanish, approximately 60% of whom were speech therapists, doctors, biologists, economists, engineers, psychologists, nurses and social workers, while the remaining 40% had finished school.All signed an informed consent and manifested that they thought they were listening well, and no objective tests were made in this regard because what was sought was to facilitate textual comprehension.The methodological process was divided into four phases , in whicTwo of the researchers did the translation from Portuguese to Spanish and then two others effected the retro translation, that is, the translation from Spanish to Portuguese, to examine the equivalence between languages and to avoid conceptual, of semantic, operational, measurement and functional variations.Then, it was evaluated by a committee of specialists composed of three speech therapists with experience in the Spanish language area. Necessary modifications were completed and the first version of the document was obtained.As in the Brazilian adaptation,At this stage the pilot test number 1 was carried out. The version of the SSQ resulting from Phase 1 was presented to them, and they were asked to read each question to answer how understandable the statement seemed to them in a range of 0–1, where 0 equaled “not so understandable” and 1 to “understandable”, as shown in the example of Afterwards, the specialist committee reviewed, the answers were analyzed, the drawbacks were identified, adjustments were executed and the second version was obtained.In this part the pilot test 2 was done thanks to the SSQ of the Phase 2. No changes were required, so it was determined that the final version had been achieved.The SSQ of Phase 3 was compared with each item of the Brazilian version,In pilot test 1 of Phase 2, it was observed that all had difficulties in questions number 2 of part 1 (56% understanding), and in 8, 9, 10, 12, 16 and 17 of part 3 (75% understanding), because their percentage of understanding was greater than 68% and lower than 84%. It should be noted that in the other questions, they reached an average higher than 85%.In pilot test 2 of Phase 3, it was noted that all responses were above 85%, which showed that the version achieved was the definitive one.In And in In the same manner, Cronbach's alpha was found, which is a method that calculates internal consistency to determine the reliability of a measuring instrument,In pilot test 1, Miranda and Almeida found comprehension averages lower than 85%, in question 14 of part 2 and in 5 of 3,On the other hand, in Portugal the participants expressed doubts in 1, 2, 3, 4, 6, 8 and 9 of Part 1, in 10, 11, 12, 13, 14 and 16 of part 2 and in 7 and 10 of Part 3.In pilot test 2, in Brazil they achieved 91.6% understanding in all questionsFor Brazilians the midpoints of the parties 1, 2 and 3 oscillated between 5.8 and 9.7, the standard deviations from 0.57 to 3.32 and the minimums from 0 to 8,Taking into account the 49 questions that constituted the test, the Cronbach's alpha in the Brazilian,As can be seen, the methodology allowed the adaptations to be made in each of the countries in question, because it is a procedure that works and could be used in other regions.Even so, when applying the test, some words caused errors of interpretation because they did not help understanding the meaning of the inquiries, as was the case of question 2 of part 1, which initially referred to a “carpet ”, or in questions 8, 9, 10, 12, 16 and 17 of Part 3, where the response options decreased the average comprehension.For example, in question number 10 of Part 3  and in the answer: somehow vs. perfectly; this caused confusion because there seemed to be no coherence between the question and the answer, thus it was modified to: not so clear vs. clear . In the As in the adaptation of European Portuguese,There is no doubt that this instrument allows an effective evaluation before, during and after the auditory rehabilitation, and that its versatility means that it can be applied to people who use different types of single or bilateral support products.As a step to follow, it has elevated its adaptation and pediatric validation and its validation for adults, both in long format and in short format, because this questionnaire needs a standard intercultural adaptation to be able to be compared in several languages and countries.The method used to carry out the translation and adaptation of the questionnaire from Brazilian Portuguese resulted in the version of the SSQ in Colombian Spanish , with an understanding percentage greater than 85%.The authors declare no conflicts of interest.


Aim: to analyze the audiological profile of elderly patients seen in a clinic from an audiology school clinic in the city of Belo Horizonte.we studied all the charts from the patients who underwent audiologic assessment from April of 2004 and August of 2007 in an audiology clinic in the city of Belo Horizonte.We studied the 313 audiological tests from patients 60 years of age or over. The results from the audiological evaluations as to the type of hearing loss were: auditory thresholds within normal standards - 22.28%; sensorineural hearing loss - 60.62%; mixed hearing loss - 14.70%, conductive hearing loss - 2.40%. The level varied between normal and profound. As to the tympanometry, 83.22% had the type A curve, and the other types of curves obtained made up a total of 16.3%. The percentage of individuals who did not undergo the test was 0.48%. 1.76% of the patients who had unilateral hearing loss and 98.24% had bilateral hearing loss.we found a greater prevalence of sensorineural hearing loss, and the degree of the loss varied from mild to profound, with a prevalence of the moderate degree. Hearing loss is the partial or total hearing disability, which can be associated with birth, acquired diseases, use of ototoxic drugs or aging. This change can affect any age range. Children with hearing loss can have development difficulties, while elderly patients have natural hearing loss with aging, called presbycusisQuality of life improvement, improvement in health conditions and chronic and infectious diseases control made people live longer. However, the effects of aging on the sensorial capacities did not change, causing diseases stemming from this aging, which is the case of the hearing loss which affects the elderlyHearing loss is one of the sensorial deficits which has the most impact on the lives of people; because it impairs the person's capacity to effectively engage in communication. Thus, there is a reduction on speech intelligibility, impairing verbal communication, interfering in receiving information, forming and expressing one's ideas. Moreover, there is patient isolation, reduced socialization and intolerance to moderate to high-intensity soundsPresbycusis is the natural aging of the human ear, in other words, a hearing disorder associated to cochlea degeneration, which affects mainly the base of it, impairing hearing perception in the high frequencies as age increasesThe main symptoms the elderly have associated with presbycusis are: difficulties in participating in talks or speaking on the phone; understanding words; locating a sound source; hearing alarms, the telephone, doorbell, approaching vehicles; and there is the need to raise the volumes of TV or radioPresbycusis is defined as sensorineural hearing loss, which varies between mild to profound in the low as well as the high frequencies, having a gradual and progressive onset, symmetrical, descending and bilateral for high frequency sounds 3 to 8KHz), often times followed by difficulties in speech recognitionKHz, ofteAccording to what has been previously reported, presbycusis has a downwards characteristic, being so described by the classification criterion of the hearing loss level of an American study-13.The elderly's audiologic evaluation must involve subjective and objective exams in order to define his/ her audiologic thresholds. Thus, some factors must be observed, such as understanding and the execution of the orders given to the patient in order to obtain an accurate result on the functional use of hearing and understanding. There must be certainty on the orders given to the patient and to check whether or not they are being understood, because the linguistic implications are directly related to the degree of hearing loss, which can vary between mild to severeThe audiologic findings described in the literature show the prevalence of type A tympanometric curves, which configuration represents normality or sensorineural alteration, such as presbycusis, for instanceOnce established that the elderly Brazilian population in recent years has been growing faster than the other age rangesThus, based on the literature investigated, this study aims at tracing the audiological profile, according to the hearing threshold and the type of tympanometric curve of elderly patients who underwent auditory evaluation in an audiology clinic.The present study was carried out after being approved by the Ethics Committee of the teaching institution where it was held, under protocol #O 0107.0.213.000-07. Thus, we surveyed the data according to the charts of the hearing exams, carried out in the institution by the undergraduate students, under the guidance of the speech and hearing professor in charge, between August of 2004 and August of 2007, adding up to a total of 313 hearing assessments and 626 ears.All the assessments were done using the following equipment: Midimate 622 audiometer and the AZ7 immittance meter device, in order to evaluate the hearing threshold and to study the type of tympanometric curve, respectively.The minimum age found was 60 years and the maximum was 94 years, with a mean age of 69.82 years. This age was selected in order to have a better sample homogeneity, as well as a complying with the greater demand from the department where the study was carried out.According to the classification criterion utilizedFor immittance measuring we used the classification criteria of the tympanometric curvesThe present study was carried out through statistical bases which characterize its intrinsic quality: sensitivity and specificity. The findings were described by analysis of frequency and occurrence, by means of descriptive graphics and tables.In most of the individuals (a little more than 60%) there were hearing thresholds of low frequency higher than the auditory threshold in the high frequencies, characterizing a descending type of curve.As to the type of hearing loss, the results from the statistical analysis revealed that 60.78% of the population investigated had sensorineural hearing loss; 14.70% had mixed hearing loss; 2.40% had conductive hearing loss and 22.12% of the individuals had hearing thresholds within normal standards .Table 1TAs to the degree of hearing loss, we noticed they were from mild to profound, and the most prevalent one was the moderate degree .Table 2DOf the 77.88% of the elderly with hearing loss, 1.76% was unilateral and 98.24% were bilateral.As to the audiometric configurations of sensorineural hearing losses, we can see that 61.66% of the individuals had audiologic configuration suggesting presbycusis, in other words, bilateral, symmetrical and descending, of grade varying between mild to severe. On the chart that follows, we depict the auditory thresholds within normal parameters.On On The higher quality of life, the improvements in health conditions and the control of chronic and infectious diseases cause a growth in the elderly population. However, the effects of the aging process on the sensorial capacities did not change, causing diseases which stem from this aging, as is the case of the hearing loss which happens to elderly, called presbycusis, which has as characteristics: bilateral, symmetrical, descending and progressive hearing lossAccording to the bibliography found, we noticed that the percentage of sensorineural hearing loss present in elderly individuals matches those in the present study. One studyThrough the protocols checked, among the elderly with hearing loss, 98.24% were bilateral, which is confirmed by the literature consulted - where there is a prevalence of hearing loss in both ears of the population studied1,13-15,18-20.Observing the data as to the type of tympanometric curves, we noticed that 83.22% of the ears studied had type A curve. In another studyIn relation to the audiometric configuration, 61.66% of the individuals studied had hearing loss with characteristics of presbycusis, in other words, bilateral, from mild to severe, descending, matching findings in the literature - where we find that presbycusis is characterized by sensorineural, symmetrical, descending and bilateral hearing loss for high frequency sounds 3 to 8 KHz) followed by the speech recognition difficulties KHz follIt is important to stress that presbycusis represents the natural order of things, it is part of human life and happens in accordance with the aging processAfter doing this study, with elderly seen in a teaching clinic, we noticed a greater prevalence of sensorineural hearing loss, and the degree of loss varied from mild to profound, with a greater prevalence of the moderate type. Still, the high frequencies proved to be the ones more involved when compared to the low ones, in most of the individuals, characterizing descending audiometric curves, typical of presbycusis. It is also worth stressing that the most frequently found tympanometric curve was the Type A.Therefore, we studied the hearing profile of elderly patients in a given population, thus enabling a bird's eye view on the quality of life of the people in the age range hereby investigated, and we report on a greater prevalence of sensorineural hearing loss varying from mild to profound, with a higher prevalence of the moderate degree.


Stage three or late Lyme disease is characterized by chronic neuroborreliosisA 61-year-old woman was hospitalized on March, 2007 for a progressive bilateral hearing loss with a gait disorder. She had a history of migraine and depression. She also suffered from vertigo of unknown origin, which had been thoroughly investigated in 2004, with a near normal audiometry . Her heaThere was no abnormality in serum inflammatory markers. In the summer 2006, her hearing progressively deteriorated bilaterally . At the Different serologies including syphilis, HIV, cytomegalovirus, listeria, brucellosis were negative. Results of all immunologic analyses were normal. Treatment was started on April 10, 2007 consisting of Ceftriaxone (8 weeks) followed by Doxycycline (3 weeks) with gradual improvement of gait and hearing. When reassessed in March 2009, the patient had returned to normal activities of daily living although still retained a slight dysequilibrium and hearing loss .The patient, who had a previous and misleading history, developed atypical symptoms at the end of 2005 that can secondarily be related to Lyme disease due to the presence of a lymphocytic meningitis, the detection of high titer antibodies and the efficacy of antibiotic treatment.The unique feature was the bilateral hearing loss which developed insidiously in the summer 2006. There are two cases of progressive bilateral sensorineural hearing loss due to late stage Lyme diseaseA progressive bilateral sensorineural hearing loss associated with neurological disorders typically occurs in late stage Lyme disease (stage 3). This feature is different from hearing loss in stage 2 Lyme disease, which has essentially been reported to be unilateral and sudden, but for whom, probably due to the early stage of the disease, the causal relationship is more difficult to demonstrate.


Digital technology can be an effective tool to facilitate emergency assistance in a pandemic, but many deaf and hard-of-hearing elders may experience challenges in using and adopting these technologies. In the context of the second wave of the COVID-19 outbreak, this study employs a qualitative research method based on in-depth interviews to explore technology challenges among deaf and hard-of-hearing elders in China. The results showed that this group's technology challenges arose mainly from barriers to the mastery of digital technology tools, among which barriers to the use of smartphones, to the accessibility of online medical consultations, and to the presentation of health codes, were most noteworthy. For the informants, these barriers led to social isolation and technology avoidance. What's more, the expectation of individuals to adopt certain types of digital intelligence technologies can inadvertently create inequities for disadvantaged groups and exacerbate the “digital divide.” This study highlights the need for emergency management systems to be inclusive of elders with hearing loss in times of public health crises, by providing effective technology support and training to facilitate individuals' access to services and to safeguard their health, interests, and livelihood. The COVID-19 outbreak caused/leads to devastating health damage in the aging population, among whom with hearing loss suffered exponential physical and psychological difficulties during the pandemic and are likely to experience extraordinary adjustment disorders as well . DespiteThe isolating effect of the epidemic has accelerated the digital transformation of all sectors of society, with increased virtual “connectivity” and greater reliance on digital technology . The benTo some extent, the technology barriers and challenges experienced by deaf and hard-of-hearing elders have received attention in the context of epidemic prevention and control efforts in China. On October 20, 2020, the China Disabled Persons' Federation (CDPF), together with the Publicity Department of the CPC Central Committee, the Ministry of Civil Affairs and other departments and units, organized the “Guidelines for Social Support Services for Protection of Persons with Disabilities during Major Infectious Disease Epidemics” , which aOn January 23, 2020, Wuhan, the initial epicenter of the outbreak, was subjected to the most severe area-wide emergency isolation measures, which were implemented in a timely manner and achieved positive epidemic prevention results. Then in July of the following year, a new outbreak occurred in Wuhan and the government again implemented emergency isolation measures that had previously proven to be effective. Compared to the first round of outbreak prevention in 2020, the second round of outbreak prevention in 2021 utilized a large number of digital technologies to regulate the human flows by zones, in order to precisely control the spread of the outbreak. At that time, digital technology became a core survival tool, and learning to use and master it became a fundamental prerequisite for people's basic travel and access to part of essential living materials.According to official statistics, there are 13,000 deaf and hard-of-hearing people in Wuhan , and morThis study is a narrative research based on in-depth interviews through thematic content analysis that explores technology challenges among deaf and hard-of-hearing elders during emergency isolation of an epidemic and their impact. An exploratory understanding of the impact of technology challenges on deaf and hard-of-hearing elders during public health emergencies was obtained through a narrative analysis of extreme situations during special times.The subjects of this study were older deaf and hard of hearing residents aged 60 years and older from eight urban areas in Wuhan, China. The third and fourth authors of the research team are able to communicate fluently with the deaf community through local natural sign language. The research team reopened an interview list that had been used in an emergency communication study survey of disability groups between October and November 2020. At that time, the research team obtained a preliminary list of voluntary participants from the Wuhan Deaf Association, and through purposive sampling, a total of 56 deaf and hard-of-hearing elders aged 60 years and older who lived alone during the emergency quarantine period of the Wuhan epidemic were selected. The number of people who were not willing to participate in the study through initial contact was 38, the number of people who could not be reached due to no answer or change of phone number was 7, and the number of people who volunteered to participate in the follow-up study was 11, resulting in an initial list of interviewees, which was then snowball sampled to expand the list. The final number of interviewees was 13. All 13 participants on this list were revisited at the initiation of this study and individually solicited for their willingness to participate in the study again. All respondents indicated that they were willing to be interviewed a second time and capable of participating in the entirety of this impact study on technology use for people with disabilities, and all participants provided informed consent.n = 7) and resided centrally in urban areas (n = 11). 1 has “congenital” type of hearing loss and 7 have “presbycusis” type of hearing loss. Digital technology use profile: (1) 2 do not have smartphones; (2) 6 could not access outbreak information via smartphones; (3) 3 could not present health codes via smartphones; and (4) 11 could not use online medical consultations  were female, 7 (53.8%) were deaf, and the participants' ages ranged from 61 to 72. The participants were mostly high school graduates or less , followed by an in-depth discussion on more specific questions one by one. With the respondents' consent, the research team used audio and video recording equipment to record all interviews, including 13 respondents' self-reported identities. Seven face-to-face interviews were conducted between May and July 2022, with each interview lasting about 2 h. Most of the interviewees used a predominantly written conversation to express their views, and four of them preferred to use natural sign language to communicate. The research team invited volunteers from the Sign Language Association, who were certified as National Professional Standard Sign Language Interpreters, to assist the research team with sign language communication, interview texts, and sign language interpretation at the interview sites. An associate professor from Yunnan Vocational College of Special Education, whose research specialty is Chinese sign language, provided guidance throughout this study's sign language transcription; a chief physician from the Department of Otolaryngology at the Maternal and Child Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, provided the medical specialty advice to the research team. The third and fourth authors in the research team, who were proficient in the sign language, were responsible for cross-checking all non-verbal information from the interviewees in the original audio and video recordings after all interviews were completed. All organized source materials were sent back to the interviewees for checking and confirmation. Following the methodological guidelines .“You all use things like WeChat (instant messaging software) to check epidemic information and emergency notifications and so on, but I don't very well use my phone. I'm talking about a smartphone, the operation, you know, it's too complicated. Obviously I don't go online either” (Interviewee 9).“Community workers are contacting everyone in the WeChat group, and I'm really not good at using WeChat, and I can't see too many outbreak notifications in the WeChat group” (Interviewee 6).“I couldn't go out during the quarantine period, so I couldn't see my friends or find anyone to talk to, and I had no entertainment to get rid of my loneliness. People said I could chat online, but how could I do that? I typed very slowly and my phone screen was very small, so I felt more and more depressed when I used it” (Interviewee 2).“I was placed in quarantine once. I was so worried when I was under quarantine observation. I prayed every day that the infection would never be confirmed. My children and I had video calls at first, once a day. Watching them through the electronic screen, I gestured and gestured while I was sad, and then I deliberately told them to stop talking every day and that I would call them back if something happened” (Interviewee 13).“The epidemic prevention and control has promoted the development of “Internet+” services in China, such as online medical consultation and online procurement of daily necessities. For most deaf and hard-of-hearing elders, online medical consultation or online appointment procurement is problematic, and it is hardly possible for them to effectively obtain the basic necessities of life. Due to the requirements of epidemic prevention and control restricting daily visits from relatives and friends (Interviewee 8), the deaf and hard-of-hearing elders are unable to get help through acquaintances and rely only on community service staff for assistance in purchasing medicine and medical care, in which not only do they face obstacles in communication, but also may increase the psychological burden of the deaf and hard-of-hearing elders and induce anxiety, depression and other psychological problems.I have high blood pressure and I've been taking antihypertensive pills, and I ran out of antihypertensive pills when I was isolated and didn't know how to buy them. They all say buy medication online, buy medication online, I don't even have a smartphone, how can I buy them, the pills? I want to get permission from the neighborhood council to buy medicine out of the community, and I don't know what online process to go through, and which software to buy medicine on” (Interviewee 7).“During the epidemic I could not buy medicine, hospitals and pharmacies were closed, and access to the community was prohibited, so I could not buy if I was worried about the problem. I was dying of anxiety, and eventually, a community sign language volunteer helped me by teaching me to consult and prescribe medication online” (Interviewee 5).“Health Code is one of the highlights of China's digital anti-epidemic efforts, bringing great convenience to the management of human flows and the prevention of epidemic transmission. The Health Code is a small program that can be installed on smartphone clients , which enables individuals to authenticate and fill in their health status and then use it as an electronic credential for local access. By comparing the data with cell phone roaming trajectory and close contacts, the platform can verify the information filled in by individuals independently and manage the information of administrators in an accurate and dynamic method. With the health code as the identification system, the healthy personnel could pass with the health code in the applicable area .According to official data, 27.2% of Chinese non-Internet users consider that not having access to the Internet will bring various kinds of inconvenience to their lives, and the inability to enter and exit some public places without a “health code” ranks first. For many in the older deaf and hard-of-hearing communities, the lack of proficiency in mastering online skills brought about by aging and a series of derived barriers from hearing impairment make their digital survival a more serious challenge. Worthy of mention is the fact that deaf and hard-of-hearing elders may not be able to self-identify their health using the health code embedded in the smartphone Apps due to a number of factors such as not having a smartphone or not being proficient in using various smartphone functions, which makes their mobility somewhat limited. This important initiative to digitize China's fight against the epidemic has unexpectedly created some difficulties in the use of vulnerable groups.To be honest I don't know how to check the health code on my phone, I tried to learn and tried many times but I can't learn it, it makes me look stupid. I don't want to click on this App again. But you need a health code to go anywhere, and of course you can't go anywhere without a green code” (Interviewee 11).“I didn't have the opportunity to get a good education as a child. It was thanks to my daughter's foresight that I was taught to set up my health code in advance when I was in isolation. I don't know what I would have done without my daughter's help” (Interviewee 6).“Now you have to show a health code to go anywhere out of the community, and I don't have a smartphone and I don't know how to operate it. Thanks to the community, the staff helped me to issue a paper health certificate so I could go out” (Interviewee 3).“Based on the China context, this study is framed at the intersection of disability studies and digital technology studies, exploring both the impact of technology challenges and barriers on deaf and hard-of-hearing elders from a technological perspective and insisting on observing the personal feelings and experiences of deaf and hard-of-hearing elders during the emergency isolation of the COVID-19 epidemic. To this end, this study highlights the subjective experience and subjectivity of people with disabilities and focuses on the digital technology use practices of deaf and hard-of-hearing elders during the epidemic through a qualitative research method of in-depth interviews. In particular, the smartphone is a tool for digital technology use, the health code is a carrier of digital technology form, and the online medical consultation is a technical expression of digital to good, one of the bright spots of digital anti-epidemic . Based oChina has about 27.8 million people with hearing impairment, accounting for one-third of the total number of people with disabilities in the country, and is the country with the largest number of people with hearing disabilities in the world . China aDuring the COVID-19 epidemic, the isolation of living spaces limited face-to-face communication opportunities between the deaf and hard-of-hearing elders and their family and friends, and the deaf and hard-of-hearing elders were unable to use online communication devices and software proficiently due to their physical disadvantages and fear and anxiety about using technology (Interviewee 6), and communicated with their family and friends online less frequently or even disconnected . Findings suggest that the social ties of the deaf and hard-of-hearing elders during the special period, such as kinship, regional and occupational ties, were no longer tight, and social support networks were forced to be disrupted or even completely broken, which made it difficult for them to receive adequate emotional sustenance during the epidemic. In particular, older adults who are congenitally deaf grew up in an environment where the compulsory education system was not well established more than half a century ago, and their adolescence was characterized by the unavailability of a quality K12 education. The objective factors mentioned above lead to the weak reading and writing ability of these groups, and their later interpersonal communication is mostly confined to a small-scaled community, with limited social contact accomplished through natural sign language. In this case, the technological feedbacks support from their children somewhat alleviate the digital survival predicament (Interviewee 6), but due to the limitations of their education level, they will still be relegated to a branch of the population that is the slowest to complete the acquisition of digital skills during the particular period of interpersonal communication breakdowns. The home isolation during the epidemic caused the elders with hearing loss to move from a group-dependent living space to a highly individualized living space. The living space was compressed and the psychological space was divided, leaving the elders with hearing loss in a double isolation of living space and psychological space during the epidemic, and this isolation was reinforced by technology challenges. From another perspective, the social isolation during the epidemic was also an important cause of technology barriers among the deaf and hard-of-hearing elders. Social isolation cut off this group from learning to use digital technology, which made them more vulnerable to unadaptation to new digital technologies and unmet needs during the epidemic due to technology challenges and barriers. In this way, it appears that digital technology becomes an enabler of reverse social isolation in the case of the deaf and hard-of-hearing elders.There are potential limitations of this study to note. First, the sample size used in this study is small and the results obtained could not represent the full sense of the situation. Second, this study is conducted through retrospective interviews and the respondents may have some memory bias, which could have some impact on the results. Finally, the study did not include individuals over age 76, who are likely to experience greater barriers in technology adoption.This study focuses on the impact of technology challenges on the deaf and hard-of-hearing elders during epidemic isolation, how they respond to intelligent technology use, and their perceptions of new digital technologies, and reveals the multifaceted phenomena and diverse experiences of coping technology barriers in this population. Digital technology can be an effective tool to facilitate the provision of emergency assistance in the event of a pandemic, but the deaf and hard-of-hearing elders is likely to experience technology challenges which can lead to serious consequences including limited access to healthcare and essential services as well as social isolation. This study not only attempts to reveal the real existence of this phenomenon, but also expects to shed light on social issues of concern through the presentation of the effects of technology barriers in this particular group. Moreover, this study emphasizes the necessity for emergency management systems to consider the wellbeing of the deaf and hard-of-hearing elders and to provide effective technical support and training to promote social support services for this group and to safeguard the health, interests, and livelihoods of individuals.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.Conceptualization, methodology, writing—review and editing, and supervision: DX. Investigation, data curation, and writing—original draft preparation: SM, CY, and ZZ. Project administration and funding acquisition: DX and CY. All authors have read and agreed to the published version of the manuscript.


The process of selecting and fitting hearing aid devices is only effective and only bring about good outcomes if the individual makes effective use of the device. Therefore, the individuals need to be happy with the outcome.To check the satisfaction of adults and elderly patients concerning their hearing aid in a high complex care clinic accredited by the Unified Health System, and to correlate this outcome with the variables related to age, gender, fitting period, daily use, as well as the type of sound amplifying device.This is a descriptive cross-sectional study in which 60 subjects were evaluated using the questionnaire: Satisfaction with Amplification in Daily Life, applied by means of oral presentation, in individual interviews by the researcher. This instrument is divided into subscales: positive effects, service and costs, negative factors and personal image.It was shown that the subjects of this study were very happy with the use of hearing aid devices. There was significant difference in relating the daily use of the devices with the overall satisfaction score and subscale of personal image.It was found that the subjects of the study were very happy with the use of hearing aids, although satisfaction was not related to the variables: age, gender, time of use and device type. In general, participants with higher daily use are happier. Hearing is a fundamental sense in life, it is the very basis of human communication. Hearing loss causes not only a handicap in the person's capacity to perceive sounds, it brings about psychosocial compromises, keeping the individual from having a healthy social life and playing his/her role in society, which has a great impact on the person's quality of lifeHearing loss has been considered a disabling disease for a long time. In recent years, much has been done to mitigate such stigmas and provide a better quality of life for hearing impaired individualsThe difficulties brought about by sensorial deprivation may be mitigated with the use of an Individual Sound Amplification Device (ISAD), which enables one to recover sound perception, reducing background noises, causing an improvement in communication skillsThe goal of speech and hearing therapists who fit ISAD is to try to please the user, guaranteeing better communication possibilities and contributing to the patient's quality of lifeDespite all the advantages technological progresses may bring about, it is mandatory to understand the real hearing difficulties of the users and their expectations as to the amplification, so as to better guide and individualize clinical carePerformance with the hearing aid reported by the user can better guide the healthcare professionals as to the proper actions to take, enabling one to recognize the advantages provided by these devices in relation to hearing difficulties, preventing users to give up on them, increasing daily use and, consequently, user satisfaction.Therefore, in order to better fit an ISAD to obtain better patient satisfaction, the user's opinion is certainly one of the most important factors.Today, questionnaires have been used with the aim of assessing user satisfaction and drawbacks in relation to ISAD use, and to know whether the fitting has been effective, providing for the auditory, social and emotional needs of these individuals.Satisfaction with Amplification in Daily Life (SADL) questionnaire, proposed by Cox & AlexanderOne of the questionnaires created to assess user's satisfaction concerning the ISAD, as well as its effectiveness is the To create this instrument, first they carried out structured interviews with ISAD users, aiming at obtaining the most important elements associated with satisfaction. Afterwards, experimental satisfaction items were created for each area of importance and, from this, they created a questionnaire with 25 items, which was distributed to ISAD users. They obtained and analyzed the results from 257 individuals, thus getting to the final questionnaire, which presented a high reliability in the test-retest correlation.The SADL was validatedMoreover, studies state that such self-assessment instrument is hugely valuable and easy to apply, efficient and accurate in assessing the individual's satisfaction with the amplification device, encompassing numerous aspectsSistema Único de Saúde (SUS), according to ordinance 589, from October 8, 2004Most of the population from the State and region go through the selection and fitting of hearing aids process in a private high complexity clinic, which has a partnership with the public healthcare service - Based on the aforementioned, the present paper aimed at establishing the hearing satisfaction of adult and elderly patients fitted with hearing aids, in the aforementioned clinic and to correlate patient satisfaction with age, gender, time using the device and type of ISAD.Sistema Único de Saúde (SUS).This is a descriptive cross-sectional study, approved by the Ethics Committee of the Institution, under protocol # 634/11. It was developed in a high complexity service which has a partnership with the Brazilian Public Healthcare System - Inclusion criteria to participate in the study were: individuals from both genders, with ages higher than 18 years, with any type and degree of hearing loss, fitted with an ISAD - supplied by SUS, seen in the clinic where the study was carried out, who agreed to participate in the study and signed an Informed Consent Form.We took off the study those individuals to whom ISADs were not indicated, those who refused to participate in the study, individuals younger than 18 years of age and those with difficulties understanding and expressing themselves concerning the questionnaire.For the sample calculation, we used as basis the mean number of repairs done to devices supplied by the SUS to adults and elderly, by month in the study venue, which is around 155. Using a 10% error and a 95% confidence level, we came to a sample of 60 patients - number of individuals in the sample.Among these 60, 33 were females and 27 were males, with ages varying between 18 and 91 years and mean age of 61 years, which came to the referral clinic between September 22 and October 25 of 2011.Of the individuals in the sample, 49 (80%) used the behind-the-year ISAD and 11 (20%) had the intracanal one. All the individuals had sensorineural or mixed, bilateral hearing loss and used digital ISAD for a minimum time of two weeks - time during which the subjects came to the clinic for the first post-fitting check.Satisfaction with Amplification in Daily Life (SADL) questionnaire, made available by the authors,The user's satisfaction with the ISAD was assessed by means of the Brazilian Portuguese version of the The questionnaire is broken down into four subscales, namely: positive effects, services and costs, negative factors and personal image. The mean score from the four subscales results in the global satisfaction score.The questionnaire has 15 multiple-choice questions, with seven options of answer for each: nothing, a little, somehow, average, considerably, much and very much. The answers are equivalent to a 7-point scale, in which the lowest score is 1, corresponding to the “nothing” answer, and the highest value is 7, corresponding to the “very much” answer, pointing to, respectively, the lowest and the highest degrees of satisfaction. Questions numbers 2, 4, 7 and 13 correspond to the items called “reverse”, in which the score of 7 corresponds to the “nothing” and score 1 corresponds to the “very much” answer.The participants were instructed to assign a score between one and seven for each question.Besides the 15 questions, the subjects were asked about the time they spend using the device daily, with the following options for answers: none, less than one hour a day, from 1 to 4 hours a day, between 4 and 8 hours a day and between 8 and 16 hours a day.The hearing loss type and degree, as well as the time using the ISAD were obtained by means of the study carried out from the patients' charts.The questionnaire was deployed by the researcher, in an unbiased way, by means of a verbal presentation and individual interviews, in order to make sure the individuals in the sample understood the questions and, consequently, improving the quality of the data obtained.Analysis of Variance (ANOVA) and Pearson's correlation statistical tests, both with a 5% significance level (p ≤ 0.05). The variables assessed were: age, gender, time spent using the device daily, time since the first fitting and type of ISAD utilized.The compiled data was analyzed by using the th percentile indicated patient dissatisfaction with the amplification device, scores between the 20th and the 80th percentiles indicated patient satisfaction and, finally, scores higher than 80 indicated that the subjects were very happy with the amplification device , and we found a higher mean value among those individuals who used the device between eight and sixteen hours per day.Upon studying the findings concerning global satisfaction and the personal image subscale, according with the time of daily use, in pairs, we found a significant difference comparing the subjects who reported using the ISAD between 8 and 16 hours per day and the findings from those who reported using it between four and eight hours daily .Regarding the comparison of the global satisfaction degree and by subscale with the fitting time variable, in which the subjects were distributed in four groups , we also did not find significant differences , suggesting that if this study's sample were bigger, the results could have been significant.Upon correlating the daily use of hearing aids with the patient satisfaction per subscale, there was no significant difference between the variable mentioned and the positive effects and services and cost subscales; however, results tend to significance (We found no relationship between satisfaction and time of use. Studies found in the literature report that the ISAD reintroduces the hearing stimulation after amplification, causing a neural plasticity which enables the central pathways to reorganize and start producing positive effects on hearing skillsThe last two findings are complementary, having seen that, since the participants of the study used their devices for over 8-hours a day, adaptation happened in less time.We did not find any difference in the degree of satisfaction among the behindthe-ear and intracanal ISAD users, and such finding is not in agreement with what has been found in other studiesFinally, we noticed that the SADL questionnaire proved to be an efficient and accurate instrument to assess the level of satisfaction of hearing aid users, as per published in the literatureWe noticed that the participants of the study are very happy with their ISADs; however, satisfaction has no relationship with the variables: age, gender, time of use, and type of individual sound amplification device. In general, the subjects with the longer time of daily use are happier with their devices.


Binaural and spatial hearing allows us to localize the source of a sound and to function in complex acoustic environments. In noisy environments we typically focus on one sound source, e.g., our conversation partner, and ignore background noises. The sound localization pathway in the auditory brainstem contributes to this ability by associating various competing sounds with their respective spatial channel. Normal hearing humans and many animals can localize and discriminate sound sources with a precision of just a few degrees. This is accomplished by comparing the interaural time difference (ITD) and interaural intensity difference (IID) that a sound creates between the two ears, which vary systematically with the location of the sound source in space. Even small alterations in this brainstem circuit can have major effects on one's ability to function in an acoustically busy environment. This special edition highlights some of these alterations in animal models and human subjects and discusses medical conditions associated with impaired hearing in noise.Gallun discusses the clear need for better diagnostic tools, including behavioral and neurophysiological tests to determine the specific alterations in any particular case.Importantly, the alterations discussed here affect central neural circuits and are not dependent on decreased ability to detect sounds; in many cases, however, a patient might experience both peripheral and central hearing loss. A combination of alterations along the ascending auditory pathway makes diagnosis and treatment of this condition very challenging. A review by Koerner et al. show the dependence and variance of physiological and behavioral measurements in a common form of age-related hearing loss alters CNS binaural circuits. Affected listeners have clinically normal hearing thresholds but struggle to understand speech in background noise. Alterations in the binaural system of these listeners cause impaired processing of temporally fast and precise binaural cues that can be detected with electrophysiological measurements that are directly related to the behavioral ability to decode binaural cues correctly. This suggests that non-invasive physiological tests can potentially be used to quantify behavioral difficulties in affected listeners.Wu and Kaczmarek). An overwhelming majority of patients with FXS and ASD are hypersensitive to auditory stimuli and have difficulty in distinguishing speech sounds from background noise. As reviewed by Rotschafer, these abnormalities of auditory processing can often be detected by electric and magnetic signals recorded from the cerebral cortex of humans.The ability to localize sounds is also severely disrupted in autism spectrum (ASD) disorder and inherited forms of intellectual disability such as Fragile X syndrome (FXS). FXS is caused by loss of Fragile X Mental Retardation Protein, FMRP, an mRNA-binding protein that controls translation and also regulates neural excitability by binding ion channels , underscores the importance of early interventions to hearing loss.In addition to genetic mutations, experiencing incorrect binaural cues during development may impair the high level of precision required for sound localization. The finding that abnormal early sound experiences can result in binaural neurons that incorrectly code for spatial location even in adulthood ; NIH DC01919, NS102239, and NS111242 (LKK); NIDCD R01-011555 and NIDCD R01-017924 (DJT and AK); and NIDCD R01-018401 (AK).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.


The H9N2 virus can infect not only birds but also humans. The pathogenicity of H9N2 virus infection is determined by an excessive immune response in the lung. All-trans retinoic acid (ATRA), the active metabolite of vitamin A, plays an important regulatory role and has been widely used in the clinical practice. This study was aimed to investigate whether ATRA could regulate the immune response to H9N2 virus infection in the lungs of mice, thereby reducing the pathogenicity of the H9N2 virus in mice.Mice were infected intranasally with H9N2 virus, and injected intraperitoneally with 0.2 mL of ATRA at low (1 mg/kg), medium (5 or 10 mg/kg), or high therapeutic dose (20 mg/kg), and toxic dose , once per day for 10 days. Clinical signs, survival rates, and lung gross pathology were compared between the ATRA-treated H9N2-infected group, the ATRA group, and the H9N2-infected group, to investigate the effect of different doses of ATRA on the pathogenicity of H9N2 virus. Additionally, the viral load and cytokine concentration of lungs were measured at 3, 5, 7, and 9 days after infection, to investigate the potential mechanism of ATRA in affecting the pathogenicity of the H9N2 virus. Expression levels of cellular retinoic acid-binding protein 1 (CRABP1), cellular retinoic acid-binding protein 2 (CRABP2), and Retinoic acid-inducible gene-I (RIG-I) were detected using Western blotting.The ATRA-treated H9N2-infected mice showed more severe clinical signs compared with the H9N2-infected group. The medium and high therapeutic doses of ATRA reduced the survival rates, aggravated lung tissue damage, decreased the expression of interferon beta (IFN-β), and increased the concentrations of interleukin-1 beta (IL-1β), tumor necrosis factor alpha (TNF-α), and C-C motif chemokine ligand 2 (CCL2) in the lungs of the H9N2-infected mice. At the same time, the expression patterns of CRABP1, CRABP2, and RIG-I were changed in mice infected by H9N2 and treated with different concentrations of ATRA.Our findings suggest that the therapeutic dose of ATRA can increase the pathogenicity of the H9N2 virus. Therefore, the consequences of those infected by influenza virus would be more severe after ATRA treatment.The online version contains supplementary material available at 10.1186/s12985-022-01809-y. The H9N2 influenza virus, the most widespread subtype of influenza viruses in poultry, has been prevalent in China since 1994, and has transmitted widely around the world in multiple avian species –8, indicAll-trans retinoic acid (ATRA), the biologically active metabolite of vitamin A, plays an important regulatory role in embryonic development, organ growth, metabolism, cell proliferation and differentiation, apoptosis, and immune response regulation –15. ATRAATRA plays its regulatory role via binding to and activating nuclear retinoic acid receptors (RARs) and retinoid X receptors (RXRs) , which aThe aim of our study was to investigate the effects of different doses of ATRA on the pathogenicity of the H9N2 virus in mice, providing guidance for ATRA treatment on the prevention of influenza virus infection, which has important public health implications.To investigate whether ATRA affects the pathogenicity of the H9N2 virus in mice, two sets of experiments were done  in 100 µL per mouse] to simulate a natural infection of H9N2 virus, followed by intraperitoneally injection with ATRA at a low (1 mg/kg), medium (5 or 10 mg/kg), or high therapeutic dose (20 mg/kg), or a toxic dose  at 0–9 days after inoculation (n = 18–22 per group). The mice were monitored for 19 days, and their body weight, food intake, survival rate, and lung gross pathology were compared between the groups.To determine the effect of different doses of ATRA on the pathogenicity of the H9N2 virus, mice were inoculated intranasally with low-dose H9N2 virus [105.5 TCID50 in 100 µL per mouse), followed by intraperitoneally injection of the low (1 mg/kg) or medium (5 or 10 mg/kg) therapeutic dose of ATRA at 0–9 days after inoculation. The mice (n = 22–24 per group) were monitored for 19 days, and their clinical signs , survival rate, pulmonary pathological changes  were compared between the ATRA-treated H9N2-infected group, the ATRA group, and the H9N2-infected group. In addition, lung viral load and cytokine concentrations were measured at 3, 5, 7, and 9 days after H9N2 virus infection (n = 5 per group), to assess the ability of the lungs to clear the virus and the innate immunity level, so as to investigate the potential mechanism of ATRA in affecting the pathogenicity of the H9N2 virus in mice. In all experiments, the mice were treated in the same order each time.To further differentiate the effects of low and medium therapeutic doses of ATRA on the pathogenicity of the H9N2 virus, mice were inoculated intranasally with medium-dose H9N2 virus (10Specific pathogen-free (SPF) male BALB/c mice (6- to 8-week-old) were purchased from the Beijing Vital River Laboratory Animal Technology Company Limited (China). Mice were housed in microisolator cages ventilated under negative pressure with HEPA-filtered air. Water and food were offered ad libitum. All animal experiments were approved by the Laboratory Animal Welfare and Animal Experimental Ethical Committee of the China Agricultural University.2 [50) of ATRA in Swiss mice was 31 mg/kg by intraperitoneal injection [World Health Organization (WHO) recommended oral supplementation at 30–60 mg of ATRA for infant children 6–59 months of age . The dos2 . As reponjection , and the50 on Madin-Darby canine kidney (MDCK) cells, and calculated by the method of Reed and Muench, as described previously [The influenza A virus strain used in this study was A/Chicken/Hebei/4/2008 (H9N2) isolated by our laboratory , 36. Theeviously , 38.5 TCID50 was used as the low-dose H9N2 virus, which would not cause mouse death but significant clinical symptoms, and 105.5 TCID50 was used as the medium-dose H9N2 virus, which could cause death in half of the mice (that is LD50).A low dose of H9N2 virus, which was close to that in natural infection, was adopted to investigate the effect of different doses of ATRA on the pathogenicity of H9N2 virus, observe the interaction between different doses of ATRA and the H9N2 virus, and simulate the infection under natural conditions. In addition, to further differentiate the effects of different therapeutic doses of ATRA on the pathogenicity of the H9N2 virus, a medium dose of H9N2 virus was used. For infection experiments, the H9N2 virus was diluted into different concentrations with sterile PBS, and inoculated intranasally in a volume of 100 µL into mice that were lightly anesthetized with isoflurane. In this study, 1050/mL of lung homogenate. Finally, lung viral load was measured at 3, 5, 7, and 9 days after H9N2 virus infection.Mice were euthanized by isoflurane overdose, and then the whole lungs were removed, weighed, and homogenized in 1.3 mL sterile PBS. The homogenates were centrifuged, filtered through a 0.22 µm cellulose acetate membrane, serial tenfold dilutions made, and then titrated on MDCK cells. Viral loads were reported as the TCIDThe lung homogenates collected at 3, 5, 7, and 9 days after H9N2 virus infection were centrifuged at 4 °C and 5000 rpm for 15 min, and the supernatants were stored at − 80 °C. Concentrations of TNF-α, IL-1β, interferon alpha (IFN-α), IFN-β, CCL2 and C-X-C motif chemokine ligand 10 (CXCL10) were measured using mouse Quantikine ELISA Kits .g, and the supernatants were separated by SDS-PAGE and transferred onto polyvinylidene difluoride (PVDF) membranes. Then the membranes were blocked with 3% bovine albumin and probed with monoclonals antibody to β-actin , CRABP1 , CRABP2  and RIG-I , followed by incubation with peroxidase conjugated secondary antibody . Proteins were visualized using enhanced chemiluminescence reagent . The relative protein levels of CRABP1, CRABP2 and RIG-I to β-actin were performed by Image J software.The expression of CRABP1, CRABP2 and RIG-I at protein level was detected by western blotting. As described above, the lung homogenates collected at 3, 5, 7 and 9 days after H9N2 virus infection were lysed with RIPA lysis buffer , quantity of total proteins were measured by BCA kit. The lysates were centrifuged at 14,000Mice were euthanized by overdose of isoflurane 5 days after infection. The lungs were removed, fixed in 10% neutral buffered formalin, and embedded in paraffin. The 5-µm tissue sections were deparaffinized, rehydrated, and stained with hematoxylin and eosin (H & E) .P values < 0.05 were considered statistically significant.Statistical analyses were performed with the IBM SPSS Statistics v20, and graphics were performed by means of GraphPad Prism software v8.0. Data were presented as mean ± standard deviation (SD). One-way analysis of variance (ANOVA) with Bonferroni correction for multiple comparions and the log-rank test for survival rate were conducted. P < 0.05), decreased to the lowest on day 7 , and then quickly returned to normal thereafter. No mice died. Taken together, mice infected with the H9N2 virus showed mild and transient clinical symptoms.The effects of the H9N2 virus on clinical signs and survival in mice were shown in Fig. P > 0.05). The ATRA-treated group (20 mg/kg) had ruffled fur on day 4 after the injection, with reduced activity, loss of appetite, and gradually wasting away. Their body weight and food intake were significantly reduced compared with the blank group (P < 0.05). On day 7, the food intake dropped to the minimum level (decreased by 35.6%). No mice died. The ATRA-treated groups  presented severe clinical signs, including dry skin, rapid wasting, decreased activity, and loss of appetite from 2–3 days after injection. Their body weight and food intake continued to decrease until death. Their body weight and survival were significantly different from those of the blank group (P < 0.01). Taken together, mice showed obvious clinical symptoms when injected with high therapeutic dose of ATRA (20 mg/kg), and died when injected with a toxic dose of ATRA (more than 40 mg/kg).The effects of different doses of ATRA on mouse clinical signs and survival were shown in Fig. P > 0.05, Table P < 0.01) and days 7–8 (P < 0.05), with the lowest on day 5 (decreased by 42.8%) after infection (Table P < 0.05), and decreased to the lowest on day 5 (decreased by 6.9%) and day 4 (decreased by 7.8%), respectively (Table P < 0.05), by 12.2–15.1% and 34.4–60.6% on day 5 after infection, respectively ; however, there was no significant difference in survival rate , 2.0% (P > 0.05), and 2.0% (P > 0.05), respectively; the food intake decreased by 33.4% (P < 0.01), 30.1% (P < 0.01), and 18.1% (P < 0.05), respectively, on day 3 after infection, and the survival rates were significantly different (P < 0.01), except between the 80 mg/kg ATRA group and the 80 mg/kg ATRA-treated H9N2-infected group , and the survival rate was 50%, which was significant different from the blank group  and medium (5 and 10 mg/kg) therapeutic doses of ATRA on the clinical signs and survival rate of H9N2 virus, mice were inoculated with 10P < 0.01). Compared with the 1 mg/kg ATRA group, their body weight was significantly different at 2–10 days and 16–19 days after H9N2 infection , but a significant difference with the 1 mg/kg ATRA group . Compared with the 5, and 10 mg/kg ATRA groups, the body weight of the ATRA-treated H9N2-infected groups also significantly decreased . Compared with the 1, 5, and 10 mg/kg ATRA-treated groups, the lung viral loads of the 1, 5, and 10 mg/kg ATRA-treated H9N2-infected groups significantly increased 3 days after H9N2 infection      , but decreased at 7 and 9 days (P < 0.05)              Fig. a–c, and 05) Fig. d, wherea05) Fig. e, f. Aft05) Fig. e, withou05) Fig. a, and th05) Fig. e. After 05) Fig. a, d, the05) Fig. c, the le05) Fig. e, and th05) Fig. f. Compar05) Fig. f, and th05) Fig. a–e. In t05) Fig. a, the le05) Fig. c, and IF05) Fig. f. In the05) Fig. a, the le05) Fig. c, and th05) Fig. f.Fig. 8EThus, the medium and high therapeutic dose of ATRA could significantly improve the pulmonary inflammatory response of the H9N2-infected mice.As shown in Fig. 50 was 31 mg/kg in Swiss mice after intraperitoneal injection of ATRA for 21 days [In the present study, we investigated whether ATRA could reduce the pathogenicity of the H9N2 virus, by modulating the pulmonary immune response. In the first part, mice were infected with low-dose H9N2 virus to simulate a natural infection of H9N2 virus, followed by the administration of different doses of ATRA. Firstly, we evaluated the clinical manifestations of mice infected with H9N2 virus alone or mice given ATRA alone. We found that compared with the blank group, the body weight and food intake of the H9N2-infected group were significantly reduced on days 5–7, and then quickly returned to normal. Compared with the blank group, the 1, 5, and 10 mg/kg ATRA-treated groups showed no obvious clinical symptoms, the 20 mg/kg ATRA-treated group showed significant body weight and food intake declines, and the 40, 60, and 80 mg/kg ATRA-treated groups showed severe poisoning symptoms, eventually resulting in the death, which were consistent with the results of a previous study by Hixson EJ et al. reporting that the LD 21 days . SecondlIn the second part, we further investigated the effect of the low (1 mg/kg) and medium  therapeutic doses of ATRA on the pathogenicity of increasing doses of H9N2 virus. We found that the low and medium therapeutic doses of ATRA could aggravate the clinical signs and damages to lung tissues in H9N2-infected mice; furthermore, the medium therapeutic dose of ATRA could reduce their survival rate. These results are consistent with the results of our first experiment. Influenza virus infection is characterized by the recruitment of large numbers of innate immune cells to the lungs that release large numbers of proinflammatory cytokines and chemokines . To inveCRABP1, CRABP2, and RIG-I have been reported to be all involved in the process of ATRA regulation of the immune response in mammals. ATRA up-regulates the expression of RIG-I in a RARα-dependent manner, and enhances the signaling cascade mediated by RIG-I, which induces expression of type I IFN and proinflammatory cytokines , 53. CRAAt present, the research on ATRA antiviral effect mainly focuses on (-) ssRNA virus, including measles virus, mumps virus, canine distemper virus and Newcastle disease virus , 56. TheTaken together, our findings suggested an inconsistent result with previous studies on the role of ATRA in pulmonary inflammation. The increased pathogenicity of the H9N2 virus caused by ATRA may be attributed to H9N2 infection and the further treatment of ATRA, which affected the expression patterns of CRABP1, CRABP2, and RIG-I, and in turn resulted in an aggravated immunopathological damage to the lung.The therapeutic dose of ATRA have a potential in increasing the pathogenicity of the H9N2 virus in mice, which might be the underlying reason for the more severe consequences of ATRA treatment for those infected with the influenza virus.Additional file 1: Flow chart of the experiment.