Sudden hearing loss (SHL) is a disease, at the same time a symptom, which needs to be treated in a timely manner and counts as an emergency health problem in the Department of Otolaryngology. There are many types of sudden hearing loss and among them, the occurrence of all-frequency descending sudden hearing loss and high frequency sudden hearing loss are high. The conventional treatment for these 2 types of sudden hearing loss sometimes is not as effective as expected. Postauricular injection of glucocorticoids could be the most effective treatment method. However, the effectiveness and safety of postauricular injection of glucocorticoid needs to be assessed systematically.The protocol for the meta-analysis was conducted under the guidance of Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). The aim is to undertake a systematic review and meta-analysis on the effectiveness and safety of postauricular injection of glucocorticoid to treat patient diagnosed with all-frequency and high frequency descending sudden hearing loss. We searched through the following databases: English databases  and Chinese databases . The final selected articles will be evaluated using Cochrane RCT evaluation criteria. Revman 5.0 will be used for data analysis. Subgroup analysis, sensitivity analysis, and meta regression will detect sources of heterogeneity. Ethics approval was not required for this protocol. The findings will be disseminated through journal articles or conference presentations.DOI 10.17605/OSF.IO/5Q9NAObjectively, evaluate the efficacy and safety of postauricular injection of glucocorticoid in treating all-frequency descending sudden hearing loss and high frequency sudden hearing loss.To provide evidence-based medicine for glucocorticoid treatment methods in patients with all-frequency descending sudden hearing loss and high frequency descending hearing loss. Sudden hearing loss at the range of 250 to 500 Hz is diagnosed as low-frequency sudden hearing loss, around 1000 Hz is diagnosed as middle frequency sudden hearing loss, above 4000 Hz refers to high frequency sudden hearing loss, hearing loss at all frequencies refers to flat-type sudden hearing loss, and extreme hearing loss at every frequency refers to complete/profound deafness The type of sudden hearing loss focused in this paper is all-frequency descending sudden hearing loss and high-frequency sudden hearing loss.Sudden hearing loss, also known as sudden deafness, refers to a sensorineural hearing loss that occurs suddenly in one or both ears within 72 hours; presented ≥30 dB at 3 consecutive frequencies, and the cause is unknown.,4,5 Glucocorticoids could suppress the immune response of the patient, adjust the inner ear microcirculation of the patient, and then produce the corresponding therapeutic effect, and reduce the situation of membranous labyrinthus hydrops. Moreover, there are many ways glucocorticoids could be administered: intratympanic injection, sustained release of glucocorticoids into the round window membrane, and postauricular injection. According to many clinicians, administer glucocorticoids through postauricular injection could avoid side effects from the whole body administration and avoid blood-labyrinth barrier blocking glucocorticoids from reaching the ear.,7 The purpose of this study is to answer the question whether postauricular injection could effectively treat all-frequency descending sudden hearing loss and high frequency sudden hearing loss. Therefore, a meta-analysis of the effectiveness of glucocorticoid injection behind the ear is necessary.Many clinicians mentioned that postauricular glucocorticoids injection may be one of the most effective treatment method for sudden hearing loss.2The meta-analysis protocol was conducted under the guidance of PRISMA-P and registered on the OSF platform. The registration number is DOI 10.17605/OSF.IO/5Q9NA.2.1Two authors will search English database and Chinese database, independently. The databases PubMed, EMBASE, and Web of Science will be searched with English. The databases included CNKI, Wanfang database, CBM and VIP will be retrieved with Chinese. Subject words and free words will be searched with “and,” “or” and “not.” We will search these databases from the time of establishment of the database to November 15, 2020. The search formula is follows: (“Injection” OR “Injectables” OR “Injectable” OR “Zhu She”) AND  AND .2.1.1(1)The included population is patients with all-frequency or high frequency sudden hearing loss; regardless of the course of the disease, sex, age, and race.(2)The intervention methods are postauricular injection of glucocorticoid and conventional treatment.(3)The treatment of the control group would be conventional treatment.(4)Observation indicators include effective rate, comparison of all-frequency or high-frequency hearing threshold, and incidence of adverse reactions.(5)The study of research is randomized-controlled trial (RCT). If the number of RCT research articles is <7, non-RCT researches can also be included.2.1.2(1)If the patients have any of the following diseases, they would be excluded from the research: acoustic neuroma, inner ear malformation, middle ear disease, hereditary deafness, mental disorder, severe diabetes, and hypertension.(2)Those who are contraindicated to glucocorticoid use will be excluded.(3)Patients during pregnancy and lactation will be excluded.(4)Abstracts, letters, case reports, reviews or nonclinical studies will be excluded.(5)Besides conventional treatment, the experimental group and the control group cannot have other intervention methods, otherwise the study will be excluded.(6)Research on data reuse will be excluded.2.2Two authors will independently select articles according to the flowchart shown below Fig. . If ther2.3Different research types require different evaluation methods. The Cochrane Risk Bias Assessment Tool is used to evaluate the quality of research of RCT. Two authors will use Revman 5.0 software  to evaluate the quality of the article, independently. If there is a disagreement, a third author will be added to discuss together and finally determine the quality of the article. The final results of the article quality evaluation are presented in the form of graphs.2.4Two authors extracted the data independently. If there is a disagreement, the third author will join and discuss the finalization of the extracted content. The information extracted from all selected articles will be stored in an Excel table and appear in the article in the form of a table Table . The sto2.4.1Q test and I2 test are used to detect the size and degree of heterogeneity. When P < .10 or I2 ≥ 50%, it indicates that there is significant heterogeneity. Relative risk is used as the effect scale of effective rate and the incidence of adverse reactions. Weighted mean difference/standard mean difference is used as the effect scale of full-frequency or high-frequency hearing threshold changes. When combining effect size, if P < .05, the combination is effective.The data analysis will be based on the number of articles included. If the number of included articles is ≥7, we will conduct a meta-analysis. If the number of included articles is <7, we will only make a descriptive systematic review. We will use Revman5.0 software for meta-analysis. The analysis includes: combined effect size, heterogeneity test, publication bias, etc. Among them, subgroup analysis, sensitivity analysis, and meta regression will be used to detect the source of heterogeneity. 2.4.2Subgroup analysis is used to explore the source of heterogeneity. Criteria for subgroup classification can be based on clinical characteristics, such as article quality, audiogram characteristics of sudden deafness , length of illness, and conventional treatment plan. In subgroup analysis, the groups are homogeneous and merged into heterogeneity. This factor is the source of heterogeneity.2.4.3I2 > 50%, the random effects model is selected. If I2 < 50%, the fixed effects model is selected. When excluding the articles one by one, it is found that the heterogeneity has changed significantly; the excluded article is the source of the heterogeneity.Changing the analysis model and excluding articles one by one is the content of sensitivity analysis. When 2.4.4P < .05, it indicates that this factor is the source of heterogeneity.In Meta-regression analysis, the dose of the drug injected behind the ear, the patient's age, the patient's sex, and the course of disease can be used as covariates to find the source of heterogeneity. When 2.4.5For publication bias, we will use a funnel chart to identify it. When there is publication bias, the funnel chart is skewed, asymmetry appears.3,9 Among them, the high frequency descending type refers to the frequency above 2000 Hz (inclusive) hearing loss ≥20 dB, the all-frequency descending type hearing loss refers to the 250 to 8000 Hz frequency range average hearing threshold ≤80 dB, and the total deafness type refers to the 250 to 8000 Hz frequency range average hearing threshold ≥81 dB. Mainstream medicine believes that different types of hearing curves suggest different pathogenesis. Among them, the all-frequency descending type is mostly striated vascular disease or inner ear vasospasm, the high frequency descending type is mostly hair cell damage, and the total deafness is inner ear vascular embolism or thrombosis formed. It is also advocated that the medications for different hearing curve types should be different. Medications for the high frequency hearing loss type and the all-frequency descending type  hearing loss include hormone medication combined with microcirculation improvement drugs and neurotrophic drugs. So, these 2 types of hearing loss are discussed together.According to the frequency and degree of hearing loss, it is usually divided into high frequency descending type, low frequency descending type, all-frequency descending type, and total deafness type.–14 According to relevant research results, injections behind the ears can effectively avoid secondary effects caused by systemic medication; symptoms such as insomnia, persistent hiccups etc. Therefore, glucocorticoids injected behind ears are applicable to a larger area than systemic medication. For example, it can be applied to patients with diabetes, gastric ulcers, etc.–17 Behind the ear injections can effectively avoid side effect caused by intratympanic injections like tympanic membrane perforation, otitis media, balance sensory disturbances, etc. Owing to the related reasons, some scholars think inject glucocorticoids behind ear is safer than tympanic injection. Some scholars believe that behind the ears injection may have its own unique drug onset mode, not only it can avoid the blood-labyrinth barrier, but also allow the drug concentrated at the cochlear. Compared with other methods, it is higher and more stable, and it's time to reach the cochlea is shorter, and its curative effect may be better.,19 In clinical practice, more and more doctors use hormone injection behind the ear as an effective treatment for sudden deafness.,20 Especially for patients with sudden deafness who didn’t have a positive response to conventional treatments, it can be used as a salvage treatment. Based on many clinicians’ observation, it is indeed effective. The “Healing and Treatment Guidelines” in the “Diagnosis of Sudden Deafness” published by Chinese experts in 2015 recommended that glucocorticoid injection behind the affected ear as a remedial treatment to treat sudden hearing loss.Glucocorticoids are the preferred treatment for sudden hearing loss, also known as sudden deafness, and the medication methods mainly include systemic medication and topical medication. The first is through the endolymphatic sac; it is found that there is a close connection between the sigmoid sinus and the endolymphatic sac, and the blood supply system of the endolymphatic sac is dual blood supply. Drugs injected behind the ear can enter the endolymphatic sac through the sigmoid sinus and the occipital artery to take effect. The second path is through anatomical fissures; bone fissures and sieve area are examples of the natural fissures. It is possible for drugs to enter the middle ear through the fissures, which can then diffuse to the inner ear to play its role. The third is through systemic circulation route; the drug injected behind the ear is absorbed into the blood, enters the internal jugular vein and the subclavian vein, and then enters the brain from the systemic circulation system to nourish the inner ear and exert its effect. The last method is through the stylomastoid artery; which provides blood supply to the inner ear, and the injection of drugs behind the ear can exert its effect through it.There may be 4 mechanisms for the postauricular injection of glucocorticoids.According to relevant literatures, it is believed that the treatment effect of all-frequency descending hearing loss and high-frequency descending hearing loss is not good enough. Injecting glucocorticoid behind the affected ear(s) seems to bring hope for these 2 types of sudden deafness patients, but it has not been obtained evidence-based support yet, so it is necessary to conduct a meta-analysis and systematic analysis of the efficacy of glucocorticoid injection behind the ear for these two types of sudden hearing loss. We will try our best to collect all data and conduct an objective evaluation of this.Conceptualization: Ying Li, Yang Liu.Data analysis: Ying Li, Jiao Liang.Data curation: Jiao Liang, Han-Jen Chiang.Formal analysis: Jiao Liang, Han-Jen Chiang.Funding acquisition: Yang Liu.Methodology: Jiao Liang, Han-Jen Chiang.Software: Jiao Liang.Study design: Yang Liu, Ying Li.Supervision: Yang Liu.Writing – original draft: Ying Li.Writing – review & editing: Ying Li, Yang Liu.


The study of cognitive impairment associated with hearing loss has recently garnered considerable interest. Epidemiological data have demonstrated that hearing loss is a risk factor for cognitive decline as a result of aging. However, no previous study has examined the effect of hearing loss in patients with cognitive problems such as Alzheimer’s disease. Therefore, we investigated the effect of conductive hearing loss in an Alzheimer’s mouse model. Positron emission tomography (PET) and magnetic resonance imaging (MRI) were used to evaluate changes in glucose metabolism and gray matter concentrations in the 5xFAD Alzheimer’s Disease (AD) transgenic mouse model with and without conductive hearing loss (HL). Conductive hearing loss was induced using chronic perforation of the tympanic membrane. Behavioral data from the Y-maze and passive avoidance tests revealed greater memory deficits in the AD with HL (AD-HL) group than in the AD group. Following induction of hearing loss, lower cerebral glucose metabolism in the frontal association cortex was observed in the AD-HL group than in the AD group. Although lower glucose metabolism in the hippocampus and cerebellum was found in the AD-HL group than in the AD group at 3 months, the gray matter concentrations in these regions were not significantly different between the groups. Furthermore, the gray matter concentrations in the simple lobule, cingulate/retrosplenial cortex, substantia nigra, retrosigmoid nucleus, medial geniculate nucleus, and anterior pretectal nucleus at 7 months were significantly lower in the AD-HL group than in the AD group. Taken together, these results indicate that even partial hearing loss can aggravate memory impairment in Alzheimer’s disease. Cognitive impairment associated with hearing loss (HL) has recently attracted considerable interest due to growing evidence suggesting that impaired hearing is a risk factor for cognitive decline . SeveralAlthough many reports point to a correlation between dementia and hearing impairment, quantitative and functional studies are challenging because the auditory areas in the brain remain poorly understood and are difficult to assess. Deaf animal models provide us with an opportunity to assess the impact of hearing loss interventions on the development of dementia, as well as the corresponding changes in brain plasticity. We have previously demonstrated cross-modal and compensatory plasticity using PET analysis in an animal model . PET is The aim of this study was to evaluate the effects of conductive hearing loss on Alzheimer’s disease. We sought to investigate the following questions: (1) Does conductive hearing loss affect memory ability? (2) Does conductive hearing loss lead to functional changes in imaging studies such as PET and MR? Five familial AD mutation (5xFAD) transgenic mice  were used in the current study . ExperimFive familial AD mutation male mice (2 months of age), which overexpress five familial AD mutations, were used in the current study. These mutations comprise three in human APP (695) with the Swedish , Florida (I716V), and London (V7171), and two in human presenilin1, PSEN1 M146L, and PSEN1 L286V. The transgenic mice were purchased from Jackson Laboratory . All applicable international, national, and/or institutional guidelines for the care and use of animals were followed. The animal study was approved by the Institutional Animal Care and Use Committee (IACUC) and the Institutional Review Board of the Korea Institute of Radiological and Medical Sciences , and all experiments were performed in accordance with their guidelines.n = 10) with induced conductive hearing loss and the control group  with normal hearing. Both groups underwent measurement of hearing thresholds, behavioral tests, and imaging studies.The animals were divided into two groups: the experimental group  and xylazine (20 mg/kg). The tympanic membrane was resected using a sharp pick under continuous endoscopic visualization . After rHearing levels were assessed using click-evoked ABRs 1 week after surgery, 3 months later, and at the end of the study. Hearing levels were tested by evaluating the auditory brainstem responses (ABRs) to click stimuli . Subdermal needle electrodes were located below both ear and at the vertex. The stimulus rate is 19.3/s using click sound of rarefaction mode. The response was amplified, and band pass filtered (100–3000 Hz), and averaged over stimulation (512 sweeps per stimulation).PET and MR scans were acquired at baseline and at 3 and 7 months after the induction of hearing loss in order to assess changes in cerebral glucose metabolism and gray matter concentrations .n = 10 per group, male) underwent an 8-h fasting period, after which they were anesthetized with 2% isoflurane in 100% oxygen . The body temperatures of the mice were maintained at 36°C using heating pads during the course of the scan. Next, 200 μCi of F-18 FDG was injected through the tail vein of the mice. After 30 min of uptake, emission PET data were acquired for 30 min using an energy window of 350–650 keV. The emission list-mode data were sorted into three-dimensional (3D) sinograms and reconstructed using 3D reprojection algorithms without the use of a filter. The size of the image matrix was 256 × 256 × 159, with a pixel size of 0.155 mm × 0.155 mm and a slice thickness of 0.796 mm.Regional cerebral glucose metabolism was measured using the F-18 fluorodeoxyglucose (F-18 FDG) PET scan (Siemens Inveon PET scanner) . Prior t1. Statistical parametric mapping analysis on small animals has been described in our previous study .Regional differences between groups were identified using voxel-based statistical analysis performed in SPM 8us study . BrieflyT2w 3D MR images were acquired using an Agilent 9.4 T MR scanner (United States). An AD quad 70 RF coil was used, and the matrix size was 192 × 192 × 192. The repetition time (RT) was 2500 ms. The effective echo time (TE) was set at 7 ms. The total image acquisition time was 3 h 36 min.t-tests were used to identify regional differences in gray matter concentrations between the groups .Modulated VBM analysis was performed in SPM eight to compare the regional gray matter concentrations in selected brain regions between the groups . Skull sThe Y-maze test was used to measure spatial working memory and reference memory, which were assessed by recording spontaneous alternation behavior . ActivitThe responses to aversive stimuli in the passive avoidance test were used to assess learning and long-term memory . The sett-test in GraphPad Prism five . A P-value less than 0.05 was considered statistically significant.Data are presented as mean ± standard error of mean (SEM). For behavioral tests, the differences among the groups were analyzed using the one-way ANOVA test and the difference between two groups were analyzed with Student’s unpaired The mean hearing level measured using click-evoked ABRs was 20 dB sound pressure level (SPL) at the normal hearing state . In the P < 0.005; P < 0.05; SPM analysis of PET scans obtained at baseline and at the 3-month time-point in the AD group revealed decreased cerebral glucose metabolism in the frontal association cortex  in the AD-HL group than in the AD model 3 and 7 months after the induction of hearing loss (shown in P < 0.05).shown in . We alsoP < 0.005). However, at the 7-month time-point after the induction of hearing loss, the AD-HL group showed lower gray matter concentrations in large areas of the brain including the FrA, simple lobule , RSA , cingulate/retrosplenial cortex (Cg/RS), substantia nigra (SNR), retroethmoid nucleus (REth), medial geniculate nucleus (MGV), and anterior pretectal nucleus (APTD) than the AD group (P < 0.005).The AD-HL and AD groups underwent behavioral assessment prior to the induction of conductive hearing loss (baseline) when they were 6 weeks old, and at the 3- and 7-month time-points after induction of hearing loss (in the AD-HL group). None of the animals showed balance or movement problems after resection of tympanic membrane. We assessed the effect of hearing loss on spatial memory using the Y-maze test. The AD group showed an age-dependent decline in working memory. We found no significant difference between the AD and AD-HL groups in the spontaneous alternation as evaluated by the Y-maze  at the 3p = 0.0037) and 7-month  time-points following hearing loss induction  and cognitive impairment, PET or MR image analyses or behavioral studies have not been employed to further characterize the relationship until now. Imaging studies using PET have provided a translational platform for clinical use and successful clinical proof-of-concept testing . FDG-PETP < 0.005), hippocampus, and Cb (P < 0.05) in the AD-HL group 3 months after the induction of hearing loss. Interestingly, this functional change was not accompanied by changes in regional gray matter concentrations at the corresponding sites. Memory decline was confirmed using the passive avoidance test. Lower cerebral glucose metabolism levels in the FrA and hippocampus related to memory deficits have also been found in our previous PET study  and the Institutional Review Board of the Korea Institute of Radiological and Medical Sciences , and all experiments were performed in accordance with their guidelines.JK and M-HP designed the study, analyzed and interpreted the results, and wrote the manuscript. H-JL, SL, HL, YJ, and YS performed experiments, analyzed data, and wrote the manuscript. YL discussed the results and edited the manuscript. All authors reviewed and approved the final version of the manuscript.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.


Few data exist on the relationship of cisplatin-related adverse health outcomes (AHOs) with disability, unemployment, and self-reported health (SRH) among testicular cancer survivors (TCS).Pt) encompassed the number and severity of platinum-related AHOs . Multivariable regression assessed the association of AHOs and CBMPt with employment status and SRH, adjusting for sociodemographic and clinical characteristics. Unemployment was compared with a male normative population of similar age, race, and ethnicity.A total of 1815 TCS at least 1 year postchemotherapy underwent clinical examination and completed questionnaires. Treatment data were abstracted from medical records. A cumulative burden of morbidity score (CBMP = .048), renal dysfunction defined by estimated glomerular filtration rate , pain , and CBMPt  were associated with disability leave; pain strongly correlated with PSN . Statistically significantly higher percentages of TCS were unemployed vs population norms . PSN , patient-reported hearing loss , and pain  were associated with unemployment. Increasing severity of most cisplatin-related AHOs and pain were associated with statistically significantly worse SRH.Almost 1 in 10 TCS was out of work  at a median age of 37 years (median follow-up = 4 years). PSN (odds ratio [OR] = 2.89, 95% confidence interval [CI] = 1.01 to 8.26, grade 3 vs 0, Our findings have important implications regarding treatment-associated productivity losses and socioeconomic costs in this young population. Survivorship care strategies should include inquiries about disability and unemployment status, with efforts made to assist affected TCS in returning to the workforce. Testicular cancer (TC) is the most common cancer among men aged 18–39 years , overallData on employment status among TC survivors (TCS), however, are sparse and derive largely from Europe ,7–10. SwTo provide new information regarding employment outcomes in a largely US-based cohort of TCS, we examined these endpoints in relation to platinum-related AHOs and sociodemographic and clinical features among 1815 TCS enrolled in a large, multicenter clinical investigation . We alsoThe Platinum Study was approved by institutional review boards at all sites, and each participant provided informed consent. Cohort methods were previously described see ,13. In bSociodemographic characteristics (including employment), health behaviors, and AHOs were assessed using validated patient-reported outcome (PRO) questionnaires see  instrumePt) scores (The cumulative burden of morbidity platinum (CBM) scores ,20, foll) scores  as descr) scores .http://www.cdc.gov/brfss/index.htm) and have been used to characterize population employment status in a broad spectrum of studies  . BRFSS i studies . Differe studies : “In genPt score were each tested for association with employment status using Pearson chi-square test; if 20% or more of cells within a contingency table had expected counts less than five, Fisher’s exact test was used.Discrete and continuous data were described using numbers (percentages) and medians (ranges). Clinical or sociodemographic characteristics, health behaviors, individual AHOs, and the CBMP less than .05 defining variables for final inclusion. Individual AHOs were then assessed for association with disability leave or unemployment in separate models adjusted for these covariates. Time since chemotherapy completion was added into models as a covariate, and interaction with each AHO was assessed with P less than .05 indicating statistical significance.Multivariable logistic regression models were developed using backward selection to identify clinical and sociodemographic variables associated with employment status, with Multivariable ordinal logistic regression models assessed association between different grades of each AHO and SRH, adjusting for previously identified SRH-related covariates in the general population : age, raAll analyses were performed with Stata v14.1  except fP value of less than .05 was considered statistically significant.All tests were two-sided, and a The median age at evaluation for 1815 TCS was 37 years (range = 18–75 years) and median time since chemotherapy completion was 3.8 years (range = 1–35 years) . Most paP = .01) . P = .01) . ProportP < .001 each). The latter were more likely to report prescription antipsychotropic medication use (24.4%) and lack of vigorous physical activity (61.0%) compared with those employed full-time . Greater percentages of TCS on disability leave experienced grade 2 or 3 cisplatin-related AHOs  compared with TCS employed full-time  despite similar times since chemotherapy completion. SRH was markedly worse among TCS on disability leave (53.7% fair or poor) or unemployed (16.2% fair or poor) compared with those employed full-time . P < .001). P = .048, grade 3 vs 0) and reduced eGFR  , with three- and fivefold odds ratios for “medium” and “high” scores, respectively. Pain  was also statistically significantly worse among TCS on disability leave vs those employed full-time . The 95% confidence interval upper limits (UL) were high for eGFR  and pain , rendering their respective odds ratio estimates  imprecise; however, lower limits indicate strong confidence that population odds ratios are at least 2 and at least 4, respectively.After adjusting for statistically significant sociodemographic and clinical characteristics, statistically significantly greater odds of disability leave were associated with PSN  . CBMPt sPt score was not statistically significantly associated with unemployment, individual AHOs including patient-reported hearing loss , PSN , and pain  were associated with increased odds of unemployment.P < .05 each) as was pain (P ≤ .001 for each grade vs grade 0). The OR for pain (grade 3 vs 0) was imprecisely estimated; however, the lower limits suggest strong confidence that the population odds of worse SRH are at least 5 times for grade 3 vs 0. Patient-reported hearing loss , audiometrically assessed hearing loss , and patient-reported renal disease  were also statistically significantly associated with worse SRH.Increasing severity of most cisplatin-related AHOs was associated with statistically significantly worse SRH after adjusting for SRH-related sociodemographic factors in the general population (see “Methods”)  Table 6Table 6. Pt score, and pain. Overall, a statistically significantly greater proportion of TCS was unemployed compared with a normative US population, with associated AHOs, including neuropathy, patient-reported hearing loss, and pain. SRH was markedly worse among unemployed TCS and those on disability leave vs TCS employed full-time. These and other new findings are discussed below.In the largest study of TCS to date, we describe for the first time, to our knowledge, employment outcomes in relationship to cisplatin-related AHOs. Importantly, our well-characterized population is largely US based and shows that at a median of approximately 4 years after treatment, about 1 in 10 TCS is either on disability leave or unemployed. Statistically significantly higher odds of disability leave were associated with increasing grades of PSN, objectively assessed renal disease, increasing CBMData on relationships between cancer and its treatment and employment status derive largely from studies of childhood cancer survivors or survivors of cancers with an older average age at onset than TC. Statistically significantly greater percentages of participants in the Childhood Cancer Survivor Study had ever received supplemental security income 10%) or social security disability insurance (14%) compared with noncancer survivors ; the presence of at least one severe or life-threatening health condition increased risk of supplemental income and disability insurance by 3.8- and 2.7-fold, respectively . Data fr% or sociP < .001). In particular, statistically significant roles for higher grades of neuropathy and objectively defined renal disease were associated with increased disability leave, and these TCS were more likely to use prescription antipsychotropic medications (24%) than those employed full-time . No agents are approved to prevent or treat chemotherapy-induced peripheral neuropathy, and there is only a moderate recommendation for duloxetine to treat related pain  cancer survivors aged 15–39 years at diagnosis . AnalyseNonetheless, it remains difficult to isolate the contributions of a TC diagnosis and cisplatin-related AHOs to unemployment status. Reasons for unemployment are mixed and may include young age with ongoing continuing education, TC-related educational delays, and work interruption. However, using BRFSS normative data, we showed across a number of age groups that a statistically significantly greater proportion of TCS are unemployed vs men of similar age, race, and ethnicity. This finding is consistent with studies in other cancer survivor populations. For example, among adult-onset cancer survivors in the United States and Europe, a meta-analysis showed that cancer survivors were more likely to be unemployed than matched healthy population controls  .P < .001). In the general US population, poorer SRH is associated with shorter life expectancy  . Data on disease ,53 and t disease  may alsoMajor strengths of our study include the large cohort size, detailed medical record abstraction, physical examinations, laboratory-based measures, and use of PROs. Collection of sociodemographic data allowed for adjustment of factors related to disability leave and SRH status in the general population . Any croIn conclusion, at a median of approximately 4 years after completing treatment, most TCS are employed and report good or better health. However, a small group experiences multiple cisplatin-related AHOs, often severe, which are associated with disability leave, unemployment, and worse SRH. These findings have important implications with regard to losses in productivity and socioeconomic costs in this relatively young population. An awareness of AHOs associated with disability leave can help focus efforts in developing interventions and strategies to ameliorate or prevent these outcomes. Our finding that cisplatin-related AHOs are perceptible to patients and are associated with SRH highlights the importance of incorporating PROs in survivorship care strategies.This work was supported by the National Cancer Institute (1R01 CA157823 to LBT and K07 CA187546 to SLK). RH is supported by the National Institute for Health Research Institute of Cancer Research and Royal Marsden Biomedical Research Centre and Josh Carrick Foundation.Role of the funder: The funder was not involved in the design of the study; the collection, analysis, and interpretation of the data; the writing of the manuscript; and the decision to submit the manuscript for publication.Disclosures: Chunkit Fung served on advisory panels for Novartis and Exelixis but the work related to these advisory panels presents no conflict of interest with research related to this manuscript.pkaa022_Supplementary_DataClick here for additional data file.


MYO6 is known as a genetic cause of autosomal dominant and autosomal recessive inherited hearing loss. In this study, to clarify the frequency and clinical characteristics of hearing loss caused by MYO6 gene mutations, a large-scale genetic analysis of Japanese patients with hearing loss was performed. By means of massively parallel DNA sequencing (MPS) using next-generation sequencing for 8074 Japanese families, we found 27 MYO6 variants in 33 families, 22 of which are novel. In total, 2.40% of autosomal dominant sensorineural hearing loss (ADSNHL) in families in this study (32 out of 1336) was found to be caused by MYO6 mutations. The present study clarified that most cases showed juvenile-onset progressive hearing loss and their hearing deteriorated markedly after 40 years of age. The estimated hearing deterioration was found to be 0.57 dB per year; when restricted to change after 40 years of age, the deterioration speed was accelerated to 1.07 dB per year. To obtain supportive evidence for pathogenicity, variants identified in the patients were introduced to MYO6 cDNA by site-directed mutagenesis and overexpressed in epithelial cells. They were then assessed for their effects on espin1-induced microvilli formation. Cells with wildtype myosin 6 and espin1 co-expressed created long microvilli, while co-expression with mutant constructs resulted in severely shortened microvilli. In conclusion, the present data clearly showed that MYO6 is one of the genes to keep in mind with regard to ADSNHL, and the molecular characteristics of the identified gene variants suggest that a possible pathology seems to result from malformed stereocilia of the cochlear hair cells. Among them, several myosin genes are known to cause both syndromic and non-syndromic hearing loss , with over 50% of congenital hearing loss attributed to genetic causes in the US , a figur, DFNA11 ; DFNB2 [, DFNA11 ; Usher s, DFNA17 ; MYH9-re4, DFNA4 ; periphe, DFNA22 , DFNB37 , DFNB30 ; MYO15A,A, DFNB3 ).MYO6 gene is located on chromosome 6q13 and its gene mutations can cause either autosomal dominant (AD) inherited non-syndromic hearing loss (DFNA22) or autosomal recessive (AR) inherited non-syndromic hearing loss (DFNB37), possibly reflecting differences in pathophysiology among the mutations. The MYO6 gene encodes myosin 6, which is known to play a crucial role as a motor protein for cargo transportation [MYO6 mutant mice degenerated gradually and formed fused or branched stereocilia [The human ortation . In the ortation ,16. Inteortation ,18. Sekireocilia . TherefoMYO6-associated hearing loss cases have been published. We have recently reported seven families with MYO6 mutations and showed their clinical features [Despite its importance in the inner ear, a limited number of features .n = 8074) cohort. In addition, we also performed in vitro functional analysis of novel missense MYO6 mutations identified in this study to clarify the cellular effects of the mutations.In this study, to obtain a more complete picture of the mutational spectrum, frequency of mutations, and characteristic clinical features of the patients, we undertook an analysis using a larger (n = 1120) were included in the 8074 subjects [A total of 8074 Japanese hearing loss patients  from 67 otolaryngology departments nationwide participated in this study. Our previous reported subjects n = 11 were incClinical data, including the onset age, progressiveness of hearing loss, pedigree, and episodes of vertigo, were collected based on their anamnestic records. Pure-tone audiometry was performed on patients over the age of 5. For very young children under the aged 4 or under, the auditory steady state response (ASSR), conditioned orientation response audiometry (COR) or play audiometry, was performed. The pure-tone average (PTA) was calculated from the audiometric thresholds at four frequencies . Severity of hearing loss was categorized into four groups: mild (PTA 20–40 dB hearing level (HL)), moderate (41–70 dBHL), severe (71–90 dBHL), and profound (>91 dBHL) .Amplicon libraries were prepared using an Ion AmpliSeq Custom Panel , in accordance with the manufacturer’s instructions, for 63 genes reported to cause non-syndromic hearing loss . After pThe sequence data were mapped against the human genome sequence (build GRCh37/hg19) with a Torrent Mapping Alignment Program. After sequence mapping, the DNA variant regions were piled up with Torrent Variant Caller plug-in software. After variant detection, their effects were analyzed using the ANNOVAR software. The missense, nonsense, insertion/deletion, and splicing variants were selected from among the identified variants. Variants were further selected as less than 1% of (1) the 1000 genome database, (2) the 6500 exome variants, (3) the Human Genetic Variation Database (dataset for 1208 Japanese exome variants), and (4) the 333 in-house Japanese normal hearing controls by using our database software. Direct sequencing was utilized to confirm the selected variants.The pathogenicity of the candidate variants was interpreted based on the standards and guidelines of the ACMG  . Co-segrMYO6 cDNA, fused with the flexi Halotag, was purchased from Kazusa Genome Technologies . The identified mutations were introduced by Infusion HD cloning  according to the manufacturer’s protocol. Briefly, site-specific primers with the mutant variations were constructed  precoated with 2% gelatin. Wild-type and mutant MYO6 plasmid constructs were co-transfected with GFP-espin1 (obtained from the James Bartles lab) [LLC-PK1-CL4 porcine kidney epithelial cells (CL4 cells) were acquired from the James Bartles lab . The dayles lab)  with Lipt-test.Cells on coverslips were fixed in 4% paraformaldehyde in PBS for 10 min and then washed three times briefly in PBS, permeabilized for 20 min at room temperature with 0.1% Triton X-100  in PBS, washed in PBS 3 times, and then blocked with 3% goat serum  in PBS for 20 min. Cells were then incubated for 1 h at room temperature with a 1:200 dilution of the rabbit anti-Halotag antibody . Cells were washed three times with PBS, and then incubated for 1 h at room temperature with a 1:200 dilution of Alexa Fluor 546 goat anti-rabbit antibody and a 1/1000 dilution of DAPI. Cells were again washed in PBS 3 times, then the coverslips were mounted onto a slide glass with a Pro-long Gold Antifade mounting medium . Images were taken with an Olympus Fluoview FV-10i confocal microscope . The lengths of the microvilli with incorporated GFP-espin1 were measured with ImageJ software  and statistical significance assessed by Student’s MYO6 candidate variants  were identified from 32 AD inherited families and a single proband known to be affected with unknown inheritance in a heterozygous states  of Japanese autosomal dominant sensorineural hearing loss (ADSNHL) patients and 0.41% (33/8074) of all inheritance modes of Japanese hearing loss patients. All identified variants were confirmed by Sanger sequencing and the pathogenicity of these variants was interpreted in accordance with the ACMG guidelines [A total of 27 possibly disease-causing s states . Among tidelines . As a reAmong the “pathogenic” variants, p.R1166X was previously reported as a cause of autosomal recessive sensorineural hearing loss (ARSNHL) and ADSNHL . In thisMYO6 variants are summarized in The clinical features of 38 cases from 33 families with The average onset age is 24.0 years . Among the 24 cases in which the age of onset was clarified, 22 cases occurred at the age of 40 or younger . Most ofMYO6-associated hearing loss and their ages when their hearing was tested are plotted in The pure-tone averages of the patients with As shown in MYO6 candidate missense variants identified in this study and the previous studies [MYO6 plasmid and incorporated the following identified variants by site-directed mutagenesis: p.P125H, p.N202D, p.R205Q, p.E216V, p.G459D, p.N485K, p.G704D, p.R813P, and p.F1249S  of HL patients with MYO6-associated hearing loss to date, clarified the precise data regarding frequency, mutation spectrum, and clinical characteristics of associated hearing loss. This study expanded our previous study  and idenvariants  and, usiMYO6-associated hearing loss was 2.40% in the Japanese AD hearing loss patients. This frequency is compatible with our previous study  [KCNQ4 [TECTA [POU4F3 [WFS1 [MYO6 is considered an important causative gene for Japanese patients with ADSNHL. However, this is not a population-specific phenomenon as Seco et al. recently also reported that the MYO6 gene is a frequent cause of AD hearing loss in the population in the Netherlands [The frequency of ; 7/266)  and is l4 [TECTA , 2.5% fo [POU4F3 , and 2.5F3 [WFS1 . Therefoherlands .MYO6-associated hearing loss is mainly found in late-onset mild hearing loss cases, who are easily overlooked. MPS is useful in identifying the causative gene mutations in such juvenile-onset mild-to-moderate hearing loss cases. Indeed, herein, we report that MYO6-associated hearing loss is characterized by juvenile-onset mild to moderate hearing loss up to age 40. Thirty out of thirty-three cases in this study also showed juvenile-onset before the age of 40, which is consistent with our previous reports  [(DFNB37)  and ADSN(DFNB37) . The p.R(DFNB37) , but was(DFNB37) . An in v(DFNB37) .In the present large cohort, the p.R1166X variant was found in four ADSNHL families and a single proband known to be affected with unknown inheritance, but unfortunately, we could not obtain audiograms from the parents in the sporadic family.MYO6-related hearing loss [A possible explanation of how the p.R1166X variant causes both recessive and dominant inherited hearing loss involves autosomal semi-dominant inheritance. Indeed, an autosomal semi-dominant inheritance mode has been previously reported in ing loss . In the ing loss .It should be noted that the phenotype of the DFNB 37 family  is basedSince the p.R1166X variant has been reported in other populations with different origins ,35, thisMYO6 variants were overexpressed. This observation could provide supportive evidence of the pathogenicity of the identified MYO6 mutations. A mutant mouse model with a homozygous MYO6 gene splicing mutation showed fused and/or branched stereocilia [RDX, CLIC5, TPRN, and PTPRQ are the components which interact with MYO6 to create protein complexes regulating stereocilia formation, maintenance, and mechano-transduction of the sound [MYO6 motor domain have been shown to inhibit MYO6 localization in hair cells [MYO6 may still allow myosin 6 proteins to maintain their motor function, as they are located in the basal region of microvilli, but disrupt complex formation or binding to other component proteins. In this paper, most of the candidate mutations were found to result in shorter microvilli; however, we could not identify any correlation between the length of the microvilli and the severity of hearing loss. Thus, further functional studies are required to be elucidated this phenotype–genotype correlation and molecular function. In vitro analysis showed that the espin1-induced microvilli of CL4 cells become shorter when patient-identified missense reocilia . It is phe sound ,37. Mutair cells . Interesir cells  and is eir cells , indicatMYO6 variants. The better prediction of the hearing loss progression speed allows us to provide more appropriate intervention for the patients, such as hearing aids or cochlear implants, with optimal timing. Careful attention should be paid to the patients with late-onset mild-to-moderate progressive hearing loss as there is the potential for marked hearing deterioration to occurs after the age of 40.In summary, using a large cohort, we could obtain a more complete pictures of the mutational spectrum, frequency of mutations, and characteristic clinical features of patients suffering from hearing loss caused by


Noise exposure and associated hearing loss affects an estimated 2 million farm youth who are exposed as farm residents, farm family workers, hired workers, children of migrant or seasonal workers, and farm visitors. Risk factors for farm youth include frequent exposure to high farm noise; farm work from an early age, and exposure to high recreational noise .N = 662 in 13 sites (Group A), N = 680 in 12 sites (Group B), and N = 637 in 11 sites (Group C).This study compared the effectiveness of two interventions and control. The programs included a community-based interactive youth educational program alone (Group A), a community-based interactive youth educational program followed by an Internet-based booster (Group B), and a no-interaction control (Group C). The study used a cluster randomized control design, with equal allocation ratio to each cluster, without blinding. Inclusion criteria included enrollment in grade 4, parental consent, English speaking, and attending a community-based educational event included in the cluster sampling. A total of 1979 youth were enrolled at 36 sites distributed across the 3 study arms in the following distribution: Comparison with pre-intervention data showed no difference in intent to use hearing conservation strategies in experimental groups. However, knowledge and attitudes toward hearing conservation were improved in the groups receiving the Internet-based booster. Participants reported frequent exposure to sources of hazardous noise .It is feasible and acceptable to incorporate hearing health education into an already existing system designed to deliver health and safety educational programming to farm and rural youth. The program was adopted by the partner agency for dissemination to up to 100,000 youth annually. Results of this study inform future intervention studies, interventions aimed at farm youth, and interventions to increase use of hearing conservation strategies, as well as offer a base for developing programs for non-English speaking children.Clinicaltrials.gov registration CT02472821.Date of trial registration: 06/09/2015 (retrospectively registered). Although farm operators are known to experience among the highest prevalence rates of hearing loss among all categories of workers , a less While noise elimination is the most preferred method of prevention of negative effects of noise, this approach is often not technically or economically feasible in the farm work environment . Consistn = 375) had increased use of hearing protection in agricultural settings and while shooting guns, but there was no difference in use between experimental and control groups in other settings. In a cluster randomized control trial of a classroom training program for 753 rural youth, Berg [There has been some recorded success in improving hearing conservation in the short-term (up to 6 months) among non-farm youth using classroom-based programs –15. As fth, Berg  reportedth, Berg  reportedGiven the challenges of retaining health behavior over time, some authors have recommended use of boosters in education programs . HoweverThe study consisted of a cluster randomized control trial, consistent with the Consolidated Statement of Reporting Trials .Through their Safety Day program, the Progressive Agriculture Foundation provides education and training to over 100,000 children and adults annually through local affiliates, making farm, ranch and rural life safer and healthier for children and their communities . Safety Farm and rural youth, as well as Safety Days instructors and coordinators were sampled. Inclusion criteria for youth participants included enrollment in elementary school grade 4, parental consent, English speaking, and attending a Safety Day event included in the cluster sampling. Inclusion criteria for coordinators included demonstrated ability to successfully coordinate a Safety Day program, interest in the study, opportunity to implement the lesson in the designated study period, and willingness to comply with study procedures. Inclusion criteria for instructors included recommendation by the program coordinator and accepting a hearing health teaching assignment at a Safety Days event included in the cluster sampling.The study used pre-existing Safety Days protocols for recruitment and consenting youth participants. One or more study team members met with groups of local community program coordinators at required pre-event training sessions  to introduce the study purpose and methods, and to recruit support for coordinator and instructor involvement.Recruitment meetings continued until enrollment quotas were met. Coordinators managed recruitment of Safety Days instructors and youth, with support of the study team.The primary outcome measure for this study was self-reported intent to use hearing conservation strategies. Additional outcomes measured included a) knowledge of hearing health, and b) attitudes toward use of hearing conservation strategies. Measures were adapted from Martin et al. , for puryou do to protect your ears at a loud concert?”For comparison purposes, a six-item, multiple-choice instrument successfully used by Martin et al. , was useThe 12-item, multiple-choice instrument to measure youths’ knowledge of noise, its effects on hearing, and hearing conservation strategies was adopted from items used by Martin et al. to measure this concept among elementary students . A samplvery embarrassing to not at all embarrassing).” The instrument has a Flesch-Kinkade reading grade level somewhat higher (11.3) than the other instruments, due to use of the parenthetical phrase “if no one else is wearing them” and the multisyllabic word, embarrassing. However, in previous use and pretesting, fourth grade students responded to this item without difficulty.A single multiple-choice item was used to measure attitude influencing use of hearing conservation strategies among youth. The instrument was adopted from a set of items used by Martin et al.  The itemIntervention 1 consisted of a 20-min face-to-face lesson delivered to small groups (n ~ 8) of fourth graders as part of a circuit of safety lessons. Content included common farm-based and recreational sources of hazardous noise, effects of noise on cochlear hair cells, effect of distance on reducing noise exposure, proper insertion of a child-appropriate insertable hearing protection device, and methods of dealing with peer pressure to increase noise exposure. Methods of instruction included a highly engaging discovery approach, with youth interacting with instructors, peers, and learning materials throughout the lesson, and demonstration and practice of HPD insertion technique.Instructors recruited for the program were interested community volunteers recruited by the program coordinators, generally with no education or experience in health care. A written lesson plan including learning objectives, key points to emphasize, suggested script, teaching-learning materials, time allotments, and selected teaching materials , were provided to each instructor at least 2 weeks prior to the planned implementation. Other supplies  were locally sourced. A study team member contacted each instructor in advance of the implementation to verify instructor receipt of teaching/learning materials and to offer individualized training and consultation. Fidelity of intervention was monitored by video recording of a sample of sessions; results are reported elsewhere .www.dangerousdecibels.org/exhibit/virtual-exhibit/). The program is developmentally appropriate, and includes content in sources of sounds, consequences of noise exposure, and prevention of hearing loss. The program is a user-driven activity where youth independently select which activities to pursue, and how long to engage. Highly interactive game-based activities include rating noise sources  as safe or dangerous, determining the best course of action  in a variety of noisy situations, and choosing a course of action when confronted with social non-support of use of hearing protection. A computer (with Macromedia Flash® and Shockwave®) and Internet connection  is required for participation. The intervention was delivered to eligible participants following completion of the three-month survey. Participation was monitored by a sign-in system required to access the site.Intervention 2 consisted of an independent visit to the Dangerous Decibels® online virtual exhibit. The Dangerous Decibels Virtual Exhibit (DDVE) is a free-to-use Web- and game-based set of eight interactive learning activities designed for children to learn about hearing health . Delivery methods were distinct, with Intervention 1 using a group-based, face-to-face discovery learning approach; Intervention 2 used a set of Web-based interactive educational games.Randomization was at the level of community program, with random assignment of programs in an equal allocation ratio to one of three study arms. There were no deviations from the original protocol. The study protocol (#HUM00077214) was approved by the author’s university institutional review board  in advance of data collection, and written parental consent was obtained before student participation.Assignment of 36 study sites to three study arms was accomplished by simple randomization using R software . After td of .48 compared to the effect of the control treatment. This is the effect size on intention to use hearing conservation strategies we found in our preliminary study and is just under what Cohen defined as a medium sized effect.  Other necessary inputs into Optimal Design were ranges of the average number of students per cluster and estimates of the intraclass correlation coefficient (ICC), a measure of the tendency of students in the same cluster to have similar (correlated) responses. To determine the number of clusters needed, we examined average cluster sizes ranging from 20 to 80, and a value of the ICC of .10  [The sample size, in particular the number of clusters for this study, was determined by power analysis for a mixed model design using Optimal Design software . The numesearch) . We alsoesearch) , 30.p-value was less than 0.05 significance level.Summary statistics based on mean, standard deviation or frequency were used to characterize the sample distributions at each time point. Since cluster randomized control design was used in this study, linear mixed models were used to test the association between outcome variables (knowledge scores) and intervention effect (fixed effect) where the sites were included as random effects. The PROC MIXED method from SAS software, version 9.4  was used to carry out the analysis. The intervention was claimed to be significant if its Study participants experienced no harms, adverse events, or unintended effects. Study procedures were highly successful in recruitment and retention of study subjects. Primarily, attention to communication with participants, high regard for participant autonomy, careful recordkeeping of participant progress through the study, and fastidious attention to follow-up are credited for these favorable rates.For each experimental group, the numbers of participants who were randomly assigned, received intended treatment, lost/excluded, and analyzed for the primary outcome are displayed in Table Recruitment of youth occurred on a rolling schedule beginning in March 2015 and continuing through October of the same year. Participants completed their three-month follow-up questionnaires from June 2015 to June 2016; 12-month data collection occurred between May 2016 and January 2017. Questionnaires were completed by study subjects following reminders by email, voicemail, or postal messages; for those not responding to these contacts, questionnaires were completed by telephone. The 308 subjects randomized to Group B who completed their 3-month questionnaires were invited to access Intervention B via Web; 175 (56.8%) of them accomplished this. A summary of subject progression through the study is included in Fig. All comparison groups showed improvement in intent-to-use scores over time. However, comparison of results of intent-to-use measures at 3 months and 12 months using ANCOVA and mixed models, respectively, showed no intervention effect regarding intent to use in either experimental group at either time point.Estimate.All comparison groups showed improvement in knowledge scores over time, and knowledge levels were retained over the 12-month study period  showed an increase in favorable attitudes toward hearing conservation approaching significance at 3 months . For example, nearly 10% (9.3%) of participants reported that they hear loud sound that “made your ears hurt or made you hear ringing sounds.” Most 85%) of participants reported exposure to at least one hazardous noise source one or more times per week. Exposure to multiple sources of hazardous noise were reported, with 85, 63, and 43% of participants reporting exposure to one, two, and three sources of hazardous noise, one or more times per week  effectiveness of the combined approach of face-to-face and Internet-based educational programs in improving youth knowledge of hearing conservation strategies, as well as their attitudes toward hearing conservation. The success of the face-to-face and Internet-based lessons in improving knowledge and attitudes affirmed the value of this novel, fast-paced, discovery-based learning method with youth. However, the lack of significant change in intent-to-use also affirms results of previous studies illustrating the challenges of making long-term changes in youth hearing conservation-related behavior. It is noteworthy that, although differences between the experimental and control groups in regard to intent to use were not significant, improvements in intent to use were observed in all groups, and changes were retained after 12 months.Interpretation of these findings are confounded by the potential of a measurement effect. This finding suggests that the baseline and subsequent two waves of testing participants in the control group  may have served as an intervention in itself, influencing participants’ intent to use hearing conservation strategies. Repetition of the study using an alternative study design  may contribute to untangling this mystery. Moreover, there are limitations to the measurement methods used here , and a corresponding need for improved methods of measuring youth hearing conservation behavior.The findings of this study are particularly relevant to clinicians, educators, and policy-makers for several reasons. First, the study shows frequent hazardous noise exposure among farm and rural youth. This finding arouses concern regarding not only the effects on hearing, but also the extra-auditory  effects of noise exposure, as noise has been related to many highly prevalent health problems. Second, at this time, the effects of noise on the young ear and brain are poorly understood. Consequently, it is prudent for parents, educators, and others to implement the precautionary principle and restrict noise exposure to persons in this age group.The results of testing of a booster intervention in this study are particularly interesting. The utility of booster interventions in enhancing the effects of hearing conservation educational programs is uncertain, as previous effectiveness studies examining the use of boosters on adult hearing protector use have had ambiguous results. In an effectiveness test of a program designed to improve use of hearing conservation strategies among youth , changesThe study had a number of strengths. First, reports of noise exposure affirmed the need for noise mitigation programs among farm and rural youth. Large numbers of participants (approaching 10%) reported that they hear loud sounds that “made your ears hurt or made you hear ringing sounds,” and most reported exposure to at least one hazardous noise source one or more times per week.Many previous tests of interventions have measured effects after short  time periods . Howeverprevention of noise-related health problems . The prevalence of noise-induced hearing loss and other noise-related disorders, their permanence, cost, and related disability speak to the significance of development of effective and sustainable interventions to address this long-standing problem.This study was one of only a few ever conducted to address accessibility and affordability of services focused on Prevention of NIHL among children and adults is included in several national health agendas in the US, including Healthy People 2020 , 32, theThere is a great need to develop, test, and implement programming to protect the hearing of the 2 million farm and rural youth affected by farm noise. In the US, policies designed to protect noise-exposed persons  rarely protect farm youth , 37–39. Additional evidence exists to support action to improve programming to protect the hearing health of farm and rural youth. In addition to its effects on hearing, noise exposure, NIHL has a negative impact on the physical and emotional functioning, social life, and employment of the affected person. Aside from its deleterious effects on hearing, noise is also associated with various somatic effects. For example, increases in hypertension and blood cholesterol were attributed to occupational noise exposure . .In addThe study was conducted in geographically dispersed communities, representing a variety of cultural and demographic compositions, suggesting that the program may be successful in a wide variety of English-speaking settings involving fourth graders.The primary outcome measure of the study, intent to use hearing conservation strategies, was measured using self-report. This measure was selected, in part, because this measure has been used repeatedly in previous intervention studies of youth hearing conservation interventions dating as far back as 1998  and as rThe hearing health educational program was delivered in the U.S. exclusively in English, and primarily to residential (non-migrant) youth. This is a significant limitation of the study, and an area for future research and program development. Furthermore, because the study enrolled youth primarily in the fourth grade, the appropriateness and effectiveness of the program for younger and older youth is untested.evidence-based program to protect a high-risk and underserved population of rural and farm youth from noise-induced hearing loss, where programs are not currently present. Results showed that the combined face-to-face and Internet interventions were more effective in increasing knowledge and improving attitudes toward use of hearing conservation strategies than comparison groups not receiving the dual interventions. Subjective reports found that the program operated well, was enthusiastically received by the host agency, and has been adopted for delivery to up to 100,000 farm and rural youth annually.In summary, although the problem of noise-induced hearing loss among farm and rural youth is long recognized, and the number of youth affected numbers in the millions, there is a lack of noise mitigation programs with demonstrated effectiveness. This study provides evidence of the effectiveness of a new This study represents one of very few clinical trials testing the effectiveness of hearing conservation interventions for farm operators or farm youth. Whereas previous trials have been limited in reach and sustainability, these results can be used to inform future intervention studies, interventions aimed at farm youth, and interventions to increase use of hearing conservation strategies. Outcomes of this study provide knowledge necessary to implement and sustain quality and cost-effective services to large numbers of farm and rural youth, a high-risk and underserved population. This study focuses on primary prevention of noise-related conditions, before the onset of noise-induced hearing loss, and before these youth add to the already high public health burden of persons with hearing loss, and thereby maximizes the opportunity for success, as treatments for noise-induced hearing loss are limited and unsatisfactory.http://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-015-2393-y.The full trial protocol can be accessed at


Excessive noise levels are a prevalent issue in food processing operations and, although there have been numerous studies on occupational noise, no single study has used a concurrent mixed-methods approach. Employing this study design allows for an understanding of the level of convergence (similarity) between measured noise levels and workers’ attitudes and perceptions towards noise. This, in turn, allows for the identification of potential challenges with respect to the implementation of hearing conservation efforts. In this study, spot noise measurements were collected using a sound level meter. One-on-one interviews were conducted with workers to determine attitudes and perceptions towards noise in their workplaces. Subsequently, the results of the noise measurements (quantitative data) were integrated with the survey responses  to identify convergence. The majority of the noise measurements were found to exceed 85 dBA—the criterion mandated by the local occupational health and safety legislation. Although all study participants felt that it was noisy in the workplace, a large proportion of respondents indicated that the noise was not bothersome. With workers’ perception being contradictory to the measured noise levels, it is a challenge to implement hearing conservation measures unless changes are made to raise the awareness of the risks associated with excessive noise exposure. Noise is a common occupational hazard found in many workplaces across the globe ,2. High Excessive noise exposure can lead to fatigue, distraction, and difficulty communicating—all of which can result in workplace injuries . From a Fortunately, excessive noise in the workplace is preventable . StudiesThis study was approved by institutional research ethics prior to its start (Ryerson REB# 2015-291-1). The exploratory study was part of a larger ongoing project examining occupational health and safety issues within the meat processing sector in Ontario, Canada which is the most common type of manufacturer in the province’s food and beverage processing industry .Electronic invitations to participate in the study were sent to a database of meat processing facilities that had employees who were former graduates of Ryerson University’s School of Occupational Health and Public Health (“School”) or who had completed occupational health and safety courses offered by the School. The inclusion criteria were that the target organization was primarily involved with meat processing and had a facility located in the Greater Toronto Area.If the representative from the organization agreed to participate, an ethics-approved study information sheet was provided via email. The information sheet was subsequently distributed and/or posted to workers at each site to: (a) explain the scope of the study and (b) outline the expectations of individuals who may be approached to be interviewed (see below).Worker interviews were conducted on site visit days, mutually agreed upon between the research team and the participating food processing facility, i.e., convenience sampling (a type of non-probability sampling method where the sample is taken from a group of people easy to contact or to reach (from dictionary.com)). At least one worker from the different areas of the plant where noise measurements were collected was approached to participate. Since each interview took up to 45 min, the maximum number of interviews per site was six as the research team was scheduled to be at each facility for approximately five hours. Exclusion criteria included those individuals who did not speak English or who had difficulties in understanding terminology such as noise-induced hearing loss, noise control measures, and hearing protective devices. After verbally agreeing to participate in the interview, individuals were given a copy of the consent form to review and sign prior to the one-on-one interviews.The interview questions were adapted from a questionnaire developed by Davies and Shoveller  which haOnce transcribed, the responses were analyzed via content analysis whereby similar comments were grouped together under one category. Research team members independently grouped the interview responses and met afterward to review the groupings until consensus was reached. Subsequently, the frequency of responses was tallied and select comments, which encapsulated the views of the respondents, were extracted. This approach was similar to the one used by Hong et al.  to assesAn initial walk-through of each site was conducted to review the layout, examine the different operations and identify locations where area noise measurements could be performed without obstructing workers and/or traffic (foot or motorized). Noise measurements were collected on the same day as the worker interviews and were intended to qualify the noise levels.Two Larson Davis SoundTrack LxT integrating sound level meters (SLM)  were employed to collect noise measurements at each participating site. The SLMs were set to the “A” frequency weighting and “slow” for the detector. Prior to sample collection at each site, SLMs was calibrated using the Larson Davis CAL150 Acoustic Calibrator .At each site, noise measurements were collected in production and packaging areas during normal daily operations. The SLMs were used to collect spot measurements around each noise source. Five to 14 pairs of measurements were obtained in every department assessed . The instruments were placed on tripods at approximately 1.5 m from the ground in accordance with standard occupational hygiene practices. Sound levels were measured at 1 m increments from each machine or noise source (maximum of 3 m from each), which is representative of where a worker may be situated, and were collected for at least 2 min each in accordance with Canadian Standards Association (CSA) Z107.56-13—“Measurement of noise exposure” standard .As per the CSA Standard on Hearing Loss Prevention Program Management , the firTo ascertain the extent to which the two sets of data converged , the resNone of the participating sites had a complete and thorough hearing conservation program in place. Each had selected elements of best practices such as warning signs, non-routine audiometric testing, etc. which varied between sites. Although hearing protective devices (HPD) were made available to all workers at every site, their use was irregular with most workers wearing the devices for part of the work shift.Every individual who was approached to be interviewed agreed to participate and all met the inclusion criteria (100% response rate). Overall, 22 individuals across all four sites participated in one-on-one interviews. The majority of respondents were female, middle-aged, had 5–14 years of experience in their current job and possessed a high school diploma as their terminal level of education . None ofAll 22 respondents (100%) felt that it was noisy every day and, according to 82% of those interviewed, it was noisy for most of the shift (not shown). Regardless, only 54.5% of respondents were concerned about noise in the workplace. In fact, 13.6% of respondents felt that noise, in general, is not an important occupational issue and 22.7% of workers did not feel that this matter deserved any further attention, i.e., the status quo was acceptable to them. Moreover, nearly 10% of respondents did not agree with the statement “you would feel better if your workplace was quieter”. However, a majority of respondents (90.9%) did indicate that more education/awareness was needed with respect to occupational noise .When interviewees were asked the question “What do you think are the best solutions to noise problems in your workplace?” several respondents felt that it was not feasible. Select responses from the interviews include:“I don’t think they can do anything to reduce noise”“No solution”“No idea”In fact, according to one respondent, it would take “a miracle” to reduce the noise levels. Overall, many respondents felt that personal protective equipment, specifically HPD, was sufficient to reduce their risk of exposure.When asked, “What kinds of problems would make it difficult for a new noise control measure to be developed and implemented?” there was one predominant theme—ensuring that the novel control measure meets food quality/safety standards. Some of the responses to this question were:“Any changes in health and safety needs to also fall within the food safety requirements. Usually a solution that can work for health and safety may not be friendly for the food safety side. For example, equipment change can create harborage sites where bacteria can build up, which is not suitable for food safety”.“Food quality is top priority”“Need to be careful regarding the sanitation aspect of it.”“It’s not that bad. The noise doesn’t bother me”—Worker 3E from Site 3 where the average noise levels exceeded 85 dBA.“I’m okay with noise in the workplace”—Worker 4E from Site 4 where the average noise levels exceeded 85 dBA.This discrepancy between excessive sound measurements and worker indifference to noise was most notable from Sites 3 and 4.By employing a mixed-methods approach, this exploratory study identified instances of disagreement between the attitudes and perceptions of workers regarding occupational noise and the measured sound levels in the workplace. In essence, despite the fact that the majority of the spot noise measurements exceeded 85 dBA, about half of the respondents were cavalier about noise in their workplace. Specifically, these indifferent workers stated that the noise was not an issue and/or they were not bothered by it. With such a large proportion of exposed workers being aloof, this presents a significant barrier with respect to implementing hearing conservation efforts as disenchanted workers can negatively affect the success of occupational health and safety initiatives ,23. ThesAnother issue that could be a hindrance to the successful introduction of a hearing conservation program is that many of the participants were resigned to the fact that noise is “part of the job” and believed that the use of HPD is sufficient to the risk. It has also been argued that where workers deem the workplace as not being a noise risk, then they will believe that it is not necessary to employ protective measures .This false notion that reliance on HPD could save workers’ hearing was also reported in a Swedish study . FurtherIn addition to the use of HPD, an effective hearing conservation program should also include engineering controls ,33 but, It bears mentioning that this study was timely as the province of Ontario had, at the time that sample collection took place, recently updated the occupational noise regulation . The curThis study is only representative of the participating sites and the times when sampling took place; noise levels may vary at other sites and at other times. Nevertheless, as indicated earlier, excessive noise is a common occurrence in food processing and the noise measurements were collected during normal operations. Although the sample size was limited, excessive noise was found in most participating sites and divergent results were reported in all four facilities. However, the divergent results could be attributed, in part, to an increased hearing threshold of workers due to hearing loss ,39). As In summary, this exploratory study confirmed that excessive noise (sound levels greater than 85 dBA) is prevalent in the participating facilities; yet nearly 50% of the exposed workers were nonchalant about this occupational hazard even though they recognized that the environment was loud. In addition, the results uncovered a fatalist attitude amongst many workers as well as their mistaken belief that HPD alone is sufficient to reduce the risk. Combined, this makes hearing conservation efforts within the meat processing industry challenging as well as necessary. Modifying worker attitudes towards noise by raising awareness of the risk associated would be an important first step to the implementation of hearing conservation efforts.


Due to increase in the life expectancy and changes related to aging, it is important to assess ADL (activities of daily living) in older adults. However, there is no standardized protocol available to assess ADLs. Considering the limitations of the available tools, a new protocol named Londrina ADL protocol was developed for which normative values are unavailable in different ethnic groups.  To develop the normative value and reference equation for the Londrina ADL protocol on the basis of anthropometric and demographic variables in healthy individuals in the age group of 40–60 years among the Indian population.  This cross-sectional study was conducted with 282 healthy individuals of both the genders between the age group of 40 and 60 and they were divided into 2 groups: 40–49 and 50–60. Each subject was made to perform the Londrina ADL protocol twice with a 30 min interval between the two protocols. The protocol is composed of 5 activities and the best out of the 2 performances were recorded.  The mean time taken among 40–49 years by females is 3.50 ± 0.50 min and by males is 3.73 ± 0.43 min. The mean time taken among 50–60 years by females is 4.25 ± 0.20 min and by males is 4.36 ± 0.18 min. The reference equation to predict reference values for the Londrina ADL protocol was as follows: equation (1): Londrina ADL predicted = 1.205 + (0.054 × age (years)) + (0.001 × height (cm)); equation (2): Londrina ADL predicted = 1.374 + (0.054 × age (years)) + (−0.003 × BMI).  The reference equation for the time to complete the Londrina ADL protocol was based on age and BMI as independent variables and can be useful for predicting the performance of healthy individuals. Functional capacity is defined as “one's maximum potential to perform activities of daily living” such as self-care , leisure, work, and household chores. On the other hand, functional performance is defined as “the physical, psychological, social, occupational, and spiritual activities people actually do in the normal course of their lives to meet basic needs” .In recent years, the consequences of aging have increased in the society due to the worldwide increase in life expectancy. Changes related to aging, obesity, and presence of chronic degenerative diseases, especially cardiopulmonary ones, may be responsible for impairments of mobility, balance, and muscle strength which interfere with the performance of daily life activities. In the age group of 40–60 years, chronic diseases such as chronic bronchitis, emphysema, asthma, bronchiectasis, and occupational lung disease are common. These may lead to loss of independence and poor quality of life. Every individual's tasks and daily routine differ. But walking is an essential component of everyone's daily activities. This made the foundation for the development of functional walk tests that helps to evaluate the mobility, functional capacity, and exercise tolerance of an individual. Therefore, the assessment of ADL (activities of daily living) is of utmost importance in this population –5.In this regard, 6-minute walk test is widely used to assess the functional capacity of an aging individual . AlthougAnother test which was proposed to assess essential ADL is Glittre-ADL which may be considered more complete than the 6-minute walk test for assessing individual's functional capacity. It is a performance-based test which involves activities such as sitting and rising from a chair, ascending and descending steps, and movements of the arm while carrying weights. This test was developed to reflect real-life situations better, thus improving the assessment of functional capacity However, the Glittre-ADL test does not include in-depth and objective assessment of problematic activities involving the upper limbs which are often limited in the elderly .Another option to assess functional status (capacity to perform ADL) is the use of questionnaires. However, the individuals might be influenced by psychological or cognitive factors which may influence the answers .There have been some studies which attempted to assess ADL objectively by using functional tests (like sit-to-stand test). However, functional tests evaluate functional capacity, not ADL performance. Furthermore, functional tests generally do not include a range of specific ADL-like tasks that would represent real life. There has been growing interest on the objective assessment of ADL performance through performance-based protocols.These protocols encompass the same activities that people perform in their day-to-day life and are thought to provide a more thorough evaluation of ADL performance . ConsideThere is lack of retrievable data on the normative value of the Londrina ADL protocol in healthy subjects in the age group of 40–60 years among the Indian population. The aim of the study is to evaluate the performance of healthy adults using the Londrina ADL test and to obtain normative data and reference equation for the same as per age, gender, and BMI.Healthy subjects with no underlying comorbidities of either gender in the age group 40–60 years were recruited for the study who were referred by a consultant pulmonologist/physician. The entire population was stratified into two groups based on the age groups: 40–49 and 50–60.N = 4pq/d2, where p, assumption for better performance = 0.4; q = 1-pd; nonresponse error = at 15%; N, sample size = 282.The sample size was calculated based on a pilot study of the Londrina ADL protocol time (5 subjects in two groups) with an assumption of 40% subjects having better performance, 15% relative precision, and 95% confidence interval adding 10% nonresponse error. The total sample size comes to 282 using the following formula. Healthy adults of either gender, who were referred by a consultant pulmonologist/physicianAge group: 40 to 60 yearsBMI: 18.0 to 29.5 kg/mHistory of cardiopulmonary diseaseHistory of musculoskeletal, neuromuscular, and peripheral vascular diseases which affects the performance of the testUse of walking aidPeople who were not able to understand the procedure(i)Chair(ii)Table with a length of 1.2 meters and a width of 0.6 meters(iii)4 objects of 250 grams4 objects of 500 grams2 objects of 1 kg2 objects of 2 kgWeight blocks:(iv)Stand with four adjustable shelves(v)Clothesline(vi)10 dry clothes: 80 to 442 grams(vii)Weight machine: Equinox BR(viii)Sphygmomanometer: Diamond Mercurial(ix)Pulse oxymeter(x)Stopwatch(xi)StadiometerA written approval was obtained from the Institutional Ethics Committee and Scientific Committee (IEC). Advertisement was given in local newspaper inviting volunteer participation in the study. Healthy individuals were approached, and the purpose of the study was explained; a written informed consent was obtained from those who were willing to participate. Subjects were screened for inclusion criteria, and eligible subjects were recruited.Demographic data were collected from each subject, and height and weight were measured using stadiometer and weighing machine. Each subject was then made to perform the Londrina ADL protocol and data were recorded.Objects on the table: the participant sits on a chair in front of the table (dimensions: 120 cm (length) ×60 cm (width) with a line separating it into 2 halves (left and right). The table had 10 objects on it , all together on the left of the table. The subject took the objects, one by one, with both hands and had put them all on the right half of the table. After that, subjects returned the objects in the same way to the left side of the table.Walking with bags: the subject walked over a 6 m line, 3 consecutive times , carrying 2 bags one in each hand. Inside the bags, there was a load representing 10% of the subject's body weight (5% in each bag).Shelves: the subjects stood in front of 4 shelves, one above the other , with a table next to them. On the table, there were 12 objects . The participant took the objects, one by one, with both hands and placed them on the shelves (without a predetermined order). The subject organized the objects on the shelves in such a way that 3 objects were placed on each shelf. When all of the objects were placed on the shelves, the subject returned them in the same way to the table (without a predetermined order).Clothesline: the subject stood in front of a clothesline positioned at eye level. Basket containing 10 items of clothing (median weight of the items = 122 g (range 80–442 g)) was placed on the ground next to the subject. The subject took all items, one by one, with both hands and hanged them on the clothesline. After hanging all items of clothing, the subject returned them inside the basket, taking them one by one with both hands.Walking: the subject had walked back and forth again on the same 6 m line described in activity 2, 3 consecutive times, but without carrying bags. Participants were instructed to perform the 5 activities at their usual pace.The Londrina ADL protocol is composed of 5 activities organized in stations inside a room . The position of the activity stations and the distance between them are shown in Before the beginning of the first Londrina ADL protocol, the evaluator demonstrated to the participant the activities of the protocol in the same order in which he/she should perform them. The instructions that were given to the participants are as follows: “Perform these activities as if you were doing them at home in a typical day. You are allowed to stop to rest if you feel it is necessary. We will tell you which station will be the next at the end of each activity.” No encouragement was given during the protocol –15.The time spent to perform the Londrina ADL protocol was registered using a stopwatch, and it was used as the Londrina ADL protocol outcome and the test was performed twice  on the same day with a 30 min interval between protocols. The better of 2 performances was taken into consideration. Other measurements before and after the Londrina ADL protocol included: blood pressure, heart rate, and sensation of dyspnea and fatigue .Statistical analysis was performed using IBM SPSS statistics for Windows version 25.0. Armonk, NY: IBM Corp. Data were expressed as mean ± standard deviation. The association between the time to complete the Londrina ADL protocol and the independent variables was tested by simple linear regression analysis, and stepwise multiple linear regression analysis was used in order to evaluate independent variables explaining the variance in the Londrina ADL protocol. A Bland–Altman plot was also used to visualize agreement between the actual Londrina ADL protocol time and the predicted value.A total of 282 healthy individuals were included with 141 healthy adults in the age groups of 40–49 and 50–60 years. Both the groups contained 71 males and 70 females each. The anthropometric data and baseline variables of males and females are presented in st and 2nd trials) with a 30 min interval. But there is no significant difference found between these two trials with respect to the time taken to complete the protocol  and height (r = 0.54) but not with the weight (r = -0.02). In a stepwise multiple linear regression analysis, age and height were selected as Londrina ADL protocol predictors. The Bland–Altman plot . In the age group of 40–49 years, the average time taken for completion of test by females is 3.50 ± 0.50 min and males have performed the test in 3.73 ± 0.43 min. Similarly, in the age group of 50–60 years, males have performed the test in 4.36 ± 0.18 min and females in 4.25 ± 0.20 min.st and 2nd trial), and the obtained results show that the majority of subjects performed their best in 2nd trial which can be attributed to the learning effect.We hypothesized that variables such as age, gender, height, weight, and BMI would be the predictors of the time taken to complete the Londrina ADL protocol as these factors can influence the individual's performance on functional tests. There is no significant difference found between males and females in both the age groups in view of the time taken to complete the protocol. Despite the protocol including activities that are more common to women's routine due to the presence of domestic tasks, males can also perform similar movements during work activities . The LonIn a similar study on older adults above 50 years of age carried out on a Brazilian population by Paes et al., it was found that the average time for the completion of the test was 5.06 ± 0.51 minutes. In our study, we found that the completion of the test by the same age group in the Indian population took 1 minute less. We found 1 minute lesser for the completion of the test in the same age group. This variability may be influenced by inclusion of other factors, such as age, health conditions, low level of physical activity, education, social class, income, life history, personality features, speed of habitual walking, or cultural aspects related to lifestyle, mood, attitude, and motivation of the subject and/or technician, and hence, older individuals are reportedly less physically active which represents the potential risk for decreased mobility. It is known that frailty is associated with functionality and other factors such as fatigue, multiple health problems, vision, hearing, cognition, and psychological disturbances (depression and anxiety) , 16.The Londrina ADL protocol provides the possibility of having a standardized method to assess different outcomes during the performance of ADL. This is a valid test because a correlation was found between movement intensity in daily life and during the protocol, which indicates a correlation between the individual's real life and the individual's performance during ADL , 17. TheA study done by Sant Anna et al. showed that subjects with COPD took an average time of 6.31 ± 0.18 to complete the test, which is 2 minutes greater when compared with healthy individuals. The disparity was due to the presence of pulmonary dysfunction which is progressive obstruction of the airflow. Extrapulmonary features, such as abnormalities of skeletal muscles (respiratory and limb), caused by aberrations in gas exchange, presence of malnutrition, use of drugs, state of physical inactivity, respiratory tract malformation, will negatively influence the subject's exercise capacity and performance of daily life activities , 18.In our study, during the Londrina ADL protocol, there was a mild increase in heart rate, respiratory rate, dyspnea, and fatigue in healthy subjects when compared before and after the test, which may be because of the multiple activities that are included in the Londrina ADL protocol as the tasks require different energy expenditure. It may be because during the exercise there is an increase in metabolic demand because of which there is an increase in cardiac output to supply the peripheral oxygen need. The increase in the initial HR is due to the removal of parasympathetic tone, and at the higher rates of work, this increase is due to the sympathetic nervous system .r = 0.45) episodes of desaturation (≥4%) in daily life especially with SPO2 being under 88%. As the Londrina ADL protocol represents better performance in day-to-day activities, the hypothesis which was given to explain the decrease in oxygen saturation in daily life was the influence of blood perfusion of body extremities. The initiation of respiratory symptoms could be better reviewed when patients report how they feel during the performance of routine activities in daily life [A study was done on the Brazilian population by Paes et al, to evaluate the episodes of oxygen desaturation during Londrina ADL protocol in patients with COPD. And they found that there is a moderate correlation of (ily life .The Londrina ADL protocol represents better performance in day-to-day activities, the hypothesis which was given to explain the decrease in oxygen saturation in daily life could be influence of the blood perfusion of body extremities and the initiation of the respiratory symptoms could be better reflected when patients reported how they feel in daily life during their day-to-day activities .The main limitations of the study were as follows: we have studied the normative values in the age groups of 40–60, as most of the pulmonary conditions are seen in these age groups. We did not study the normative values in the age groups of 30–39 and 60–70 years. We also did not study the influence of other factors such as balance, peripheral muscle strength, and cognition and behavior which have an influence on the time taken to complete the test. We did not analyze the relationship between Londrina ADL protocol performance and other limiting factors like fatigability or breathlessness within each age group.Future studies can be done on pulmonary conditions and cardiovascular diseases to assess the performance of ADL and compare with our findings as reference values to determine the reliability of the equations.In our study, we concluded that the reference value for Londrina ADL protocol in healthy individuals in the age group of 40–49 years in females is 3.50 ± 0.50 min and in males is 3.73 ± 0.43 min, and in the age group of 50–60 in females is 4.25 ± 0.20 min and in males is 4.36 ± 0.18 min.


Age related hearing loss, or presbycusis, is a global condition that is increasing in its prevalence. Despite being one of the most common chronic conditions among the older population, there is much more to understand about its association with other aspects of physical and emotional health and well-being. Current research is suggesting that hearing loss is more prevalent in those with cognitive impairment compared to those without cognitive impairment. This study analyzed the incidence of hearing loss and its linkage to mild cognitive impairment in a community-dwelling geriatric population. With the increasing prevalence of this condition in both rural and urban communities of Alabama, it becomes a more pressing matter to understand comorbidities and risk factors for future decline in functioning. This study was conducted in an interdisciplinary geriatrics primary care outpatient clinic in a Family, Internal, and Rural Medicine department affiliated with a university medical center in the Deep South. Ninety-one participants completed the Montreal Cognitive Assessment (MoCA) and a hearing screening. Hearing screenings were conducted in quiet rooms in the medical center using Phonak hearing screening cards. Detection of 500, 1000, 2000, and 4000 Hz tones was assessed. Pearson correlation analyses demonstrated an association between hearing loss mild cognitive impairment. Poorer hearing was significantly associated with lower scores on the MoCA. Conducting behavioral health screenings like this in other primary geriatrics clinics and community settings could improve care and identification of patient needs by integrating important data regarding comorbidities and independent living.