Hearing loss has been described in patients undergoing chemotherapy, given the ototoxic nature of these drugs. An audiological investigation is relevant in such cases.to assess audibility thresholds at high frequencies in individuals with cancer that was treated successfully with cisplatin and its associations, to verify possible hearing loss as a side effect of therapy. Site and date of the study: Campinas, Sao Paulo, in 2006.Ten volunteers aged between 5 and 27 years were assessed by a clinical history, otoscopy, and conventional and high frequencies audiometry in this clinical and experimental study.A kappa coefficient statistical analysis revealed significant differences between ears in 50% of 14 frequencies that were evaluated. Eight participants presented hearing losses, which started at 1 kHz, increasing markedly at 6 kHz and above. Fisher's Exact Test revealed a significant association only with the dose and the right ear at high frequencies.It is possible that the hearing loss detected in this study is at least partially due to the ototoxicity of antineoplastic drugs; such loss may occur even after treatment is interrupted. We suggest that a protocol for audiological follow-up of patients undergoing chemotherapy should be created. Cisplatin is a potent anticancer drug that is widely used in the treatment of advanced cancer in adult and children. One of its side effects is ototoxicity, which related directly with the dose and the administration route; a single high dose may affect hearing more intensely than the same amount given in fractionated doses.Individuals using chemotherapy, for instance with cisplatin, could avoid degeneration of the organ of Corti if ototoxicity were monitored and/or detected early.9Further studies have shown that high frequencies are needed for discriminating between consonants and for recognizing speech; individuals with hearing loss of any degree at these frequencies find it difficult to understand speech in noisy environments.The main use of high frequency audiometry is in monitoring the audition of patients in which hearing losses are suspected; the main conditions are ototoxicity, sequelae of otitis media, chronic renal failure, presbyacusis, assessment of auditory processing, investigation of auditory changes in families with inherited hearing loss, and monitoring of individuals that are frequently exposed to noise.12Cancer is a range of disease in various sites and of different morphological types, which have in common two main biological features: uncontrolled cell growth and the ability to extend beyond the tissue of origin. Variability exists relative to the stage in which each cancer is detected by available diagnostic methods.Germ cell tumors, also known as teratomas, endodermal sinus tumors or embryogenic carcinomas, originate from the aforementioned germ cells, and follow an abnormal path. When cells in these tumors begin to divide, tumors are formed with parts of hair, teeth, skin and others. In different cases, germ cells originate malignancies, behaving aggressively. Such germ cell tumors may occur at any age in childhood; testicles, ovaries, the vagina, the sacrum and coccyx (lower vertebrae) are frequently involved, as well as less frequent sites such as the head and neck, the liver and the brain. These tumors, however, are less frequent compared to leukemia and brain tumors.Neuroblastomas are about 8% of cancers in children aged below 15 years. This is a solid tumor that develops in nervous tissues located in the neck, the thorax, the abdomen, the pelvis or in adrenal glands. About 97% of neuroblastomas are sympathetic nervous system embryogenic malignancies, occurring almost exclusively in the newborn and young infants. Unlike germ cell tumors, neuroblastomas are the most common cancers in the first years of life; its incidence is twice that of leukemia. In many cases when it is diagnosed, it has already metastasized to the lymphnodes, liver, lungs, bone and bone marrow. The neuroblastoma is primarily a tumor of young children. Two thirds of neuroblastoma cases are diagnosed in children aged below 5 years.Another tumor type is the rabdomyossarcoma, a malignancy that originates in primitive mesenchymal cells, at any site of the body. It is the most common soft tissue sarcoma in infancy, and is usually located in the head and neck.The osteosarcoma is a primary bone malignancy that occurs in children, teenagers and young adults. Its peak incidence is in the second decade of life; it is about 5% of the malignancies in childhood and adolescence.Cisplatin ototoxicity and high frequency pure tone audiometryHigh frequency audiometry has been suggested as a method for monitoring the effect of ototoxic drugs on hearing.To assess high frequency auditory thresholds in successfully treated cancer patients aged from 5 to 27 years, treated with cisplatin and associated drugs, to verify possible hearing loss as a sequel of therapy.To assess, in patients treated with cisplatin and associations, possible differences in the ototoxic effect between the ears that were evaluated, the incidence of auditory changes, the number of affected ears at each frequency, the comparison between conventional and high frequency audiometry, and the historic variables that might have influenced the hearing of these patients.Participants The sample included volunteers who visited a speech therapy clinic located in the city of Campinas (Sao Paulo state) after being contacted by telephone from the hospital in which they had been treated for cancer. Fifty individuals were contacted, of which 10 accepted the invitation to participate in this study.These 10 subjects, of both genders, were aged between 5 and 27 years at the time data were collected, and had started cancer therapy at ages 6 months to 13 years. All had been cured at the time this study was done. All had been treated with cisplatin, which is ototoxic,1,2,4,5,9 associated with other drugs, some of which were also ototoxic. An otorhinolaryngologist assessed all participants before the research audiological tests were done, as part of the method. Other drugs that the subjects had used in cancer therapy included doxorubicin, vincristine, actinomycin D, cyclophosphamide and etoposide. Of these, vincristine and actinomycin D are also ototoxic.The following was noted about the otological history: participant 1 reported otitis soon after chemotherapy; participant 2 complained of tinnitus, dizziness, hearing loss and headaches, but did not report when these symptoms started; participant 5 reported bilateral pruritus and hearing loss; participant 6 reported tinnitus and pruritus; participant 7 reported hearing loss; participant 8 reported tinnitus and otalgia; participant 10 reported otalgia. Participants 3, 4 and 9 had no otological complaints.a)Clinical history taking;b)Inspection of the external ear to verify the presence of ear wax and/or foreign bodies or secretion in the external auditory canal that might interfere with testing;c)Conventional pure tone audiometry and high frequency audiometry, done in an acoustic booth.A clinical history script for obtaining data about participants was written. The following equipment was used in audiological testing: a TK otoscope for inspecting the external auditory canal. An Interacoustics AC40 Clinical Audiometer with two frequency fields, one at 128 to 8,000 Hz and the other at 8,000 to 20,000 Hz, according to the ANSI S3.6 (1989) and ISO 389 standards. Telephonics TDH 39 P headphones were used for conventional audiometry ; Koss R/80 headphones were used for high frequency audiometry . An acoustic booth was used. The SAS - system for Windows - V8, was used for the analysis of results. Procedure The Research Ethics Committee approved the project and the free informed consent form (Protocol 620/05), after which participants were informed about the testing procedures to clarify any doubts. Patients that agreed to participate signed the free informed consent form. The following procedures were applied to all patients:The descending technique was used for obtaining auditory thresholds at 250, 500, 1,000, 2,000, 3,000, 4,000, 6,000, 8,000, 9,000, 10,000, 11,200, 12,500, 14,000 and 16,000 Hz . Threshold testing was started by reducing the intensity of the sound stimulus in 10 dB intervals until no further response was obtained. Next, the stimulus was presented 5 dB above that level and then decreased again in 5 dB intervals until no further response was obtained. The auditory threshold was considered as the lowest intensity at which a response was obtained.The procedure was applied to both ears of each patient in a single session lasting about 20 minutes. Data were treated statistically using different methods, according to the aims of this study.Criteria for establishing the presence of auditory alterations In this study, any threshold change higher than 25 dBNA in adults and 15 dBNA in childrenThe kappa (k) statistics index was used to check possible differences in ototoxicity between ears. This statistical test is a measure of agreement used in nominal scales for verifying by what amount observations differ from expected variations by chance. K statistical values range from 0 to 1, where 0 indicates lack of agreement beyond chance and 1 is perfect agreement.In this study, close frequencies  were calculated as different but with less weight in weighted k statistics. The weighted k value was considered as evidence of a larger difference between frequency categories that are more distant from each other. See Incidence of auditory alterations Eight of 10 participants assessed by conventional pure tone audiometry and high frequency audiometry presented hearing loss, while two had hearing within normal limits for their age, according to the criteria described under Method. Auditory alterations relative to the affected frequenciesComparison between the incidence of auditory alterations in conventional audiometry and high frequency audiometry.Clinical historic variables that altered the hearing of patientsThe literature states that cisplatin ototoxicity is directly related to the dose and the manner by which the drug is given.Fisher's exact test revealed a significant association only for the variable dose and the right ear at high frequencies. There was no association between variables in the remaining conditions.Concerning a possible difference in ototoxic action between ears, the kappa statistics suggested differences between the right and left ears in half of the sample. As to the incidence of auditory alterations in the sample, eight participants had hearing loss. The data revealed that there was significant hearing loss at around 6,000 Hz in 5 cases, suggesting that conventional audiometry would be sufficient to diagnose high frequency involvement. Apparently in these cases high frequency audiometry would have no preventive value, as conventional audiometry would provide enough data for justifying preventive measures, such as recommending that the patient undergo otorhinolaryngological and phonoaudiological monitoring due to the possibility of progression of hearing loss. Participant 5 had already started using a hearing aid for four years; in this case chemotherapy had ended 3 and a half years before starting to use the hearing aid. Hearing loss was present at and above 1,000 Hz according to the audiometric evaluation; also in this case, high frequency would have had no preventive value.The results of participant 4 deserve further analysis. In this case, there was bilateral non-symmetrical hearing loss . Conventional pure tone audiometry  had shown 10 to 15 dBNA in the left ear at all frequencies, in other words no loss. High frequency audiometry of this ear, however, showed progressive loss; it was 35 dBNA at 10,000Hz and showed no response at 14000 and 16000Hz. In this case, high frequency audiometry made it possible to identify the onset of a degenerative process, which would not have been perceived in conventional audiometry. In this case, high frequency audiometry was effective in detecting a problem, allowing preventive monitoring and interventions.Participant 7 also stood out; there was unilateral left hearing loss between 9,000 and 11,200 Hz. Conventional audiometry was within normal limits. High frequency audiometry made it possible to detect the frequency range in which the results were from 20 to 30 dbNA. This was the most significant case of the sample, since it was possible to detect the onset of high frequency auditory degeneration, even though these changes were small from the standpoint of auditory acuity. In this case, high frequency audiometry demonstrates its preventive value; the audiogram suggests a trend towards worsening of hearing loss, particularly when considering the patient's age (11 years). Audiological information, thus, makes it possible to recommend monitoring and possible interventions. Analysis of hearing loss at each frequency shows that ears were affected at and above 1 kHz, and that there was a marked increase in hearing loss at and above 6 kHz. This suggests that in this sample, high frequency audiometry could have identified hearing losses in all 8 participants with hearing loss, even if it had been the only test. Confirmation of this is seen in the comparison between conventional pure tone and high frequency audiometry as applied to this sample. Two data sets were clearly identified; one composed of ears with losses up to 4,000 Hz and another composed of ears with losses at and above this frequency. Thus, contrary to what might have been suggested above, high frequency audiometry may be considered an important tool for detecting and monitoring hearing losses, which is in agreement with the literature.20Of all the variables affecting the hearing of patients, such as right and left ears, the presence or absence of hearing loss, the mean age at which chemotherapy was started, the duration of therapy, drug dosages, conventional and high frequency audiometry, only the variable drug dose mg/m2) in the right ear at high frequencies was significantly different P=0.044; p<0.05). This points, therefore, to evidence suggesting that the chemotherapy drug dosage used by the participants included in our sample may have had an important role in causing hearing loss, notwithstanding the time elapsed since the end of chemotherapy and this study and the impossibility at this point of establishing its effect isolatedly. These results are consistent with the literature that was presented at the beginning. in the r4; p<0.0520This study aimed to assess high frequency auditory thresholds in subjects aged 5 to 27 years that had been successfully treated for cancer with cisplatin and associated drugs to test for possible hearing loss as a sequel of therapy. Although the variable drug dose was significantly different only for the right ear at high frequencies, it is possible that hearing loss detected in 8 of 10 participants is due, at least in part, to the ototoxic effect of anticancer drugs (cisplatin + vincristine + actinomycin D + associated drugs). Such hearing loss may occur slowly and insidiously, especially because of the drug dose and the duration of these substances in the body, even after treatment has ceased.4 This study points to the importance of introducing routine audiological monitoring in chemotherapy for cancer patients.


Sound localization relies on the neural processing of binaural and monaural spatial cues generated by the physical properties of the head and body. Hearing loss in one ear compromises binaural computations, impairing the ability to localize sounds in the horizontal plane. With appropriate training, adult individuals can adapt to this binaural imbalance and largely recover their localization accuracy. However, it remains unclear how long this learning is retained or whether it generalizes to other stimuli.We trained ferrets to localize broadband noise bursts in quiet conditions and measured their initial head orienting responses and approach-to-target behavior. To evaluate the persistence of auditory spatial learning, we tested the sound localization performance of the animals over repeated periods of monaural earplugging that were interleaved with short or long periods of normal binaural hearing. To explore learning generalization to other stimulus types, we measured the localization accuracy before and after adaptation using different bandwidth stimuli presented against constant or amplitude-modulated background noise.Retention of learning resulted in a smaller initial deficit when the same ear was occluded on subsequent occasions. Each time, the animals’ performance recovered with training to near pre-plug levels of localization accuracy. By contrast, switching the earplug to the contralateral ear resulted in less adaptation, indicating that the capacity to learn a new strategy for localizing sound is more limited if the animals have previously adapted to conductive hearing loss in the opposite ear. Moreover, the degree of adaptation to the training stimulus for individual animals was significantly correlated with the extent to which learning extended to untrained octave band target sounds presented in silence and to broadband targets presented in background noise, suggesting that adaptation and generalization go hand in hand.Together, these findings provide further evidence for plasticity in the weighting of monaural and binaural cues during adaptation to unilateral conductive hearing loss, and show that the training-dependent recovery in spatial hearing can generalize to more naturalistic listening conditions, so long as the target sounds provide sufficient spatial information. Sensory experience plays a vital role in calibrating neural circuits in the brain, so that they can be optimized to the prevailing sensory conditions. The experience-dependent plasticity of the maturing brain enables the processing that takes place within those circuits to adjust to growth-related changes in sensory inputs and to be matched to the statistics of the environment during sensitive periods of development . PlasticIn the auditory domain, the recovery of sound localization accuracy in mammals experiencing a unilateral conductive hearing loss has been widely used as a model for training-dependent plasticity . Sound lAdaptation to monaural hearing loss can be achieved by reweighting the different localization cues—with greater reliance placed on the unchanged monaural spectral cues available at the open ear—or through compensatory changes in binaural cue sensitivity . In addiSpatial cue reweighting is therefore thought to be context specific, disappearing when normal binaural inputs are again experienced following earplug removal, and may arise from changes in the relative reliability of different localization cues . HoweverThe extent to which perceptual training generalizes to untrained stimuli determines its therapeutic value. Previous studies have assessed adaptation to unilateral conductive hearing loss by presenting target sounds against a silent background in order to maximize learning. However, more naturalistic listening conditions can change abruptly as we navigate our daily lives, as do the target sounds we need to attend to. Therefore, determining whether auditory spatial learning generalizes beyond the training stimulus and to more complex listening environments is crucial for designing effective training protocols as part of rehabilitation strategies for hearing-impaired individuals.In this study, we address both the persistence and generalization of auditory adaptive learning. Our results show that the cue reweighting that occurs when adult ferrets are first trained with abnormal auditory spatial cues takes place more readily when subsequent periods of monaural occlusion are experienced, indicating that the effects of learning persist for at least several months. However, adaptation to conductive hearing loss in one ear appears to reduce the capacity of the auditory system to compensate for occlusion of the contralateral ear. We also show that the training-dependent recovery in localization accuracy does generalize to other acoustic conditions and that the degree of adaptation correlates with the generalization of learning.Mustela putorius), aged ∼6 months at the start of the study and sourced from Marshal BioResources (United Kingdom), were used. All procedures were approved by the Committee on Animal Care and Ethical Review at the University of Oxford and licensed by the Home Office under the Animals (Scientific Procedures) Act (1986).Eleven adult female pigmented ferrets .Ferrets were trained by positive reinforcement on an approach-to-target sound localization task, using water as the reward. During the testing periods, the animals were housed in enriched cages in groups of 2 or 3 individuals with Behavioral testing was performed in a circular arena (Ø 140 cm) located inside a soundproof chamber . The areFerrets were trained to stand on a platform at the center of the arena and lick a waterspout facing the 0° position for a variable time, 300–500 ms, which triggered the presentation of a target sound stimulus from one of the 12 peripheral loudspeakers. An infrared beam at the back of the platform and a proximity infrared detector at the central waterspout were used to ensure the animal was positioned correctly when the stimulus was presented. The animal then had to signal its location by approaching the loudspeaker to obtain a water reward from its associated waterspout, which was equipped with an infrared detector and located just below the loudspeaker at the same azimuth. Only correct responses were rewarded . An incorrect response was followed by a “correction trial,” whereby the same sound was presented from the same location as in the previous unsuccessful trial. As in our previous work, up to two correction trials were allowed. If both correction trials elicited incorrect responses, an “easy trial” was triggered, in which the same sound was presented continuously until a response was made. Data from correction and easy trials were not included in the analysis.We also obtained a more absolute measure of localization accuracy by tracking the ferret’s head movement using a reflective strip attached to the midline of the animal’s head. A high-speed camera located above the central platform captured the reflectance of the head-strip for 1 s from the onset of the target sound. The image acquisition rate was 60 frames per second (FPS) for the first part of the study (Imaging Source DMK21BF04) and 500 FPS for the second part of the study, following an upgrade to a high-speed camera (DMK 37AUX287).All animals were trained and tested on the approach-to-target sound localization task in a quiet background (hereafter referred to as “silence”) for 1–2 months until they showed a stable level of performance before the ear-plugging experiment started. Sound localization accuracy was measured using single bursts of broadband noise (low-pass cut-off frequency 30 kHz) in blocks of constant stimulus duration . Within each block, we pseudorandomly varied both the stimulus location across the 12 loudspeakers and its level over a 56–84 dB SPL range in steps of 7 dB.A reversible unilateral conductive hearing loss was induced by inserting an earplug (E-A-R Classic 3M) into the external auditory meatus and securing this in place with a silicone mold  placed in the concha of the external ear. Earplug insertion and removal were performed under sedation . An otoscopic examination was performed and a tympanogram  was obtained both before insertion and after removal of an earplug to check the health status of the external and middle ear. No abnormalities were detected. Sedation was reversed with atipamezole hydrochloride . The acoustical effects of these earplugs have been characterized in previous studies in our laboratory in ferrets  and humaAs in our previous work , 2019, wTo explore the persistence of the adaptive learning with one ear occluded, one group of 4 ferrets was subjected to several periods of unilateral conductive hearing loss interspersed within variable periods of normal binaural hearing.Once their localization performance under normal hearing conditions had been measured using broadband noise bursts as target sounds in silence, a temporary unilateral conductive hearing loss was induced by inserting an earplug in the right ear . Target A second group of 7 ferrets was used to explore whether the adaptive learning induced by training animals wearing an earplug to localize broadband noise target sounds on a silent background extended to other stimuli and acoustic conditions that were not available during training.The sound localization performance of the animals was measured using different stimuli before, during and after occlusion of one ear. As before, adaptation to the earplug was achieved by training the animals to localize 1,000-ms broadband noise burst targets presented in silence, after which the animals were tested using different stimuli and background sounds with the earplug still in place. The target sound was either broadband (BB) noise (low-pass cutoff at 30 kHz) or one-octave wide narrowband noise (NB) centered on 16 kHz. The duration of the target sound was again 1,000 ms, and its level and location were pseudorandomly varied as before. These stimuli were presented either in silence (s) or in the presence of continuous background noise presented from an overhead loudspeaker. The background noise consisted of a broadband stimulus (low-pass cut-off at 30 kHz), whose envelope was either unmodulated (um) or amplitude modulated (am) at 5 Hz. The combination of these targets and backgrounds produced five different testing conditions: BBs, NBs, BBum, NBum, and NBam. The combination of broadband target sounds presented in an amplitude-modulated background (BBam) was discarded as a testing condition, because no difference was observed in localization accuracy between modulated and unmodulated backgrounds with this target sound in normal hearing conditions. Broadband target sounds were therefore only presented in silence (BBs) or with an unmodulated background (BBum).n = 4) were trained to localize 1,000-ms broadband noise bursts in silence in the same fashion as described in previous sections. Every 2 days, we interspersed broadband and narrowband sounds (1/6-octave bandwidth centered at 15 kHz frequency to restrict the cues to ILDs)   at two dThe angular position of the head-strip in each video frame was used to produce head movement traces. Trials in which <10% of consecutive frames contained measurable data were rejected. The start of a head turn was defined as a movement exceeding a threshold speed of 50 deg/s in the same direction  over at least three consecutive frames. The timing of the last frame before a change in this initial direction was taken as the end of the head turn. The final head bearing was defined as the mean head angle calculated over the three frames before the end of the head movement. For the learning generalization experiment, traces were down-sampled to 50 FPS to make the data analysis comparable to the learning persistence experiment , in whicThe rate of adaptation for each of the periods of monaural occlusion was computed by fitting regression lines to the percentage of correct responses across training day, with the shaded areas in the figures representing 95% confident intervals. The probability of making a correct response was compared across animals, hearing conditions , and stimulus characteristics using a linear mixed model with a Bernoulli-distributed data, probit link function. Final head bearings were compared using repeated measures ANOVA. Data normality was checked using Q-Q plots and applying the Shapiro–Wilk test. All statistical tests were performed using RStudio  or SPSS .p < 0.0001) (p = 0.001)  . The acc 0.0001) . Despite 0.0001) , their p= 0.001) . The lac= 0.001)  gave no n = 7) are shown in The approach-to-target responses of one cohort of ferrets   , with thp = 0.055; Before investigating the effects of further exposure to unilateral conductive hearing loss in either the same or the contralateral ear, it was first necessary to show that ferret localization behavior adapts equally well to occlusion of either the left or the right ear. This is illustrated in The head-orienting responses were affected in exactly the same way by plugging either the left ear in one group of ferrets  or the rPrevious work has suggested that adaptation to the altered cues resulting from monaural occlusion leave a “memory trace,” since a second period of ear-plugging has a smaller impact on localization accuracy . Here, wn = 4) first experienced four periods of right ear occlusion, separated by short (7 days) or long (6 months) periods of normal binaural hearing. To determine whether they were then able to adapt to a different set of altered spatial cues, we subsequently measured their performance when the contralateral left ear was occluded instead (see a = 10.366). Sound localization accuracy recovered with twice-daily training and the highest rate of adaptation (b = 6.4) was observed during this first period of monaural occlusion  of normal binaural hearing following a prior period of monaural occlusion  and had the smallest initial localization errors when the earplug was first inserted and lowest slope values . This, tp = 0.126, p = 0.99, respectively)  , providiThe spatial pattern of errors also provides insights into the potential basis for the recovery of sound localization accuracy at different stages during the adaptation process. Localization errors on the side of the open left ear were consistently low at the start of the second, third and fourth periods of right ear occlusion , which cWe have previously shown that the primary auditory cortex (A1) plays an essential role in adapting to an earplug in one ear, but is not required for retrieval of the memory trace that facilitates adaptation during a second period of monaural occlusion . This raIn contrast to the start of the first period of right ear occlusion (right plug 1), where a marked left-right asymmetry was observed in the size of the head orienting errors due to the animals consistently turning toward the side of the open ear, these responses were more symmetrically distributed to appropriate sides of the midline at the start of the second period of right ear occlusion (right plug 2) . In bothWe next examined whether ferrets that had learned to localize accurately following occlusion of one ear also exhibit similar adaptive plasticity when the direction of the binaural imbalance is reversed by plugging the other ear. The same group of ferrets that had experienced four periods of right ear occlusion now had their left ear plugged . This rep = 0.01), whereas no difference between the left and right hemifields was found for the first right earplug run (p = 0.139)  . This is= 0.139) , nor is p = 0.003) . As with repeated plugging of the right ear, this resulted in a much smaller initial deficit than when the animals first received an earplug in the left ear , and the= 0.003) . These rTo explore the extent to which the improvement in localization accuracy following adaptation to unilateral conductive hearing loss generalized beyond the standard broadband noise training paradigm, we tested the performance of a group of ferrets using a combination of different target sounds and acoustic backgrounds before and after they had been trained to adapt to an earplug. The target sounds were either broadband noise (BB), for which all acoustic spatial cues would have been available, or narrowband noise (NB) with a one-octave bandwidth centered on 16 kHz, selected to reduce the availability of binaural cues and to provide limited access to high-frequency spectral localization cues . The tarAfter measuring their localization accuracy with all combinations of targets and acoustic backgrounds  and left-right errors . Sound localization accuracy was also degraded to a small but significant extent in the presence of both types of background noise  and the NB target sounds slightly less well (88.9 ± 1.13%) . This was particularly the case for the NB targets, with a greater difference in performance between BB and NB targets when one ear was occluded than prior to ear-plugging , as indicated by the greater distance to the identity line for the data from the NB targets in t-test, df = 6, p = 0.002) and left-right errors . Following adaptation to monaural occlusion, the ferrets localized NB targets significantly worse on the side of the plugged ear    . This is= 0.156) . We obseGreater inter-animal variability in performance was found with NB than BB target sounds . FerretsThe lack of an aftereffect following earplug removal is consistent with a primary adaptation strategy to unilateral conductive hearing loss in which the animals learn to rely more on the intact monaural spectral cues provided by the non-occluded ear than the normally dominant but now distorted binaural cues. However, adaptive changes in binaural cue sensitivity appear to contribute as well, as shown by the recovery in localization accuracy observed in humans when pure tones are interspersed during training with one ear occluded . Our finAn additional factor that needs to be considered is that the relatively long training stimulus  may have allowed the animals to sample dynamic spatial cues as they were approaching the perceived sound source location. The very similar pattern of adaptation observed in the head orienting responses , which hTo gain a better understanding of the processes underlying training-dependent adaptation to unilateral conductive hearing loss, we interspersed sessions in which high-frequency narrowband sounds [1/6 octave bandwidth centered on 15 kHz, as in p < 0.001) (p = 0.071) (p = 0.341)  . By cont= 0.071)  or 200 m= 0.341) .The sound-evoked head movements measured for these animals  and NB  stimuli when the duration used was too short for the animals to be able to use dynamic cues to any degree, suggesting that the ferrets may benefit from re-sampling the longer stimuli during and after the initial head turn. Nevertheless, some adaptation still took place with 200-ms noise bursts so long as they were sufficiently broadband to provide access to other auditory spatial cues (These results therefore indicate that that 1/6-octave bandwidth noise bursts centered at 15 kHz do not contain sufficient spatial information to support the adaptive improvements in localization performance that take place during the training runs with BB noise. Furthermore, localization accuracy was reduced for both BB (GLMM, target duration, ial cues . AdaptivPerceptual learning enables auditory perceptual skills to be improved with practice or training , and allThe earplugs we used disrupt binaural localization cues by attenuating and delaying the sound at the occluded ear , 2016. TCompensatory changes in binaural cue sensitivity have been reported in adult humans who adapt to the presence of an earplug in one ear  and haveFollowing earplug removal, the auditory system switches back to relying more on binaural cues for azimuthal localization. This is shown by our finding that subsequently replugging the same ear again degrades localization accuracy see also . A capacThe effects of occluding one ear are different, however, with our results showing that additional training is required to achieve the same level of adapted performance whenever the same ear was re-plugged, with the magnitude of the initial drop in performance positively correlated with the duration of prior normal experience and greatest at the start of the first ear-plugging run. Thus, although it takes longer for the brain to adjust to the altered spatial cues resulting from monaural occlusion than to revert to normal inputs, previous ear-plugging experience leaves a “memory trace” so that less adaptation is required when the cues are changed again in the same manner. This was particularly the case for locations ipsilateral to the open ear, suggesting that upweighting of monaural spectral cues is facilitated by prior experience.Switching the unilateral conductive hearing loss to the contralateral ear also resulted in an impairment in localization accuracy that partially recovered with training. However, the localization performance of the ferrets improved to a significantly lesser extent than when the hearing loss was previously experienced on the other side. This is consistent with evidence that ferrets raised with one ear occluded adapt by changing the relative weighting of the spectral cues in opposite directions for each ear . If thisIn these experiments, we measured the accuracy of the ferrets’ head orienting responses following sound presentation as well as the target location they approached to receive a reward. Our previous work has shown that restricted lesions  or reverWe observed a very similar pattern of training-dependent plasticity for each measure of sound localization, including the partial retention of learning when abnormal spatial cues are again experienced by replugging the same ear. Since silencing the primary auditory cortex impairs adaptation but not the retrieval of previous learning , it is lAdaptation of the head-orienting responses also allowed us to address the potential contribution of sensorimotor behavior to auditory localization plasticity . Head tuAlthough these findings indicate that head movements do not play an essential role in adjusting auditory localization to compensate for a conductive hearing loss in one ear, the recovery in accuracy is more complete when longer duration noise bursts are used for training see also , suggestInvestigating the generalization of perceptual learning to untrained stimulus properties can provide valuable insights into the neural substrates of learning and retrieval . In termOur results show that the adaptation achieved after training ferrets to localize broadband noise with one ear occluded was positively correlated with their ability to generalize this performance improvement to untrained octave band noise. These narrowband stimuli would have provided high-frequency binaural cues and a subset of the directional spectral features produced by the filter properties of the head and ears . While tThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The animal study was reviewed and approved by the Committee on Animal Care and Ethical Review, University of Oxford.AK and FN conceived and designed the study, with contributions from AS and VB. AS, FN, and VB acquired the data. AS led the data analysis, with contributions from KW and FN. AS, FN, VB, and AK wrote the manuscript. All authors contributed to results interpretation and final manuscript preparation.


To identify likely association between blood hypertension and hearing loss. Design: A non-paired case-control study. Setting: Institutional work carried out at Universidade Norte do Paraná, in South Brazil.154 cases and 154 controls, both genders, aged 45 to 64, included in the research after sample estimation. Methodology: Hypertension was verified through blood pressure readings and by a systematized questionnaire about hypertension and the use of medication for blood pressure. Hearing was assessed through tonal threshold audiometrics and audiologic anamneses. Non-conditional logistic regression was used in order to control likely confusion or modification of effect of other variables on interest associations.There is a significant association between blood hypertension and hearing loss. Hearing loss in the population under study suggests that hypertension is an accelerating factor of degeneration of the hearing apparatus due to aging.The results in this research, through evidence of association between blood hypertension and hearing loss, can allow for an integrated work of cardiologists, nephrologists, otorhinolaryngologists, audiologists and other health professionals concerned with alterations caused by blood hypertension. Most adult acquired hearing loss have gradual onset and may impair oral language reception.According to data from the ASHA (American Speech - Language - Hearing Association)The relevance of Arterial Hypertension as a human disease is due to its clinical complications, morbidity and mortality, as well as the heavy burden to the patient, family and public coffers. Few diseases are responsible for so frequent and severe complications as the ones accruing from Arterial Hypertension: stroke, heart, kidney and peripheral vascular insufficiencies. Moreover, it is estimated that about half of the deaths of patients above 50 years are due to cardiovascular diseases, and 80% of them have high blood pressureThe size of this “High Blood Pressure” situation in Brazil is estimated through rates established on international papers, and based on projections from the Brazilian Institute of Geography and Statistics Census of 1990, there are today about 90 million Brazilians aged above 20 years. If we consider the hypertension prevalence to be 20%, there must be at least 18 million hypertensive Brazilians, of which about 50% are not aware they have the diseaseKatzSince the second half of last century, studies have analyzed if individuals with arterial hypertension have more hearing loss when compared to other individuals. However, results have been unclear, and there is the need of further studies in this area to prove if there really is a prevalence increase of such alteration as far as peripheral and central hearing are concerned in the affected population.Initially, Rosen et al.MarkováNazar et al.Brohem et al.In a controlled-case study carried out in Kenya with 50 elderly individuals using ABR, Chen et al.Marchiori et al.Rey et al.Amstutz-Montadert et al.Since there are not too many papers in the literature that may lead us to strong evidence, our paper aims at checking if there are associations between arterial hypertension and hearing loss in individuals with ages ranging between 45 and 64 years.The results attained with the present research project will certainly serve as basis for a greater integration between cardiologists, nephrologists, otorhinolaryngologists, speech therapists and other health care professionals involved with arterial hypertension and hearing loss care, bringing about relevant data for the professionals involved in order to improve quality of care in the therapy and rehabilitation of these patients.This research was carried out through a case-controlled study, after the project was analyzed and approved, and an informed consent was signed, pertaining to resolution 196/96-CNS, for the duration of the project, that extended to 2004.308 middle aged individuals were part of the research (aged between 45 and 64 years). The 154 patients with hearing loss (incident cases) were obtained in the sequence of medical visits, while the 154 individuals without hearing loss (controls) were recruited by the patients themselves, under the instruction that they had to live close to the patients they were matching and could not be siblings or parents, in order to avoid genetic biases regarding both Arterial Hypertension and Hearing loss.We excluded patients with previous history of: specific hearing disorders (such as rubella and head injuries), specific metabolic disorders (such as diabetes) and specific vascular disorders (such as strokes), and also individuals who worked or had worked in an environment that could cause noise-induced hearing loss, patients with kidney diseases and with prior history of hospital stay or ingestion of potentially ototoxic medication or drugs were also taken off the study.The major variable of exposure in our study was Arterial Hypertension, and the outcome variable was hearing loss.The instrument for hearing assessment was an audiologic interview which is routinely used in the department of Audiology - UNOPAR, based on the interview protocol  do you take?Questions:Blood pressure was measured indirectly with a proper cuff and mercury gauge - Tycos®. We respected the guidelines established by the III Brazilian Consensus on Hypertension of 1998, which are equivalent to the standards proposed by the European Society of HypertensionPatients with arterial blood pressure ≥ 140 × 90mm of Hg in different measures, and those who answered yes to questions 1 and 6 and identified the medication(s) they were using were considered positive for high blood pressure.We noticed this association between hearing loss and each one of the variables in a first stage , through the attainment of an odds ratio estimate per point and per range, besides the Mantel-Haenszel chi-squared statistical value; and the significance of variables such as smoking, alcohol intake, physical exercises, gender, age, BMI (body mass index) and schooling were all considered. In the next stage we selected the variables that had significant values for the descriptive level. Non-conditional logistics analysis (since there was no pairing), was used in order to attain the odds ratio for hearing loss and to help investigate the existence of interactions between the variables, controlling the effects of the previously selected factors. The statistical modeling process was carried out using the Stepwise selection method.The sample size was calculated using the Epi 6 software, considering data from a pilot study developed with the population in question, in which the ratio of hearing loss and high blood pressure individuals was defined (37.7%) as was the ratio of individuals without hearing loss and high blood pressure (18.8%), with age varying between 45 and 64 years. With an odds ratio of 2.63 and a power of 95% the total N of participants was estimated to be 308.As to the complete distribution of the cases and controls according to hypertension and hearing loss, we saw that 72 individuals had hearing loss and high blood pressure, 82 had hearing loss and no normal blood pressure, 46 did not have hearing loss but had high blood pressure and 108 did not show hearing loss, nor high blood pressure. .Table 1CThe cases presented average age in years of 56.1, a little higher than the 52.8 presented by the control group.There were more women among the cases 57.8%, and among the controls 77.3% when compared to men.We could notice that, regarding schooling, all the groups presented higher incidence of individuals with first grade education completed, and among individuals with hearing loss and hypertension the incidence was 30.6%; among individuals with hearing loss and no high blood pressure, the incidence was 23.5%, among individuals without hearing loss and high blood pressure the frequence was 50% and among individuals without hearing loss and without high blood pressure, the frequence was 26.9%.Most individuals in this research did not smoke; among the individuals with hearing loss and high blood pressure, 84.7% did not smoke. Among individuals with hearing loss and without high blood pressure, 91.3% did not smoke and among the group without hypertension and without hearing loss, 83.3% did not smoke (p= 0.5920).Most individuals in this research did not drink alcoholic beverages; the group of individuals with hearing loss and hypertension, 94.4% said they did not ingest alcohol; in the group with hearing loss and without arterial hypertension, 96.3%; in the group without hearing loss and with arterial hypertension, 100%; and in the group without arterial hypertension and without hearing loss, 94.4% reported the same (p= 0.4206).As to the practice of physical exercises, in the group of individuals with hearing loss and arterial hypertension, 63.9% reported they did not practice any type of exercise; in the group of patients with hearing loss and without arterial hypertension, 65.9%; in the group without hearing loss and with arterial hypertension, 67.4%; and in the group without arterial hypertension and without hearing loss, 68.5% reported the same (p=0.9298).As to the type of hearing loss in the sample, the individuals with arterial hypertension and those without arterial hypertension presented a similar frequence of sensorineural hearing loss, and in the first group, 83.7% of the ears presented the aforementioned loss, while in the second group, 81.8% had it (p=0.1310).As to the degree of hearing loss in the sample, the individuals with arterial hypertension and those without it had a similar frequence of mild hearing loss, in the first group this rate was of 62.0% and in the second group 63.6% (p=0.0881).The arithmetic average of body mass index in the group of individuals without hearing loss and with arterial hypertension was of 30.3 and in the group with hearing loss and arterial hypertension it was of 29.7; while the group with hearing loss and without arterial hypertension this value was of 27.6 and in the group without hearing loss and no hypertension this number was of 26.8, showing that in this study there was a higher body mass index in the individuals with arterial hypertension.As to the use of anti-hypertensive medication, we noticed that of the 72 cases with hypertension, only 5 (6.9%) did not use the medication, and of the 46 controls who had hypertension, only one (2.1%) did not use medications; thus, of the 118 hypertensive individuals in this study, only 6 (5%) did not use medication to treat their hypertension at the time of the exam.As to the association of antihypertensive drugs, 24 cases (33.3%) and 11 controls (23.9%) used more than one anti-hypertension drug, which prevailed among cases - 6 individuals (8.3%) and among the controls - 5 individuals (10.8%), with association of diuretic agents plus ACE inhibitors.Among the cases, 34 (47.2%), and among controls, 17 (36.9%) used ACE inhibitors.Among the cases, 25 individuals, and among controls, 14 used diuretic agents, 17 of the cases and 15 of the controls used β-blockers and one of the cases and 3 controls used angiotensin II antagonist inhibitors; 8 of the cases and 2 controls used calcium channel blockers; 3 of the cases and 1 control used α-blockers; and 4 cases and 5 controls used other anti-hypertension medications such as cloridine, α-metildopa and minoxidil and, 7 cases and 4 controls were using other drugs simultaneously such as antiarrhythmics, vessel dilators and antiplatelet aggregation drugs.Arterial hypertension, advanced age and male gender proved to be independent risk factors for hearing loss .Table 2RThe logistic regression model shows that hypertension (p=0.0322), higher age (p=0.0011) and male gender (p=0.0004) are independent risk factors for hearing loss.The present study showed the existence of an association between hearing loss and arterial hypertension in individuals between 45 and 64 years, and contributed with such evidence to explain this controversial aspect of human health. Such association between hearing loss and arterial hypertension has been an important object of research in recent decades, with highly antagonic conclusions, and some authors back this associationAs to the methodological characteristics of this study, the care taken in outlining the age factor, focusing on the age range of middle aged individuals, between 45 and 64 years as they do in hypertension investigationsPertaining to the statistical analysis, we used logistics regression since this is a model that with a good adjustment obeys the principle of sobriety, and it also describes the relation between one result and a set of simultaneous explanatory variables, since the logistics analysis controls a great number of variables at the same time, allowing the data to be used in a more efficient wayWith aging, there is a higher number of chronic diseases. Systemic arterial hypertension and hearing loss have important prevalence in the elderly populationDespite these structural changes caused by age, many authors mention presbyacusia, which usually start at around 65 years of age and is a hearing loss type accruing from aging itself and is associated to specific audiologic characteristics, being a descending, bilateral and symmetrical sensorineural hearing loss typeSome studies justify that the sensorineural hearing loss that happens with aging is related to a microcirculatory insufficiency that occurs due to vascular occlusion caused by emboli, hemorrhage or vasospasm, and these happen because of a syndrome of hyperviscosity or microangiopathy caused by diabetes or hypertension, and the latter could, through histopathological mechanisms cause the sensorineural hearing lossIn an experimental study using rats with arterial hypertension, it was noted that hypertension is an important risk factor for age-related hearing loss. Action potentials, electrochemistry and potassium concentration in the cochlea of these genetically predisposed to hypertension animals were measured together with their normotension counterparts. With aging, the hypertensive animals had a higher action potential threshold, a higher electrochemical potential happened only in the extremely aged animals, while potassium concentration increased not only in the endolymphatic cells, but also in the perilymphatic ones. These data suggest that ionic modifications to the cell action potential are involved in the hearing reduction that happens to hypertensive animals. These data help us understand hearing loss in hypertensive individualsIt is known, however, that environmental factors, to which human beings may be subject, such as noise, inhalation of toxic substances, certain metabolic and circulatory alterations; infections, injuries of many natures and genetic inheritance, may also influence the individual's hearing, often times accelerating the process of cochlear degenerationAs to gender, there was a difference in the men to women ratio in both groups, due to the fact that we did not pair the sample – cases were taken at random, during regular medical visits, while the controls were brought by the hearing impaired patients themselves, under the instruction that they could not be siblings or parents of these patients, and we had to take off the study a greater number of men because of a hearing impairment suspicion – those who worked or had worked in noisy environments.Many papers have approached the theme gender and hearing loss in relation to ageCollet et al.Due to a reduction in mortality rates, there is an increase in life expectancy all over the world. In Brazil, according to the recent census (2000), the elderly population corresponded to 5.85% of the population, and its growth was of 1.02% in relation to the previousscensus from the 90's. The aging index also increased from 13.90% in 1991 to 19.77% in 2000Since medical development together with socioeconomical factors have drastically reduced the number of premature deaths, cardiovascular diseases and cancer are actually the main causes of death; and this is due not only to an increase in the incidence of these pathologies, but also to a greater longevity and mainly to medication control and efficacy in eliminating infectious diseasesThe new challenge are the chronic conditions related to aging, many detectable and preventable already in middle age, and such conditions are currently seen in the many health care specialties in delaying those. Fries sees this as “morbidity compression”, in other words, live a life with relative health and compress diseases to a short period of time right before deathAccording to the Brazilian Council on Arterial Hypertension, high blood pressure is multicausal and multifactorial, because most of the time it does not cause any symptoms to the patients and it involves education aiming at achieving a number of goals, and for that there is the need to form a multidisciplinary care teamThe care related to arterial hypertension and hearing will certainly serve to avoid the frustrations caused by the reduction in one's capacity to understand oral language caused by a reduction in hearing accuitySince the study has shown that arterial hypertension is an independent risk factor for hearing loss, besides the male gender and advanced age, we highlight the importance of preventive processes that may mitigate the mechanisms that cause degeneration of the hearing apparatus caused by circulatory problems, most specifically high blood pressure.


Patient-reported outcome measures, inventory and or questionnaire, allow patients to present their perspective of the impact of their individual condition on a day-to-day basis, independent of the analysis of test results by the expert clinician. Outcome measures are recommended when there is evidence showing their reliability, validity and sensitivity. There are standardized patient-reported outcome measures for hearing in English language; however, other languages lack these instruments.Adapt the Amsterdam inventory for auditory disability and handicap to Brazilian Portuguese and analyze its validation measures.n = 31 and 18, respectively) and analyzed the measures of instrument validation, reliability, and reproducibility. Moreover, we calculated the correlation between pure tone thresholds and scores on the questionnaire.We conducted two studies. In Study 1, we translated and adapted the Amsterdam inventory for auditory disability and handicap to Brazilian Portuguese according to good practice guidelines; this included the pre-test stage. In Study 2, we administered the Portuguese version to adults with and without hearing loss (r = 0.83) between the mean pure tone threshold and the hearing difficulties values, as measured by the instrument's scores.The results obtained in Study 1 demonstrated the feasibility of the translation process and the instrument's cultural adaptation, as well as its applicability, resulting in the Portuguese version of the Amsterdam inventory for auditory disability and handicap. In Study 2, the results revealed construct values for the questions and domains, as well as for the total reliable score. The intra-interviewer test–retest condition showed excellent reproducibility (ICC = 0.97). Finally, there was a strong positive correlation (The English version of the Amsterdam inventory for auditory disability and handicap could be translated and adapted to Brazilian Portuguese. An analyses of the validation process yielded reliable, consistent, and stable results. Updated data from the World Health Organization (WHO) estimate that among the 360 million people with incapacitating hearing loss, 328 million are adults or elderly people.4The functional evaluation of hearing involves techniques and technological resources to identify hearing disorders, with hearing loss being the most frequently identified condition. This evaluation must be performed through the accurate analysis of signals obtained from a set of tests and/or exams, which is not complete without the elucidation of the hearing difficulties of the subject under evaluation. Patient-reported outcome measures (PROMs) allow patients to present their perspective of the impact of their condition on a day-to-day basis, independent of the analysis of test results by the expert clinician.7Although PROMs are useful instruments that improve the quality of care offered to patients, they can be a potential trap for healthcare professionals with less knowledge about the requirements needed to select the instrument, as well as its application, analysis, and interpretation.8There are standardized PROMs for hearing in EnglishThe Amsterdam Inventory for Auditory Disability and Handicap (AIADH) is one instrument to measure PROMs. Proposed by Kramer et al.,19The validation measures of the English-language AIADH as an instrument to measure self-perception of hearing difficulties in daily activities were detailed and studied by Meijer et al.In view of the above factors, our objective was to translate and culturally adapt the AIADH into Brazilian Portuguese and analyze its results in order to legitimize its use. To fulfill these objectives, we performed two studies; the first verified the feasibility of translating and adapting the AIADH into Portuguese, and the second evaluated measures of reliability, validity, and acceptance of the instrument.A cross-sectional observational study was performed at the Medical School of Ribeirão Preto-University of São Paulo, with approval from the Research Ethics Committee of the Institution (n° 754.278/Ago 2014). All participants signed a informed consent form.The AIADH, as proposed by Kramer et al.,22The process of translating and adapting the AIADH was performed in four stages according to recommendations in the literature,Stage 1 (Translation): The original version of the AIADH was delivered to three independent professionals, fluent in the English language and without prior knowledge of the instrument, who were asked to translate the instrument into Portuguese, resulting in three different versions called a, b, and c. The three versions were delivered to three consultants who were given guidelines for analyzing each question in the three versions and respond whether they had the same content. The answers of the consultants were subsequently analyzed by the authors of this work. Following satisfactory agreement between the authors for each question, a single version, referred to as version 1, of the AIADH in Portuguese was formulated.Stage 2 (Retro-translation): The Portuguese version 1 of the AIADH was sent to a translator and retro-translated into English who had no prior knowledge of the instrument. The AIADH retro-translation and original English version were sent to two English-speaking consultants to see if the two versions could be characterized as possessing the same content and referred to the same instrument. The consultants’ answers were analyzed by examining the concordance between them. If this was satisfactory, version 1 of the AIADH in Portuguese was considered viable for study continuation; in the presence of a weak agreement, we would repeat Stage 1.Stage 3 : The version obtained after satisfactory agreement between the authors was then referred to a review committee to examine linguistic and cultural similarity. The test resulting from this step was referred to as adapted version 1.Stage 4 (Pre-test): The adapted version 1 was tested in interviews regarding the intelligibility of its questions. We invited 25 randomly selected adults in a common area of the hospital linked to the university. The inclusion criteria were 18–50 years of age and patients who did not seek otorhinolaryngology and/or speech and hearing Services. All patients underwent pure-tone audiometry at the frequencies of 0.5, 1, 2, and 4 kHz. A mean value of >20 dB HL was interpreted as indicating hearing loss.All 25 volunteers, regardless of the mean tonal thresholds, were interviewed with the AIADH adapted version 1 and answered questions about the applicability of the inventory to verify whether additional instrument adaptations were required.The volunteers were instructed and asked about the following aspects: (a) Interrupting the interviewer in case a word they did not know or understand the meaning of emerged; (b) If the four possible answers to the questionnaire would meet their demands; and (c) If they would classify the questions as easy or hard to answer.The material resulting from this stage, with satisfactory results’ concerning its applicability was designated the AIADH in Brazilian Portuguese (Pt-AIADH).To analyze the instrument's validity and to determine whether it could be used to differentiate between populations with and without hearing loss, we recruited another 31 subjects. All subjects were previously identified with hearing loss by the public health system, and were referred to the Hearing Health Program of the Medical School of Ribeirão Preto-University of São Paulo.The inclusion criteria were: a minimum age of 18 years, with no upper age limit; the presence of post-lingual acquired hearing loss of any nature; no previous experience of sound amplification devices; no apparent symptoms of conditions affecting communication observed during spontaneous conversation; and no need for caregivers and/or aids for locomotion and/or activities of daily living. This information was verified with a companion, when present. We did not establish exclusion criteria for this stage. The presence of hearing loss was identified when the mean frequencies of 0.5, 1, 2, and 4 kHz were >20 dB HL.The Pt-AIADH was performed by a single researcher on two days with the same subjects, with a minimum interval of 30 days between the interviews, to examine the test-retest reproducibility (reliability).Thereafter, we compared the Pt-AIADH scores between subjects with and without hearing loss . The HLG was comprised of 31 volunteers from Study 2; the NHG was comprised of 18 of the 25 subjects from Study 1, Stage 4, who corresponded to those with mean tonal thresholds within normal limits for both ears.We used the Kappa concordance test in Stage 1 and 2 of Study 1.α) test by question and domain. We used the Guttman Split-Half coefficient testIn Study 2, the reliability of the Pt-AIADH was estimated using the Cronbach's alpha coefficient , as well as between the original instrument and the resultant back-translation into Portuguese  exhibited a level 1 agreement.The Portuguese version 1 of the AIADH was studied by the review committee for its grammatical and cultural adaptation , which generated the adapted version 1. The adapted version 1 was applied in a pre-test condition in 25 subjects with a mean age of 34 years (54.5% women). The calculation of the mean tonal thresholds suggested hearing loss in some subjects . All 25 The described results enabled the identification the instrument as the Pt-AIADH .The Pt-AIADH was applied to 31 subjects, with a minimum age of 25 and a maximum of 92 years . All subjects presented with hearing loss, thus constituting the group with Hearing Loss (HLG), with 74.2% (23/31) and 25.8% (8/31) being of the sensorineural and mixed types, respectively. Concerning laterality, 96.8% (30/31) had bilateral impairment and only 3.2% (1/31) demonstrated unilaterality. The descriptive values of the tonal means are shown in The Pt-AIADH responses were studied in relation to their reliability. Internal consistency was the first variable examined. We initially performed the calculation for each of the 30 questions separately, then for each of the domains, and later the instrument. Next, the correlation between the two halves of the questionnaire was calculated. For these analyses, the lowest value was always ≥0.80, except for the result of the analysis of the second part of the inventory, which was 0.72 .Table 2MThe second variable analyzed for reliability was the intrasubject reproducibility ; 100.00% of the 31 subjects with hearing loss responded to the Pt-AIADH at two time points, the score results at the two points were similar, if not equal . The intCorrelations among the five domains of Pt-AIADH were also calculated . The resSubsequently, we conducted a study to verify whether the instrument differentiated groups with and without hearing loss . The HLG comprised 31 subjects from Study 2, while the NHG comprised 18 (72.00%) of the 25 subjects in Study 1, Stage 4 of the pre-test phase, who corresponded to those subjects with mean tonal thresholds within normal limits.p < 0.0001*; U′ = 32; mean of the worst ear HLG vs. NHG, p < 0.0001*; U′ = 0)  .p < 0.0001*) were observed, showing that the HLG presented greater hearing difficulty than did the NHG (n = 49) with the total Pt-AIADH score. We used the corresponding tonal means of the best ears of the two groups and found a strong significantly positive correlation ; briefly, the higher the tonal mean, the greater the hearing difficulty  were compared between the two groups. For all domains, significant differences .This work was supported by The authors declare no conflicts of interest.


Beauveria bassiana. These Atg22-like proteins exhibit different sub-cellular distributions. BbAtg22A localizes in lipid droplets. BbAtg22B and BbAtg22C are completely distributed in the vacuole, and BbAtg22D has an additional association with the cytomembrane. The ablation of Atg22-like proteins did not block autophagy. Four Atg22-like proteins systematically contribute to the fungal response to starvation and virulence in B. bassiana. With the exception of ∆Bbatg22C, the other three proteins contribute to dimorphic transmission. Additionally, BbAtg22A and BbAtg22D are required for cytomembrane integrity. Meanwhile, four Atg22-like proteins contribute to conidiation. Therefore, Atg22-like proteins link distinct sub-cellular structures for the development and virulence in B. bassiana. Our findings provide a novel insight into the non-autophagic roles of autophagy-related genes in filamentous fungi.In yeast, Atg22 functions as a vacuolar efflux transporter to release the nutrients from the vacuole to the cytosol after the degradation of autophagic bodies. There are more than one Atg22 domain-containing proteins in filamentous fungi, but their physiological roles are largely unknown. In this study, four Atg22-like proteins (BbAtg22A through D) were functionally characterized in the filamentous entomopathogenic fungus  Beauveria bassiana acts as an important representative entomopathogenic fungus and has been widely considered in the biocontrol of insect pests [B. bassiana, this process is associated with the entire infection cycle and plays essential roles in the fungal stress response, development and virulence [ct pests ,2. In euct pests . In B. birulence ,5. HowevB. bassiana, Atg1 (a serine/threonine protein kinase) are indispensable for autophagosome induction and expansion [B. bassiana pexophagy, peroxisomes are labeled by pexoxin 14, which is recognized by Nbr1 (neighbor of BRCA1 gene 1). Then, Nbr1 recruits the targeted peroxisomes into the autophagosomes via the direct interaction with Atg8 [B. bassiana, which is not prevalent among fungal species [B. bassiana might use a set of Atg22-like permeases at different stages of its lifecycle, and the action mode of Atg22-like proteins needs to be revealed at the molecular levels.At present, 43 autophagy-related genes (ATGs) have been identified and functionally characterized in yeast ,7, in whxpansion . The comxpansion ,11,12. Ixpansion . Atg11 axpansion . In B. bith Atg8 . Among tith Atg8 . In yeas species . This imB. bassiana via the construction gene disruption and complementation mutant strain. Four proteins displayed divergent sub-cellular localizations and biological functions, including fungal differentiation, stress resistance and virulence.In this study, four Atg22-like proteins were functionally characterized in B. bassiana ARSEF2860 (Bba2860) was obtained from the U.S. Department of Agriculture Entomopathogenic Fungus Collection ,as maintained previously [Escherichia coli DH5α (Invitrogen) was cultured in a Luria-Bertani medium with the necessary antibiotics for plasmid construction. In fungal transformation, Agrobacterium tumefaciens AGL-1 acts as a donor strain and is cultured in YEB broth . Czapek-Dox agar (CzA)  was used as the chemical defined medium in the following experiments.Wild type (WT) strain of eviously , and theB. bassiana genome [http://smart.embl-heidelberg.de, accessed on 15 December 2022) [Four Atg22-like proteins have been recognized in the a genome . Their der 2022) . Cellular localizations of the Atg22-like proteins were determined as described previously . All of B. bassiana disruption mutants were generated using homologous replacement coupled with a fluorescence reporter [X1/PX2 and PX3/PX4, respectively. The resulting fragments were sequentially cloned into the XmaI/BamHI and XbaI/HpaI sites of p0380-bar using the ClonExpress II One Step Cloning Kit , generating the gene disruption vector (p0380-bar-X). The resulting vector was transformed into the WT strain with the Agrobacterium-based transformation method, and the transformants were screened on CZA plates with phosphinothricin (200 µg/mL). To complement the gene loss, the full-length gene was amplified with the primer pair PX5/PX6, and the obtained fragment was inserted into the plasmid pPK2-NTC-GFP containing the nourseothricin-resistance gene [X7/PX8, and the gene disruption mutant was further verified with the fluorescence-coupled double screening method. All of the reporter . All prince gene . For scrFusion protein GFP-Atg8 (GA8) was used as a marker to track the autophagic process . Plasmid7 conidia/mL) was inoculated on the plates, and the germination percentage was examined at 24 h post-incubation, at 25 °C.To assess conidial germination, WA plates (1.5% agarose) were used as the nutrient-limited medium, while SPA plates  were used as the nutrient-rich medium. The conidial suspension  included trehalose (3%), sucrose (3%), glucose (3%), fructose (3%), olive oil (0.5%) and oleic acid (0.2%). Nitrogen sources  included NH4NO3 (0.5%) and gelatin (0.5%). The conidial suspension  was inoculated on a plate. The radial growth was determined by measuring the colony diameter after 7 d of incubation at 25 °C.The fungal radial growth on the plate was assayed by replacing sucrose or NaNO7 conidia/mL) were evenly spread on agar plates and cultured for 7 d at 25 °C. Mycelial discs, 5 mm in diameter, were suspended in 0.02% Tween-80 solution. The conidial concentration was examined and used to calculate the conidial yield . The fungal development under a submerged condition was assayed in SDB medium (SDAY without agar). The conidia were inoculated into SDB at the final concentration of 105 conidia/mL and cultivated for 3 d at 25 °C with constant shaking. The concentration of blastospores in the media was determined using microscopic counts, and the blastospore yield was shown as the number of spores per ml of culture.The conidial production was determined on a SDAY plate. Aliquots  for 10 s. In the intrahemocoel injection assay, conidial suspension  was injected into the host hemoceol. Tween-80 solution (0.02%) was used to suspend the conidia and also as the control in the assays. The daily-recorded mortality was used to calculate the median lethal time (LT50) by the Kaplan-Meier method with a log-rank test for determining the difference between the paired survival trends. For pathogenicity tests, the last instar larvae of TM Plus Reagent  according to the manufacturer’s protocol. The cDNA was reverse transcribed using the PrimeScript® RT reagent Kit (TaKaRa) and used as templates to perform the qRT-PCR reaction on a Mastercycler® EP Realplex  cycler. All primers are shown in −∆∆CT method [The transcriptional analyses for the genes were performed as reported previously . The wilT method . Fungal One-way analysis of variance (ANOVA) was applied in the comparison of the phenotypic measurements between the disruptant and the wild type or complementation mutant, and the statistical significance was determined by a Tukey’s honest significance test (Tukey’s HSD). The analyses were performed with the software of GraphPad Prism 8 . B. bassiana and are named as BbAtg22A (EJP69073), BbAtg22B (EJP65688), BbAtg22C (EJP65315), and BbAtg22D (EJP61453) [B. bassiana contained a typical ATG22 domain. Phylogenetic analyses indicated four B. bassiana Atg22-like proteins clustered in different clades, in which BbAtg22A was clustered with yeast ATG22 ), which was 16.00% lower than that of the wild type (97.33 ± 1.89%) (Bbatg22A (22.00 ± 2.16%), ΔBbatg22B (25.00 ± 0.82%), ΔBbatg22C (44.67 ± 3.86%) and ΔBbatg22D (13.00 ± 2.45%) were significantly lower than that of the wild type (62.00 ± 4.55%) with decreases of 64.52%, 59.68%, 27.96%, and 79.03%, respectively. There was no significant difference between the complementation strains and the wild type.The conidial germination was assayed on GM and WA plates, which represented nutrient-rich and -limitation conditions, respectively A. On the± 1.89%) . On the ± 1.89%) C, at 24 7 conidia/mL) on a SDAY plate, incubated at 25 °C. The microscopic examination indicated that the ΔBbatg22B, ΔBbatg22C and ΔBbatg22D mutant strains produced significantly enlarged conidia-forming structures at 4 d post-incubation, and there was no significant difference between the wild type and the ΔBbatg22A mutant strains   C. No sigBbatg22C, the blastospore yields of the other three disruptants were significantly lower than that of the wild type (1.30 ± 0.06 × 108 spore/mL). The yield of ΔBbatg22A decreased to 1.00 ± 0.07 × 108 spore/mL; ΔBbatg22B decreased to 0.99 ± 0.10 × 108 spore/mL; ΔBbatg22D decreased to 1.06 ± 0.03 × 108 spore/mL . The yield of ΔBbatg22C was slightly lower than that of the wild type, but it was not statistically significant  were 4.00, 4.17, 4.17, 4.50, and 4.00 days, respectively. In the cuticle inoculation bioassay, the LT50 values were prolonged by 1.42, 1.42, 0.75, and 0.75 days, respectively, when compared with that of the wild type  [B. bassiana contribute to blastospore formation in the liquid media and host hemolymph. In B. bassiana, other genes related to lipid metabolism are associated with morphological transition, including acetyl-coenzyme A (CoA), synthetase 2 (Acs2) [B. bassiana [B. bassiana develop the conidiation process to generate conidia, which facilitates fungal dispersal and initiates the follow-up infection cycle [B. bassiana [Fusarium oxysporum (a plant pathogenic pathogen), Atg22 is required for hyphal development and conidiation [In the host hemocoel, tospore) . The dimtospore) . Excludi2 (Acs2) , and ste2 (Acs2) . BbAtg222 (Acs2) ,21. BbAcbassiana . Thus, Bon cycle . Autophaon cycle  and has bassiana ,13. In Fidiation . These rB. bassiana. These findings suggest that filamentous fungi evolve more Atg22-like proteins to adapt to different ecological habitats. This study improves our understanding of the roles of Atg22-like protein in filamentous fungi beyond its conserved roles in autophagy.Taken together, the four Atg22-like proteins display distinct sub-cellular localizations and play different roles in fungal differentiation, the response to starvation stress, and virulence in


We observed that ω-3 PUFA intake was associated with an 11–55% risk reduction in developing colorectal adenoma, and the association was modified by the gut bacterial evenness level. We also found that three specific gut bacteria and four BAs metabolites that were measured in normal colonic mucosa tissue were positively associated with colorectal adenomas. These findings provide important insights and imply that the improvement of ω-3 PUFA intake and/or alterations in the gut microbial environment may become a potential risk reduction strategy for colorectal cancer prevention.Dietary omega-3 polyunsaturated fatty acids (ω-3 PUFAs) may protect against colorectal adenoma development, and the gut microbiota and microbial metabolites (particularly bile acids) are important in dietary fat metabolism. We aimed to evaluate the impacts of ω-3 PUFAs, gut microbiota, and bile acids (BAs) on colorectal adenoma occurrence in a case–control study (n = 50). We compared microbiota and metabolite signatures between cases and controls according to fold change (FC). Odds ratios (OR) and confidence intervals (CI) were estimated from logistic regression for associations of ω-3 PUFAs and the microbiota with CRAs. We observed an inverse association between overall ω-3 PUFA intake and CRAs, especially for short-chain ω -3 PUFAs . Such inverse associations were modified by bacterial evenness (p-interaction = 0.03). Participants with higher levels (FC > 2) of bile acid-relevant metabolites were more likely to have CRAs than the controls, and the correlation between bile acids and bacterial diversity differed by case–control status. Our findings suggest that ω-3 PUFAs are inversely associated with CRA development, and the association may be modified by gut microbiota profiles.Omega-3 polyunsaturated fatty acids (ω-3 PUFAs) are thought to protect against colorectal adenoma (CRA) development. We aimed to further understand the underlying mechanisms by examining the relationships between ω-3 PUFAs and the gut microbiota on CRAs. We assessed the mucosal microbiota via bacterial 16S rRNA sequencing among 217 CRA cases and 218 controls who completed PUFA intake questionnaires. The overall microbial composition was assessed by α-diversity measurements . Global metabolomics was conducted using a random subset of case–control pairs ( The public health burden of colorectal cancer is considerable. Approximately 151,030 new cases of colorectal cancer are expected to occur among the US population in 2022 [Accumulating laboratory studies support the hypothesis that ω-3 PUFAs may protect against colorectal carcinogenesis, mainly through inhibiting inflammation and cell proliferation processes . There aFusobacterium species in adenoma cases compared to in non-adenoma controls [The gut microbiota may play an important role in explaining the underlying mechanisms of ω-3 PUFAs on colon carcinogenesis  because controls ,11. Othecontrols ,16,17, bPrevious studies ,19 have Currently, no large human studies have assessed the potential interactions of ω-3 PUFAs, gut bacteria, and BA on developing colorectal adenomas. In this case–control study with a relatively large sample size and mucosal tissue-based microbial metabolites, we first aimed to examine the associations of ω-3 PUFA intake and adherent gut microbiota (and their interaction) in relation to colorectal adenomas. Furthermore, we assessed the associations between BAs, gut microbiota, and adenomas in the subset of samples with metabolomics data.Our analytical population was identified from the Diet and Health Study V (DHS V), which included participants (age ≥ 30 years old) who had undergone screening colonoscopies at the main hospitals of the University of North Carolina  between August 2008 and March 2010. Those who provided informed consent, agreed to take part in a phone interview, consented to provide rectal biopsies during the procedure, and/or agreed to have blood drawn were considered to be eligible for this study. Participants who were less than 30 years old; unable to provide informed consent; had polyposis (>100 polyps), prior colon resection or cancer, colitis, prior colon adenomas, familial polyposis syndrome, inadequate preoperative, or incomplete examination (cecum not reached); and who had used antibiotics within the previous three months were excluded . All eleInformation about demographic characteristics, education, family history, medical history, nonsteroidal anti-inflammatory drug (NSAID) use, smoking, and other lifestyle exposures was collected by telephone interview using a well-structured questionnaire within 12 weeks of the colonoscopy. The interviewer did not know the results of the colonoscopy. Dietary intake during the year prior to the colonoscopy was assessed using the National Cancer Institute quantitative food frequency questionnaire . Intake Biopsy collection was carried out as previously described ,24. PrepBacterial genomic DNA was extracted according to standard procedure . BrieflySequencing of the microbiota was performed using a modified protocol of Fadrosh et al. . First, The DNA extraction, PCR, and sequencing processes all included appropriate negative and positive controls for quality assurance.We used appropriate controls during the DNA extraction, PCR, and sequencing steps, which included a Bacteria Mock Community consisting of aerobes and anaerobes, negative DNA extraction and reagent controls , and no template control for PCR.Raw bacterial 16S sequences were quality filtered and analyzed using QIIME , followiPi is the proportion of each species (taxa) in the sample [The Shannon–Wiener Diversity Index (H), which measures diversity, was derived using the formula H = −e sample . Richnese sample . For eace sample . Evennese sample .Non-targeted metabolomics was performed using normal rectal tissue biopsies from a subset (due to the assay cost) of randomly selected samples (25 CRA cases and 25 controls without adenomas) using Metabolon . Following receipt, the samples were stored at −80 °C until analysis. The samples were extracted and prepared for metabolome analysis as previously described . Briefly2, 25–29.9 kg/m2, ≥30 kg/m2), cigarette smoking , total energy intake (continuous), fruit and vegetable consumption (continuous), red meat consumption (continuous), saturated fat consumption (continuous), vitamin E consumption (continuous), and overall bacterial composition diversity estimators . Backwards elimination and the change-in-estimate approach were then used to simplify the full adjustment set and to assess the extent of the missing data of covariates . Therefore, the final multivariable models for ω-3 PUFA–adenoma association were only adjusted for age, sex, race, BMI, total energy intake, saturated fat, vitamin E, and overall bacterial composition estimators.We used multivariable logistic regression to estimate the adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the relationship between ω-3 PUFA intake and colorectal adenomas. We categorized the participants into subgroups based on the distribution of ω-3 PUFA intake (by tertile) among the controls. Potential confounders were selected a priori based on the literature and a directed acyclic graph . These cStatistical analysis of the gut microbiota and mucosal metabolome was performed in MicrobiomeAnalyst  and Metap-values of < 0.05 or fold change (FC) thresholds of >2 (or reversely <0.5) were considered statistically significant. Furthermore, the significant bacteria and metabolites were entered into a logistic regression model to further examine their relationship with colorectal adenomas.For metabolome analysis, we used a similar approach to the one used for the microbiota. Briefly, metabolite concentrations were normalized by the total sum scaling method followed by log transformation and comparative analysis, PCA, and PLS-DA. For both microbiota and metabolome analyses, significance tests comparing the profiles of the cases and controls were adjusted for multiple comparisons using the False Discovery Rate (FDR) method ,32. MicrFor interaction analysis, the bacterial richness, evenness, diversity, and abundance of significant specific bacteria were further dichotomized based on the median among the controls, and we used the level ≤ median as the referent group. A multivariable joint effect analysis to assess the potential interaction between the gut microbiota and ω-3 PUFAs was performed by including the interaction terms of the gut microbiota composition/abundance and ω-3 PUFAs in the model. Models with and without interaction terms were compared to compute the likelihood ratio test (LRT), with α = 0.05 . Given tAll analyses were conducted using MicrobiomeAnalyst , MetaboAThe characteristics of our study participants by case–control status are presented in trend = 0.06). A similar, but stronger and significant, association between SC ω-3 PUFAs and colorectal adenomas was observed . The trend of an inverse association was not found for LC ω-3 PUFAs (ptrend = 0.22).The results of the adjusted analyses showing the association between ω-3 PUFA consumption and colorectal adenomas are shown in Sphingomonas and Marinomonas at the genus level were significantly higher in the cases, while the abundances of Sutterella and Parabacteroides were significantly lower among the cases than among the controls, with FDR-adjusted p-values of < 0.05. There are statistically significant positive associations with colorectal adenomas per one-unit increment in the abundance of Sphingomonas  and Ralstonia , but an inverse association with the abundance of Pseudoalteromonas . We did not observe statistically significant associations between bacterial diversity measures and colorectal adenomas.Overall, we identified 37 bacteria at the genus level. The results of the differential abundance analysis for eighteen of the top-contributing bacteria and their association with colorectal adenomas are presented in p-interaction < 0.05). Among the subjects who had higher levels of bacteria evenness, the risk of adenomas in relation to the consumption of higher levels of SC ω-3 PUFAs was greatly reduced . In contrast, the corresponding ω-3 PUFA–adenoma association among the lower bacteria evenness subgroup was increased to be above the null . In another comparison analysis, relative to those with both a low level of gut microbiota and a low intake of SC ω-3 PUFAs, adenoma risk tended to be the highest among those with both a high abundance of microbiota and a low intake of PUFAs. We found no significant differences in the SC ω-3 PUFA–adenoma association caused by bacteria diversity and richness nor by the abundance of six specific bacteria .The associations between SC ω-3 PUFA and colorectal adenomas as stratified by the gut microbiota diversity measures and specific bacteria abundances are displayed in We further evaluated the association between colonic mucosal metabolites and adenomas in a subset of 25 cases and 25 controls. We identified 305 metabolites, 38 of which were significantly different between the cases and controls above a two-fold threshold (data not shown). A significant number of 11 microbial metabolites (BAs) were among these differential metabolites; two were primary BAs and nine were secondary BAs. The differential analysis and the association between these 11 BAs and colorectal adenomas are shown in p = 0.06); however, it tended to be negatively correlated with bacterial diversity among the controls . The concentrations of 7-ketodeoxycholate and 12-dehydrocholate were consistently higher (fold changes > 2) among the subgroup of controls with high levels of bacterial richness and diversity as well as a high abundance of Marinomonas, Parabacteroides and low SC ω-3 PUFA intake  ratio [Ralstonia . However, in general, we did not observe a significant association between ω-3 PUFA intake and gut microbiota composition, which is consistent with findings from a recent randomized trial [Analysis of the interaction between ω-3 PUFAs, the gut microbiota, and colorectal adenoma risk revealed the modifying role of gut bacterial evenness. A high intake of SC ω-3 PUFAs was significantly associated with a reduced risk of developing colorectal adenomas among a subgroup of subjects with high bacteria evenness, but not among those with low bacterial evenness, suggesting that the overall distribution of the bacterial community could be crucial for ω-3 PUFA metabolism and colorectal carcinogenesis. Several potential mechanisms support this important finding on the modification effect of bacteria evenness on the association between ω-3 PUFA intake and colorectal adenomas. A key aspect to consider is the role of ω-3 PUFAs and the resident gut microbiota in inflammation and immune regulation. It is believed that the commensal gut bacteria maintain a symbiotic interaction with the mucosal immune system and are in a state of tolerance under normal/healthy conditions. Disruption of the symbiotic environment may trigger chronic inflammation through increased mucosal permeability, bacterial translocation, and the increased activation of components of the innate and adaptive immune system ,13,38. EB) ratio . The F/BB) ratio . ω-3 PUFB) ratio . We founIn a subset of subjects with mucosal metabolomics data, we found a positive association between the concentrations of specific BAs (particularly taurine-conjugated secondary BAs) and colorectal adenomas. Our findings are also consistent with previous laboratory studies ,43,44. IAlthough we were unable to perform an interaction analysis to examine the modification effect of BAs on the ω-3 PUFA intake–adenoma association due to the limited sample size, we observed a negative correlation between the SC ω-3 PUFA and BA concentrations measured in normal mucosal tissue. There is a hypothesis that ω-3 PUFAs may promote bile discharge and increase the quantity of BAs that escape enterohepatic recirculation  without This study has several limitations. First, our findings depend on self-reported ω-3 PUFA intake determined via FFQ. This could result in potential misclassification and, for the case–control study, recall bias. However, our FFQ was validated to represent dietary intake habits for the past 5–10 years, which is also the standard for nutritional epidemiology research. In addition, we observed a strong positive association between ω-3 PUFA-related tissue-cased metabolites such as docosapentaenoate with colorectal adenomas , which may support the results of the questionnaire-based ω-3-PUFA measurements well. Furthermore, all the FFQs and other study questionnaires were completed within 12 weeks of colonoscopy and diagnoses to minimize bias. Similarly, several features of ω-3 PUFA intake, such as harvesting, storage, processing, and cooking methods, may also influence the accuracy of reporting due to the PUFA content measured in the US Department of Agriculture database potentially differing from our participants’ actual consumption . Second,To the best of our knowledge, the current study is the first to examine the potential modifying effect of the gut microbiota on the association between ω-3 PUFA intake and the risk of developing colorectal adenomas as well as the first to identify the correlation pattern between ω-3 PUFAs and bacteria composition with the colonic mucosal tissue-level BA concentration. The questionnaires were administered within months of colonoscopy, which was likely to reduce the possibility of dietary changes due to adenoma status and the impact of recall bias when completing the FFQ. Strengths of this study also include the consecutive recruitment of study participants, the use of colonoscopy and pathological evaluations of polyps to classify the participants to adenoma status, and the extensive data on established and potential risk factors for colon adenomas. The risk factors  identified in In summary, we found significant associations between SC ω-3 PUFA consumption, specific gut bacteria abundances, and colonic tissue-level BA concentrations that had a direct influence on the occurrence of colorectal adenomas. We also identified the interactions among all three of these factors, which suggests complex interplay between ω-3 PUFAs, the microbiota, and BAs that contributes to the development of colorectal adenomas. Our results imply that improved ω-3 PUFA intake and/or alterations in the gut microbial environment may become a potential effective risk reduction strategy for colorectal cancer prevention. Furthermore, our observation of the interaction between ω-3 PUFA intake and bacteria evenness and the negative correlation between ω-3 PUFA intake and tissue-level BA concentration requires replication and further investigation into the underlying biological mechanism. This information could help to identify sub-groups of population that may be more susceptible to the effects of increasing ω-3 PUFA intake and may yield more precise preventive and therapeutic interventions to improve outcomes for patients with colorectal adenoma and/or cancer.