Noise level can be quantified and qualified based on sound characteristics such as intensity, type of spectrum, duration and distribution of the noise exposure during one's working hours.Objective: To assess noise spectrum and the audiometric configuration of workers.Materials and Methods: Contemporary cross-sectional cohort carried out in the Federal District Brazil. We did an environmental analysis  of the noise in companies from different industries, with audiological assessment of 347 workers.Results: The spectral analysis revealed peaks at different frequencies for each industry investigated . We noticed that the frequencies of 14 kHz and 16 kHz had significant differences between the various industries, with a greater prevalence of the metallurgical.Conclusion: The use of noise pressure measuring device, coupled to a frequency analyzer and high frequency audiometric assessment yielded an early detection of hearing damage, helping better organize preventive measures. The noise level of harm may be quantified and qualified based on some sound characteristics, such as its intensity, the type of spectrum, duration and noise exposure distribution throughout the day of workThese measures can be obtained using sound pressure measuring devices coupled to frequency analyzers. Such devices show the sound pressure level (SPL) corresponding to the selected frequency band (sound spectrum). Thus, environment noise monitoring helps in the acoustic classification of operational units, enabling the identification of the noisiest places and equipment, collecting information which will be used to select and optimize individual hearing protection devicesAudiometric evaluation is the most used procedure in environments with noise above 85 dB(A). Such assessment aims at protection the worker's hearing and is fundamental in Hearing Protection Programs - HPPp < 0.05) in the group with noise exposure, concluding that such approach enabled the early detection of hearing loss among the workersUpon comparing the results obtained in conventional audiometry with those from high frequency audiometry in workers exposed and in those not exposed to noise, a study showed that the tonal thresholds were significantly higher in the high frequencies ; find in the national classification of economic activities as risk grade 3 or 4, according to the NR 4, Charts I and II of the Ministry of LaborAmong the workers, we selected those who met he following inclusion criteria: work for at least one year in the current position in an 8-hour shift; not having worked in another activity with noise exposure; not working directly with chemicals; not using ototoxic drugs, not having a history of high frequency acoustic trauma, be a male, be in an age range between19 and 65 years; accept to participate in the study and sign the informed consent form.SLOW), as per established by Ordinance # 19, from 04/09/98, of the Ministry of Labor and EmploymentSIE Badge) model from 01 dB - Brazil. For assessment purposes, we selected one worker who worked in the noisiest machine of each industry. The reference criterion which serves as foundation for the daily exposure limits adopted for a continuous or intermittent noise corresponds to a dose of 100% for the exposure of eight hours at the level of 85 dB(A)exp) for a work shift (T0). The equivalent noise level - Leq - represents the equivalent level of sound pressure, according to the definition of the NBR (10.151)crit of 85 dB(A)eq), which represents a continuous noise level in dB(A).Checking the sound pressure levels, dose and spectrum were made by a team specialized in environment acoustics. As far as sound pressure levels (SPL) and frequency spectrum are concerned, the measurements were carried out in a central point of the facility, capturing the general noise of the environment. In order to check the SPL, we used the sound pressure level measuring device coupled to the frequency analyzer model SIP-95, manufactured by 01 dB Brazil. This equipment was properly calibrated by a specialized company, with frequency filters in bands of 1/3 and 1 of octave, operating in an “A” slow response compensation circuit , as per established by the Ministry of Work and LaborAll the tests were carried out in the employer's facilities, under favorable conditions to the test (silent places).Welch Allyn otoscope with WA accessories; Reduson (portable) audiometry booth; two-channel clinical audiometer from Interacoustic, model AD 40 with a TDH 39 phone, in order to check the tonal threshold between 0.25 and 8 kHz. In order to assess the frequencies above 8 kHz, we used the high frequency KOSS HIPRO phone.In order to do the audiological assessment, we used the following devices: In conventional audiometry, the procedure was based on checking the minimum response level for air stimuli for the frequencies between 0.25 kHz and 8 kHz. The worker who had hearing thresholds above 25 dBHL in the frequencies of 0.5 kHz and 4 kHz was also submitted to checking hearing thresholds by bone conduction. The high frequency audiometry analyzed the audiometric thresholds in the frequencies of 9 kHz, 10 kHz, 12 kHz, 14 kHz and 16 kHz.The results from occupational audiometry were grouped according to the criteria specified below in only two categories: normal audiometry - all audiometries which had tonal values equal to or lower than 25 dBHL in all the frequencies; and audiometry levels suggesting Noise Induced Hearing Loss (NIHL) - all audiometries which had a notch higher than 25 dBHL in at least one of the frequencies from 3 kHz. Thresholds higher than 25dBHL were considered a notch in one or more isolated frequencies, as a recovery in the following frequencyExcel® format. The analysis was made using the SPSS 13®  for Windows® and SigmaStat 3.11® for Windows®. The chi-squared test was utilized to check for possible associations between variables. We considered the results from each ear, subdivided into right and left ear and the audiometric data was inserted in a variance analysis model of mixed design with the factors: industry of the worker  and frequency . The multiple comparison procedure utilized the Bonferroni correction method. For the additional pos hoc analysis, we used the ANOVA test of one path. The statistical significance level was established as 5% (p < 0.05). All the tests were bicaudal.The database was created in This study was approved by the Ethics in Research Committee, recorded as 048/2004. All the workers who participated signed the informed consent form.The environment assessment was carried out in three industries . Such measurements could not be checked in the cement factory, because the company did not authorize it.eq) as an indicator of environment noise spectrum in the different companies, the results are shown on eq value points to the noise intensity in the three industries and in the type of spectrum found: frequency peak at 8 kHz in the metallurgical industry, 4 kHz in stone works and 2 kHz in wood works. In the metallurgical plant, we noticed the highest Leq value if compared to those from the other industries, with intensities of 85.4 dB  in the three industries that the values went beyond the tolerance thresholds defined as 100%. Among these industries, the wood had a dose which was 29 times higher than the legally established valueIn the anamnesis, there were reports of clinical problems, such as difficulties to hear, otalgia, vertigo and tinnitus with the possibility of having more than one complaint per worker.Data concerning the individual protection equipment (IPE) showed that 285 workers (82.1%) reported they used it. The workers in the wood works industry are the ones that least use hearing protection (42.6%). On the other hand, the workers of the metallurgical and stone works industries stood out in using IPE.Among the frequencies with a notch, we found a higher sensitivity in the high frequency results (92.3%) when compared to the conventional frequencies (65.3%). Upon analyzing each frequency separately, we found a greater prevalence (75.4%) in the frequency of 16 kHz. Although we have found an increase in the prevalence of a notch suggestive of NIHL in the frequency of 6 kHz (53.8%), this data was not statistically significant .The analysis of the association between the industry and the auditory notch suggestive of NIHL showed a statistically significant association between the presence of the notch in the frequencies of 8 kHz, 12 kHz, 14 kHz and 16 kHz and the industry, with a weak power of association .1, 689 = 218,235, p < 0.001). The mean value of the results from workers with more than 40 years was significantly higher in comparison to workers below 40 years of age (p < 0.001). The effect of the industry co-variable was not significant on the mean values of the audiometric thresholds , in opposition to the sound frequency variable . The multiple comparisons procedure found significant differences among all the frequencies, except at 9 and 10 kHz (p = 0.318).In the results from the high frequency audiometries, we noticed a significant effect of the age co-variable . Pos hoc analyses showed significant differences between the industries on the frequencies of 14 kHz  and 16 kHz . The stone works had lower audiometric thresholds than the cement manufacturing  and the metallurgy .Concerning the interaction between the industry and the frequency, it was statistically significant .Concerning the industry variable and the mean value of audiometric thresholds, we noticed that on frequencies 0.25 kHz to 16 kHz, regardless of industry, there was a similarity in the audiometric trace, and as it progresses to the high frequencies, the auditory threshold would increase. Although the 6 kHz, 9 kHz and 12 kHz frequencies had differences between the industries, only the 14 kHz and 16 kHz were statistically significant (eq than the other industries (91.0 dB)  .Table 4CThis study tried to investigate the association between the noise spectrum and the audiometric configuration in workers from different industries exposed to occupational noise, and it was possible to identify factors associated with the work conditions, which can predispose such patients to hearing impairment.The prevalence of NIHL found in this study corroborates most of the literature findingsWe noticed that the mean value of audiometric thresholds and the presence of a NIHL-suggestive notchThe fact that the prevalence of the NIHL-suggestive notch is greater in the high frequencies could be explained because of the very cochlear anatomy and function dynamics, besides the lack of vascularization in the cochlear basal regionIn Brazil, NR 7 from the Ministry of Work and LaborThus, we can state that without doing the high frequency audiometry, it would not have been possible to detect the worker's hearing loss in an initial stage. Therefore, this procedure was fundamental for the early detection of the NIHL-suggestive notch; this fact has also been pointed out by other authorsp < 0.001) in the workers older than 40 years. It is worth stressing that the high level of sound pressure associated to the years of profession and/or to age may compromise not only the hearing, but also the well-being of the workerThe results from the conventional audiometric thresholds as to the high frequency audiometry, presented significant difference  is located in a region near that of the highest cochlear vulnerabilityAmerican Academyof Otorhinolaryngology - Head and Neck SurgeryIn the assessments carried out among the different industries, we found a sound pressure level higher than 100 dB, with a daily dose higher than what is allowed by law (100%). Such result has corroborated the ones in the literatureeq of 91.0 dB, high frequency noise spectrum (peak at 8 kHz), sound pressure level of 103.3 dB(A), and dose higher than 100% (1422.0%). The statistical analysis of the assessments carried out indicated a statistically significant association (p < 0.005) of having notches in the high frequencies . These findings draw our attention, because this industry stands out in IPE compliance. Thus, such findings bring about some questions: the use of an ear IPE would be inadequate, or the model would not meet the type of noise found. The physical characteristics of the noise produced in the metallurgical industry would be more harmful that what is seen in the other industries assessed, affecting the high frequencies in a greater proportion.In regards of the results found, two industries stood out: the metallurgical and wood works. Upon the environment assessment, the metallurgical had higher intensities than the others, with a global Lp < 0.031). This evidence may be partially justified by the fact that the spectrum frequency peak found in such industry was of 2 kHz, because this is a frequency which is not located on the cochlear baseIn the wood works, the workers were the ones submitted to higher sound pressures (108.5 dB(A)), with a higher dose of noise during their work hours 2,924.1%), and who had lower compliance towards using an ear IPE. Contrary to what was expected, these industries  were the ones which had significant lower data concerning the presence of NIHL–suggestive notch when compared to the other industries assessed , there is an extension of the auditory effectsIt was not possible to establish a clear association between the audiological configuration and the noise spectrum in the different industries. Nonetheless, it is suggested that the type of noise spectrum may impact the audiometric results and, in order to prove such fact, it is necessary to have a study involving one sample extended to other industries, which spectral peak is in lower frequencies.In the present study, the assessment of the spectral type was fundamental to understand the high prevalence of a NILH-suggestive notch in the metallurgical industry and in the creation of a hypothesis which would justify the audiometric results found in the wood industry. Therefore, we believe special attention must be given to the type of noise measured in the companies, because most of the times, when such checking happens, it is done by using only the sound pressure level measuring device and not the frequency analyzer.It is not enough to legally have a hearing protection program. It is necessary to have proper proposals to change the work environment in a more guided way, as, per example, understanding of the type of noise spectrum and high frequency analysis. Moreover, the information given the workers about the use of an ear IPEThis study found some hurdles in its execution, among them we stress that the companies did not accept well to participate in this study, which positively contributed to less severe results than those potentially presented by the set of companies in that given industry. It is possible that the companies acceptance is associated to the idea of better work conditions. Another factor which hampered this study was the lack of authorization to carry out the spectral assessment and the dosimetry in the cement factory.We did not find significant associations concerning the audiometric configuration and the noise spectrum standard which would enable to check the influence of spectral profiles on hearing loss, recorded by audiometric responses of the workers assessed.


Brucine (BRU) and brucine N-oxide (BNO) are prominent, bioactive, and toxic alkaloids in crude and processed Semen Strychni. Studies have demonstrated that BRU and BNO possess comprehensive pharmacological activities, such as anti-inflammatory and analgesic. In this context, a comparative study of BRU and BNO was performed by combination analysis of in silico ADMET prediction, in vivo toxicity evaluation, and potential action mechanism exploration. ADMET prediction showed that BRU and BNO might induce liver injury, and BRU may have a stronger hepatoxic effect. The prediction was experimentally verified using the zebrafish model. The BRU-induced hepatotoxicity of zebrafish larvae had a dose-response relationship. The mechanism of BRU-induced hepatotoxicity might relate to phosphorylation, kinase activity, and signal transduction. By comparison, signal transduction and gap junctions might involve BNO-induced hepatotoxicity. Our results provided a better understanding of BRU- and BNO-induced hepatotoxicity. We also built a foundation to elucidate the material base of the hepatotoxicity of traditional Chinese medicine Semen Strychni. Brucine (BRU) and brucine N-oxide (BNO) are bioactive and toxic constituents isolated from Semen Strychni. It is traditional Chinese medicine and has been mainly used to treat several diseases such as rheumatoid arthritis, cancer pain, and myasthenia due to its analgesic and anti-inflammatory activities ,3,4,5,6.BNO can be partly transformed from brucine during the processing of Semen strychni, which is considered a potential mechanism for processing detoxification . The traDrug toxicity research is essential to ensure medication safety. As for the main ingredients of natural medicines, a toxicity study provides evidence to elucidate the mechanism of toxicity and discover potentially unknown adverse reactions. Up-to-date data show that hepatotoxicity is one of the major causes for failure in drug development, drug withdrawal, and limiting drug clinical application ,30,31. OThe present study aimed to test the hypothesis of the hepatoxicity of BNO as compared to its parent drug BRU. For this purpose, ADMET predictor in silico was used to obtain unreported druggability information, complement the reported experimental results, and predict their potential toxicity. A transgenic zebrafish line with liver-specific dsRed expression in the liver was used to validate the predictions and evaluate BRU-and BNO-induced liver injury. Furthermore, our study preliminarily explored the mechanism of BRU and BNO using network pharmacology.With the web server ADMETlab, physicochemical properties, medicinal chemistry, and ADMET properties of BRU and BNO were calculated . CommentAs for predicted results of ADMET properties, most notably, BRU- and BNO-induced human hepatotoxicity (H-HT) may exist, as category 1 represents H-HT positive(+) and category 0 represents H-HT negative(-). As BRU is predicted to be a substrate of P450 CYP1A2, CYP3A4, CYP2C19, and CYP2D6, it may have stronger hepatotoxicity than BNO. A previous study . BRU mayThis study used computer simulation for the ADMET prediction of BRU and BNO, which was short time-consuming, feasible, effective, and practical. However, the prediction value could only be analyzed by comparing with the reference range, which required more validation studies. Further experimental research should be carried out at the cellular and animal level.Wild-type zebrafish embryos were exposed to different concentrations of BRU and BNO, and embryonic death was observed under the microscope. The results were shown in As shown in Compared to the non-administered control group , the higThe functional and signaling pathway enrichment analysis of BRU- and BNO-related gene clusters were performed by GO and KEGG, respectively.In order to clarify the biological actions, a functional enrichment analysis was performed, and the enrichment results were displayed in order of significance, as shown in As for BRU, the top 10 remarkable significant biological processes were chosen according to the corrected FDR from small to large, involving protein phosphorylation, phosphorylation, signal transduction, peptidyl-serine phosphorylation, protein autophosphorylation, peptidyl-tyrosine phosphorylation, intracellular signal transduction, peptidyl-threonine phosphorylation, and other processes.Protein phosphorylation is a fundamental process of cellular biological effects, and many diseases are characterized by an imbalance in the activities of both protein kinases and phosphatases. Protein phosphorylation also plays a vital role in the regulation of cell proliferation. Kinases are also the primary regulators of cancer. Members of the receptor tyrosine kinase family are involved in the occurrence and regulation of many cancers. Studies showed that BRU might exert an antitumor effect via several mechanisms.As for BNO, the top 10 biological processes were signal transduction, response to xenobiotic stimulus, phospholipase C-activating G-protein coupled receptor signaling pathway, sensory perception of pain, regulation of synaptic vesicle exocytosis, Positive regulation of ERK1 and ERK2 cascade ERK1, G-protein coupled receptor signaling pathway, and others.G protein-coupled receptors (GPCRs) are the largest class of membrane proteins in the human genome, which are the targets for most drugs . Both opThe enrichment results are displayed in order of significance, as shown in p < 0.05) were obtained for BRU, mainly involving PD-L1 expression and PD-1 checkpoint pathway in cancer, prostate cancer, neuroactive ligand-receptor interaction, progesterone-mediated oocyte maturation, T cell receptor signaling pathway, Yersinia infection, Fc epsilon RI signaling pathway, calcium signaling pathway, endocrine resistance, phospholipase D signaling pathway, and other biological processes.A total of 135 pathways (p < 0.05) were obtained from BNO, mainly involving neuroactive ligand-receptor interaction, calcium signaling pathway, endocrine resistance, estrogen signaling pathway, bladder cancer, pathways in cancer, relaxin signaling pathway, gap junction, proteoglycans in cancer, cocaine addiction, and other biological processes.A total of 22 pathways  and 155 edges, as shown in According to the physiological processes that have been reported to be associated with drug-induced liver injury (DILI), further analysis of functional and pathway enrichment results associated with BRU- and BNO-induced hepatotoxicity was performed.Protein kinases, which catalyze the phosphorylation of proteins, contribute to antagonizing or promoting liver injury . ResearcSame as BRU, signal transduction may be involved in BNO-induced hepatotoxicity. In terms of the pathway, gap junctions should be concerned. Recent studies found that dysfunction of gap junctions is also involved in various liver pathological processes, such as acute liver injury ,49.https://admetmesh.scbdd.com/, accessed on 12 May 2022) was applicated on the ADMET prediction of BRU and BNO. It is one of the most comprehensive platforms. It provides a computational model supporting the calculation of 88 ADMET-related endpoints, including 17 physicochemical properties, 13 medicinal chemical properties, 23 ADME properties, 27 toxicity endpoints, and 8 toxic groups [A freely accessible web-based ADMET predictor platform ADMETlab 2.0 (c groups .Acetaminophen (APAP) was used as positive control chemical. Brucine  and acetaminophen  were national reference substances obtained from the National Institutes for Food and Drug Control . BNO was prepared in our lab. The structure of BNO was confirmed by NMR and MS. The purity of BNO (>95%) was normalized by HPLC. The structures of brucine and brucine N-oxide were shown in the Wild-type zebrafish  were used to perform a zebrafish embryo toxicity test. Zebrafish maintenance and embryo collection for the test according to the guideline of OECD was described in the ZHT was initiated at 72 hpf and terminated at 120 hpf. A transgenic zebrafish line with liver-specific dsRed expression was used to assess the potential hepatotoxicity of the two chemicals. Wild-type and transgenic line of zebrafish larvae at 72 hpf (20 larvae in each group) were exposed to BRU and BNO at 0.01, 0.025, 0.05, and 0.1 mM for a 2-day treatment period, respectively. Transgenic zebrafish larvae (72 hpf) in the positive control group of APAP were dosed at 1, 8, and 16 mM for 2 days. Larvae at 120 hpf (at least 10 larvae in each group) were taken to record the liver morphology under a fluorescence microscope. The liver size of zebrafish larva was quantified using Image J software. The experiment was repeated three times. The liver toxicity of BRU and BNO was determined by measuring the liver size changes, which was calculated as follows: Liver size (%) = liver area (drug)/liver area (control) × 100%.http://www.swisstargetprediction.ch/, accessed on 7 July 2022), with the species set as “mouse”. The Gene Symbols were retrieved from the UniProt database  corresponding to the target name.100 potential targets associated with BRU and 40 potential targets related to BNO were screened from the SwissTargetPrediction database .GO (gene ontology) is a comprehensive database describing gene function for systematically analyzing gene function at the molecular and cellular levels. It can be divided into three parts: Molecular function (MF), biological process (BP), and cellular component (CC). KEGG (kyoto encyclopedia of genes and genomes) is a public database resource for high-level functions and biological systems , integrating genomic, chemical and system functional information. The categories of KEGG are represented by signaling pathways. GO enrichment analysis and KEGG pathway analysis were performed using Database Visualization and Integrated Discovery system (DAVID) (Cytoscape 3.7.2 software was used to construct a “component-target-pathway” network to obtain the relevant pathways and targets of BRU and BNO, respectively.The experimental results were described as mean ± SD. The concentration-effect curves of compounds were drawn using GraphPad Prism 8.0. SPSS software was used for statistical data and statistical significance was determined based on one-way ANOVA analysis. The LSD method was used to compare the two groups.The results provided by the ADMET predictor indicated that both BRU and BNO might induce liver injury. Moreover, the probability of inducing hepatotoxicity of BRU is greater than that of BNO. The hepatotoxicity of BRU and BNO in wild-type and transgenic zebrafish showed a dose-dependent relationship. The BRU-induced hepatotoxicity in zebrafish is greater than that of BNO. Through network pharmacology analysis, it was found that potential mechanisms of BRU-induced hepatotoxicity might relate to phosphorylation, kinase activity, and signal transduction. While signal transduction and gap junctions might be involved in BNO-induced liver injury.


Age-related hearing changes are the most frequent cause of sensorineural hearing loss in adults. In the literature no studies exist concerning the importance of speechreading in individuals with presbycusis. Equally, no such studies have been carried out with speakers of the Portuguese  language.To evaluate whether the intelligibility of words in presbycusis is improved by speechreading, in such a way that looking at the interlocutor's face while he is talking functions like a “third ear”, and to determine the statistical relevance of the intelligibility improvement by speechreading.t pairs tests) adopting the significance level of 0.05 (5%).Eleven individuals (22 ears) with bilateral and symmetrical sensorineural hearing loss compatible with presbycusis were evaluated. The subjects were aged between 57 and 82 years, with an average of 70 ± 11.51 years and median of 69.5 years. A complete medical and audiological profile of each patient was created and all patients were submitted to a vocal audiogram, without and with observation of the audiologist's face. A descriptive and analytical statistical analysis was performed , so we rejected the null hypothesis, showing that there was statistically significant difference with speechreading; the same conclusion was obtained by analysis of the confidence intervals.We noticed better performance in intelligibility with speechreading. The Individuals with presbycusis in this study, performed better on spoken word intelligibility when the hearing of those words was associated with speechreading. This phenomenon helps in such a way that observation of the interlocutor's face works like a “third ear”. Age-related hearing changes are the most frequent cause of sensorineural hearing loss in adults.Auditory difficulties faced by individuals with presbycusis can be compensated by using speechreading as a strategy, with the objective of assisting the recognition of the spoken message, and providing more effective communication.All individuals use speechreading. In fact, even individuals with normal vision and hearing use speechreading unconsciously and its use enables an increase of intelligibility in noise. Studies show that speechreading activates the auditory cortex in individuals with normal hearing in the absence of auditory stimulation.9There are no studies in the literature that evaluate the importance of speechreading in individuals with presbycusis. In addition, and considering that each language has its particularities, we note that no such studies have been carried out with speakers of the Portuguese  language (PPt).The authors hypothesize that in presbycusis the intelligibility of words is aided and complemented by speechreading, in such a way that observation of the interlocutor's face articulating the words functions like a third ear. This study aims to evaluate how speechreading increases the intelligibility in presbycusis and determine the statistical significance of improvement.Centro Hospitalar de Lisboa Ocidental (CHLO), Lisbon, on 16/03/2015. Individuals agreed to participate in the research and signed the informed consent.This study was analyzed and approved by the Health Ethics Committee (CES) of The sample included patients of the Otolaryngology Department of Egas Moniz Hospital in CHLO, that had been sent to the Audiology Department for audiological exams. It is an analytical and cross-sectional study, in which we used a convenience sample composed of 11 individuals (22 ears) who fulfilled the following inclusion criteria: aged 55 or more years, bilateral and symmetrical sensorineural hearing loss compatible with presbycusis, type A or As tympanogram (Jerger classification), vocal audiogram with Speech Reception Threshold (SRT) ≥ 40 dB, oral communication ability, PPt as first language and informed consent acceptance, after clarification of the procedures involved. Individuals with the following criteria were excluded: presence of tinnitus that could interfere with the audiometry, external or middle ear pathology, neurological and/or psychiatric disorders that could interfere with language, serious visual changes or no use of corrective lenses during the evaluation.x–y graph (intelligibility curve), comparing the intensity of the stimulus with the percentage of words understood. Gender as a variable was not studied.All patients were submitted to an evaluation protocol with a complete medical and audiological profile. An audiologic study  was performed, after which patients were reassessed in the office. If inclusion criteria were fulfilled, two new vocal audiograms would follow, after several weeks, sequentially without and with observation of the audiologist's face, in order to quantify the improvement of SRT with associated speechreading. All vocal audiograms without and with speechreading were performed by the same audiologist  and the procedure was carried out with the knowledge of the patient. The examinations were conducted in a soundproof test room according to ISO 8253 and 389, with a Madsen Electronics audiometer, model Orbiter and 922 TDH39 earphones, noise-excluding headset ME70 and bone conductor B-71. On vocal audiometry the stimulus consisted of disyllabic phonemes with phonetic balance for PPt; the phonemes sequence was used randomly, with analysis of the following parameters: detection, reception and maximum discrimination of speech thresholds. The results were presented in the form of t-test for paired samples, and in the case of nonparametric, the Wilcoxon test. We applied a significance level of 0.05 (5%) with 95% interval. We tested if there was a statistically significant difference between the SRT and the threshold of discrimination.The data were collected into a database and the statistical study was performed using the Statistical Package for the Social Sciences (SPSS), version 20.0 for Windows. In a first phase, we tested the conditions for application of statistical tests , after which we were able to choose parametric or nonparametric tests. To evaluate the effect of speechreading on speech discrimination, we planned to use, in the case of parametric tests, the Student's The age of the analyzed participants ranged from 57 to 82 years, with a mean age of 70 ± 11.51 years and a median of 69.5 years. SRT values were recorded with and without speechreading. This led us to two samples with quantitative and paired data. In other words, it is the same person before and after (respectively without and with speechreading). The main data referring to the characterization of the studied group is presented in t-test, data from the difference (between the two samples) had to present a normal distribution (applicability condition). Therefore since the sample size was less than 50, we used the Shapiro–Wilk test , so the null hypothesis was not rejected. Therefore we concluded that data of the difference had a normal distribution and the paired t-test could be used. Equal conclusion was drawn from the box plots analysis .As the d t-test  was zeroThe production of each phoneme triggers a characteristic position of the facial structures, such that someone with knowledge of the language can deduce, up to a certain extent, which phoneme was produced. The visual information of the speech articulation increases the auditory processing, when associated with direct information about the signal content, increasing discrimination of phonemes.You can check this phenomenon in your daily clinical practice, when you speak to individuals who have hearing disabilities from presbycusis. If you speak initially with your mouth covered and then uncovered, at intensity near the patient's discrimination level, the observation of your face enhances intelligibility.In the literature, there are no studies that address the importance of speechreading in intelligibility, in patients with hearing loss due to presbycusis and particularly in Portuguese language (PPt) speakers. This study demonstrates that these individuals demonstrate better performance on intelligibility of spoken words when the hearing of these words is associated with speechreading. The importance of this stimulus in strengthening the discrimination was so notorious that one may conclude that observation of the interlocutor's face works as a “third ear”.Given the relevance of the results obtained, their publication was considered important, although the study presents limitations regarding the sample size, mainly due to the number of refusals. An improvement in the statistical significance of the results would be possible with a more appropriate sample, if a greater loss of discrimination (increase in SRT) correlates with an increasing importance of speechreading and if there is variability in the gender and/or age of the patients, despite the degree of hearing loss on presbycusis presenting variability due to genetic and environmental factors.The results of this study are in line with others conducted in sensorineural hearing loss, but where the cause was not presbycusis. These studies found that individuals with this hearing loss had a better speechreading ability,Another important issue that this study raises, in terms of the importance of speechreading in these patients, is the need to understand the role of hearing rehabilitation  and hearing aid fitting. This rehabilitation may allow an improvement in the ability of speechreading, with a positive impact on the patient's life.It is concluded that the individuals of this study, whose native language is PPt and who have hearing disabilities from presbycusis, demonstrate better performance on intelligibility with speechreading. More extensive studies are needed, in particular correlating the importance of speechreading with age and the degree of hearing loss. It would also be important to broaden the understanding of communication in presbycusis and extrapolate the importance of hearing rehabilitation and hearing aid fitting in these patients, providing better social integration and better quality of life.Study carried out at the Department of Otolaryngology of Egas Moniz Hospital, Centro Hospitalar de Lisboa Ocidental (CHLO), Lisbon, Portugal.The authors declare no conflicts of interest.


Aging can alter, temporal processing and affect speech perception.Aim: To compare temporal processing auditory processing in elderly subject to and new hearing aid users.Materials and Methods: The study included 60 elderly patients with bilateral sensorineural hearing loss. The procedures selected were the Duration Pattern Tests (DPT) and gaps in noise (GIN) test were used to analyze the responses of correct identification, and the temporal acuity threshold before and after the fitting of hearing aids. Study design: clinical and experimental research with non-probability sample of convenience.Results: There was no statistically significant difference between the responses from GI and GII individuals. The elderly users of hearing aids had a lower gap detection threshold, greater recognition of gaps and of discrimination of the duration pattern in relation to when they were only potential users.Conclusion: There was a deterioration in temporal processing skills, regardless of hearing loss degrees. Thus, the effect of acoustic stimulation by the use of a hearing aid improved resolution and temporal ordering. Presbycusis is a type of hearing loss associated to aging, characterized by a descending bilateral sensorineural hearing loss, and it causes numerous problems both in communication and in the social lives of the elderlyIndividuals with presbycusis have difficulties to discriminate acoustic clues - which help in speech understanding, especially in acoustically-challenged environmentsNumerous papers bear evidence that among auditory processing skills, those associated with temporal processing are the most affected by agingThe temporal processing role in speech is the discrimination of subtle clues and similar words. Temporal processing involves temporal resolution aspects, temporal masking, temporal integration and sortinggaps with 2 to 3 ms intervals presented in only one ear, and the auditory cortex neurons are responsible for detecting temporal acuity thresholdgap detection testsgap detection test in noise (GIN) has been recommended in current studies as a precursor tool to assess the temporal resolution auditory skill in children, young adults and elderlyThe temporal resolution hearing skill is important for human speech understanding, being a prerequisite for readingThe temporal sorting auditory skill involves the participation of numerous perception and cognitive processesThis skill must be analyzed by means of tests involving the temporal pattern recognition of pure tones, such as the Pattern Duration Test (PDT), which is considered a sensitive tool to identify lesions to the Central Nervous Auditory System (CANS), and it also does not suffer impacts from peripheral hearing lossThe improvement in speech recognition caused by the use of a hearing aid usually happens between six and 12 weeks after using the amplification device, a time span called acclimatizationThe use of digital technology and the progress in signal processing have brought about great benefits concerning the communication of patients with presbycusis. Directional microphones, noise suppressors and non-linear amplification improve considerably the signal intelligibility in the presence of competitive noisesWith this study we hope to broaden the current knowledge vis-à -vis the effects of acclimatization in the neurological process of hearing, by means of behavioral tests of the auditory processing in elderly who are candidates to a hearing aid fitting.Thus, the goal of the present study was to check and compare temporal processing responses in elderly candidates to hearing aid fitting, besides analyzing whether schooling and age impacted temporal processing skills.This study is an experimental research with a non-probabilistic sample by convenience.This study was approved by the Ethics in Research with Human Beings Committee of the institution with approval CEP number 1953/08. All the individuals included in the study signed an informed consent form authorizing their participation in the study.The subjects of this study were selected among the elderly patients seen at NIAPEA - candidates to selection and fitting of a hearing aid, according to criteria from the Auditory Health-Care ordinance # 587, from 10/07/2004We considered the elderly with more than 60 years of age, based on the National Elderly OrdinanceThe initial sample was made up of 65 elderly in the age range between 61 and 85 years. During the assessments, two patients were taken off the sample because on the day of the assessment they had air conduction changes and decided against participating in the study because of difficulties in undergoing longitudinal assessments. The final sample was made up of 60 elderly, 20 men and 40 women. The individuals were gathered in two groups, called Group I (GI) and Group II (GII), based on the degree of mean values of the 500 and 4000 Hz sound frequencies in the audiogram. GI individuals had mean values between 41 and 50 dBHL in the frequency range between 500 and 4,000 Hz and, in GII, the mean varied between 51 and 70 dBHL.The individuals included in the sample had to have the following criteria: no evidence of neurological impairment to prevent the understanding of the requested tasks, be native Brazilian Portuguese speakers, have symmetrical bilateral sensorineural hearing loss with hearing thresholds between 41 and 70 dBHL in the frequency range between 500 and 4,000 Hz, bilateral type A tympanometric curvesThe two participant groups were assessed with the procedures selected for this study at two different times. The first was before fitting the hearing aid, called First Assessment. The second time was after an effective time of hearing aid use, called Reassessment. In order to guarantee that the hearing aid was being used, follow up visits were scheduled between the First Assessment and the Reassessment, with one professional from the institution being responsible for checking the hearing aid fitting in these patients.Gap in Noise Detection test (GIN). The temporal tests were employed at two different times, in the first assessment, before hearing aid selection and fitting, and, in the second, after a minimum of three months using the hearing aids.The temporal processing assessment was based on a Pattern Duration Test (PDT) and The function measured with the PDTgap detection and the temporal acuity threshold. The CD recording was presented through earphones, and the test sound presentation level was of 30 dBSL, based on the mean hearing thresholds in the frequencies of 500; 1,000 and 2,000 Hz. We used track two for the training and tracks three and four were used to assess the right and left ears, respectively. Each track had six-second white-noise stimuli, with five-second intervals between the stimuli. The gaps are inserted in the white noise in given positions and with different durations, which can be 2, 3, 4, 5, 6, 8, 10, 12, 15 or 20 ms. With such procedure it was possible to assess the capacity to detect and discriminate mild differences between acoustic signals, in other words, the auditory skill of temporal resolution. We used the term “recognition” in the number of times the participants showed having identified the stimulus. The number of times the stimulus was detected was expressed in percentage and was called “gap recognition percentage”. The minimum value at which the individual perceived the gap in at least 4 of the 6 stimuli presented was called “temporal acuity threshold”. The normality criteria followed for this test were in accordance with DiasThe GINBefore test reassessment, we utilized a tool available in the hearing aid fitting software called Data Logging. This tool enabled us to assess the mean number of hours of hearing aid use since the day of the first fitting. When the patient did not use the hearing aid effectively, the fitting problem was checked and a new follow up visit was scheduled. In such cases, the reassessment was only done after a minimum effective use time of 3 months. Upon reassessment, the patient was submitted to the tests using the hearing aid, and the transducer remained the TDH 39 earphone. The noise suppressor was turned off, so that it would not impact the responses during the GIN test.The special auditory processing tests were presented from a Sony D-152 K Compact Disc player, coupled to a two-channel Grason-Stadler GS 61 Clinical Audiometer, with TDH 39 P earphones and MX-41 AR pad, calibrated according to the ANSI 69 standard.#].In all the statistical tests utilized, we established a significance level of 0.05. The statistically significant values were marked with an asterisk [*] superscript. In case of a trend towards significant results, the calculated value was marked with the number symbol  and, in the reassessment it was 0.90 .gap in its maximum value in the test; as far as reassessment is concerned, only one individual from GI and four from GII did not identify the Maximum gap in the GIN gap that was 20 milliseconds.p = 0.373).There was a significant difference between the mean GIN_Li values in the two assessments, and the reassessment mean was lower than that in the first assessment. The mean drop in the threshold was -2.2 ms , being equal in the two groups; there were no differences between the groups in the mean values of the temporal acuity threshold, and such result was valid for the two assessments  and 0.92 in the reassessment .We noticed a positive correlation between schooling and the percentage of correct answers in the PDT.There was a trend towards a negative correlation between GIN_Li and schooling.The distribution of correct answers of the two assessments and schooling ranges can be observed in The new users of hearing aid in this study were followed for a minimum period of 12 weeks of use in order to analyze the effects of acclimatization. This was all done based on the studies by GatehouseIn the present study, the degree of hearing loss did not influence performance in the PDT. G1 individuals found three sounds in rapid sequence similarly to G2 individuals . We founStudies have shown that PDT performance in young adults and elderly populations with and without hearing loss was worse in elderly when compared to the young individuals in this task, without influence of mild to moderate hearing loss and with a worse performance in disorders of Central Nervous System and Brain auditory pathwaysThus, the studies show that the aging process deteriorates the temporal ordering processIn the present study, the moderate or moderately severe hearing loss did not impact the performance of the elderly in these tasks of recognizing the duration pattern, and the mean values are within the range of mean values of the studies with elderly listed in the literatureNumerous studies report that the process of selecting and fitting hearing aids must consider the HLD (C) caused by the age effect, as the difficulty to discriminate temporal clues which identify speech contrastsIn the present study, we noticed that after a period of daily use of the hearing aid, there was an improvement in recognizing the duration pattern both in GI (mean of 68.1%) and GII (mean of 59.3%), agreeing with a study published in the specialized literaturegap recognition percentage in the GIN test.In the GIN test  and 3, tgap recognition and a greater threshold of temporal acuity than children and youngstersgap recognition in noise varied from 39.1% to 57.6% and the acuity threshold varied between 7.3 and 10.2 ms. In children, youngsters and adults, the recognition threshold was higher than 70% and the temporal acuity threshold varied between 3.9 and 5 38 ms15,18,19,20,38,40National and international literature studies show that elderly have a lower percentage of gap detection thresholdsIn the elderly with hearing loss, this threshold can be higher than in elderly without hearing lossgap recognition was lower and the temporal acuity threshold was higher than what was reported about elderly in the literatureIn the present study, the mean percentage of gap recognition according to the variable EarNumerous papers state that there are no differences between the temporal acuity threshold and the percentage of In the present study we noticed that both in the GIN_% and in the GIN_Li there was a strong agreement between the two ears , in agreOne of the main complaints of elderly patients with hearing loss is the difficulty to understand speech in noise. Numerous studies showed that temporal resolution is affected by aging and causes difficulties to understand speech in noiseThe inclusion of tests which assess the Central Auditory Processing in the process of selecting and fitting hearing aids has been increasingly recommended by authors in the specialized literaturegap recognition increased and the temporal acuity threshold reduced after a time using the hearing aid. We noticed that during the reassessment there was a statistically significant improvement in the temporal resolution hearing skill, and the temporal acuity threshold had a 2.2 ms reduction, and the percentage of gaps recognition in noise increased 5.6% both in the GI and in GII.In the present study, the percentage of gaps in the noise range, being represented with the 22 ms threshold. Upon reassessment, only five individuals kept the 22 ms threshold. These findings suggest that there was an effect of the acoustic stimulation in the CAS information processing after the hearing aid fitting.We must stress that in the first assessment, 14 individuals did not detect gap recognition percentage was low (mean of 29%), compared with studies published in the specialized literature featuring young peoplegap recognition with age, nor the recognition of duration pattern with age , and in the reassessment (12 ms), and the with age . It is bp = 0.058) between the temporal acuity and schooling, that is, as schooling increases, there is reduction in the temporal acuity threshold.We noticed that, in the sample investigated, there was a positive correlation between age and PDT performance, that is, the more years of schooling, the better the PDT performance . Upon reStudies which assessed the temporal ordering and resolution skills in elderly with schooling higher than that in the present study, showed a better performance both in PDT as in the GIN_LiWe believe that the application of the GIN and the PDT tests can be an important tool to help monitor the benefits of fitting a hearing aid in elderly patients.•Insofar as temporal processing/ordering skill and temporal resolution are concerned, there was a decline in skills, regardless of the hearing loss level, showing the effects of aging;•There was an effect of the acoustic stimulation in the processing of information in the Central Nervous System, after acclimatization with the hearing aid, because the individuals had an improvement in their hearing skill, temporal ordering and temporal resolution;•We found that schooling influenced resolution and temporal ordering tasks in the elderly.


The Eustachian tube (ET) is an osteocartilaginous canal that connects the middle ear to the nasopharynx. It is one of the critical structures essential for middle ear functions. ET dysfunction causes discomfort in the affected ear and decreased hearing. This is the first case report of improving hearing and middle ear aeration and ET function secondary to body weight reduction. A 27-year-old male patient presented to the otology clinic complaining of decreased hearing for two years. Initial ear examination revealed retraction of TM on the left ear with two retraction pockets, and on the right ear, the TM was dull with one retraction pocket. The patient reported losing some of his body weight during those six months. Ear examination revealed improvement in the TM retraction in both ears. The improvement in hearing was evidenced by a serial audiogram, while the middle ear aeration was evidenced by clinical examination. The Eustachian tube (ET) is an osteocartilaginous canal that connects the middle ear to the nasopharynx. It is one of the critical structures essential for middle ear functions. It is responsible for the processes of protection, aeration, and draining  AutophonIt has been found that a healthy and functional ET has been associated with a reduced incidence of ear complications secondary to ETD . PatientETD causes discomfort in the affected ear and decreased hearing. Effusion, atelectasis, and retraction with cholesteatoma are well-known sequelae of ETD. Also, patients with ETD are at a high risk of tympanic membrane (TM) perforation secondary to atmospheric pressure change (Barotrauma) .This is the first case report of an improvement in hearing and middle ear aeration and ET function secondary to body weight reduction. The improvement in hearing was evidenced by a serial audiogram, while the middle ear aeration was evidenced by clinical examination.A 27-year-old male patient not known to have any medical illness apart from allergic rhinitis presented to the otology clinic complaining of decreased hearing for two years. There was no ear pain, ear discharge, autophony, tinnitus, or aural fullness sensation. The patient revealed a history of pressure equalization tube (PET) insertion in both ears 12 years prior to this presentation. Initial ear examination revealed retraction of TM on the left ear with two retraction pockets Figure , and on There are three physiological functions for the ET: (1) regulation of the middle ear pressure, (2) safeguarding of the middle ear from nasopharyngeal pathogens, and (3) drainage of the middle ear. The ET length has been reported to be between 31 mm and 38 mm . The norWeight loss is linked to lower blood pressure and glucose levels, as well as a lower incidence of hypertension and non-insulin-dependent diabetic mellitus, according to observational studies  and intePatulous ET is defined as a patency abnormality that causes autophony. The patulous ET symptoms were first reported in 1858 by Jago . PatientThis report shows that the patient's body mass index (BMI) was 42.9, which is classified as obesity class 3 depending on the WHO classification for obesity, and his BMI reduced to 39.4 changing his obesity class to class 2. This moderate weight loss of roughly 8% of the initial body weight has a favorable effect on ETD as well as on other well-known systemic conditions such as hyperlipidemia and diabetes. This observation can be the basis for other studies that may prove an association or a cause-and-effect relationship. This will be novel conservative management for ETD without any serious side effects on the patient.This report shows that the moderate weight loss of roughly 8% of the initial body weight has a favorable effect on ETD as well as on other well-known systemic conditions such as hyperlipidemia and diabetes. This observation can be the basis for other studies that may prove an association or a cause-and-effect relationship. This will be novel conservative management for ETD without any serious side effects on the patient.


Hearing impairment has a high impact on communication between cancer patients and their oncologists. What is the patient’s perspective on this problem and how can physicians draw lessons from it?Together with otorhinolaryngologists and hearing-impaired patients, we developed a questionnaire including the sections: WHO (Five) Well-Being Index (5 items), Abbreviated Profile of Hearing Aid Benefit (APHAB) as established self-estimation of hearing function (24 items), use of hearing aid (4 items) as well as patients’ experiences (15 items), difficulties (9 items) and wishes (7 items) regarding the communication with physicians. The experiences, difficulties, wishes, and life satisfaction of cancer patients were analyzed between groups based on participants' APHAB scores, well-being and use of hearing aids. A total of 104 cancer survivors  were included.Between the groups of subjectively hearing-impaired and normal hearing participants, we registered a significant difference in difficulties in conversation, wishes for physician–patient communication and psychological well-being. Depending on participants’ well-being, wishes and difficulties differed. Differences were also found between participants with and without hearing aids in terms of difficulties in conversation, but not in terms of their wishes and well-being. A large proportion of participants classified as subjectively hearing-impaired according to APHAB already had a hearing aid.Cancer patients with hearing loss are very restricted in their understanding of given information and hearing aid use cannot completely compensate for this. Consequently, communication guidelines should be considered and specific educational tools need to be developed for these groups. As the world is in the midst of a major demographic change, physicians get used to have more and more elderly patients. Difficulties due to sensory impairments in this patient group may contribute to an inappropriate medical care. In particular, an increase of age-related hearing loss is expected in the next years because of the demographic transition  cancer patients with and without subjective hearing loss, (2) cancer patients wearing a hearing aid and those without and (3) cancer patients with poor well-being and those with good well-being. Furthermore, the use and the satisfaction with hearing aids of cancer patients using them and specific experiences in conversations during medical consultation will be evaluated. The findings may contribute to a better detection of hearing loss among individuals with cancer and to identify proper ways of how to effectively communicate and share important medical information with them.Cancer patients were identified based on their known medical history and were invited to participate in the offices of an ophthalmologist and an otorhinolaryngologist in the city of Weissenfels . Participation was anonymous and voluntary. Informed consent was obtained from all individual participants included in the study. Between 01-04-2021 and 31-07-2021, 104 attendees filled out the questionnaire.General information on the study .Demographic data: Gender, age, education level, profession, cancer anamnesis and localization of cancer.WHO (Five) Well-Being Index (WHO-5): With its high clinimetric validity, this questionnaire is one of the most commonly used questionnaires to assess subjective psychological well-being : This questionnaire is established for self-estimation of hearing function containing 24 items in four sections: ease of communication, background noise, reverberation and aversiveness of sounds. The scaled answers are allocated to percentages. A correctly answered questionnaire to form a total APHAB score contains of at least 4 out of 6 answered questions of each category , regularity of use, satisfaction, evaluation of hearing enhancement.Experiences in direct conversations with physicians: Participants should evaluate typical situations in conversations with their physicians on a Likert scale ranging from “1—not applicable” to “4—fully applicable” and “0—not sure.” The 15 items were taken from a questionnaire by Münstermann et al. .Difficulties in conversation: Nine items to answer with the similar Likert scale as described above. To ensure the content validity, the questions were developed with the help of two otorhinolaryngologists.Further wishes regarding the communication with physician: Seven items with similar Likert scale. To ensure the content validity, the questions were developed with the help of two otorhinolaryngologists.The questionnaire contained eight main sections:All data were collected in MS Excel. For statistical analysis, the free software GNU PSPP was used.For reliability analysis, Cronbach’s alpha was calculated to assess the internal consistency of the subscale “It´s hard for me to…” (seventh section) and “I would wish, that…” (eighth section). The internal consistency of the scale “It´s hard for me to…” which consists of nine items is satisfying, with a Cronbach´s alpha for positive effect = 0.89. A comparable positive effect was proven for the scale “I would wish, that…” with a Cronbach´s alpha of = 0.82. Consequently, two new variables could be generated which reflect the difficulties and wishes in direct conversations with their physicians.r was calculated and interpreted according to Cohen  as hearing-impaired or hard-of-hearing participants.One hundred and four participants completed the questionnaire. Age ranged between 32 and 90 years, with a mean of 73.4 years and median of 76.5 years. Forty-nine (47.1%) of the interviewed participants were male, fifty-five (52.9%) were female. The largest group (84.6%) were pensioners; more than half of the participants (66/102) reported high education levels .Detailed demographics of participants in the survey are shown in Table Eighty-six of all participants answered the WHO (Five) Well-Being questionnaire. Of these, 62.8% (54/86) scored above 13, 32/86 participants (37.2%) showed scores below 13, which indicates poor well-being and potentially depression WHO .Barely more than half of all participants  did not show values for subjective hearing impairment by reaching an APHAB score below 40%. The other forty-six participants  were registered as tending to subjective hearing difficulties.Forty-eight of all participants reported having a hearing aid. Only 57.4% 27/47) of them wore them all day long Fig. . Most pa7/47 of tU = 459.50, Z = − 4.47, p < 0.001). According to Cohen (r” (effect size) results in a mean effect (r = − 0.471). Similar significant difference was identified in desires for physician–patient communication .As described, all participants who answered the APHAB questionnaire correctly were separated into two groups. We registered a significant difference between participants with and without hearing loss tendency in difficulties in the conversation with their physician  with a mean effect according to the Pearson correlation coefficient (r = − 0.306).Moreover, a significant difference was detected by having a look at people’s well-being  could be shown in difficulties in conversation . A significant difference could not be seen in either wishes for conversations with their physician  or in level of well-being .Nearly half of all participants wore a hearing aid  and 54/102 did not (52.9%). A significant difference with a mean effect . Further on, wishes for discussions between patient and physician were significantly different in groups of people with good and poorer well-being; . Both correlations showed a low effect (r = − 0.293 and r = − 0.299) according to Cohen  with subjective hearing difficulties reported problems to announce themselves at the reception. A total of 17.4% (8/46) fully agreed with the statement that it is easy for them to understand the physician´s speech. The majority 24/45, 53.3%) must mostly or always concentrate very well to understand the words and phrases of the physician. According to the given answers, only 13 out of 46 participants (28.3%) understood all verbal instructions for behavior patterns, medication and medical examinations given by their physician. Furthermore, it was sometimes, mostly or always inconvenient for 63.0% (29/46) for the hearing-impaired asking back if they partly did not understand what had been said by the physician  with a strong effect (r = − 0.594). Furthermore, a significant difference could be measured when being asked if they have to concentrate a lot to hear the physician’s words and phrases . Similar significant difference between the two groups was seen in the statement “I understand all verbal instructions on behaviors/ medications/ controls”  with a mean effect (r = − 0.476) . No significant difference could be measured in relation to the statement “If I don't understand something, I always ask for it to be explained to me again” . By asking if wearing a surgical face mask makes it even more difficult for participants to understand what is being said, a significant difference between the two groups was seen  with a mean effect (Pearson correlation coefficient r = − 0.374)  with hearing loss had no problem telling their physician they partly did not understand what had been said in the conversation. The vast majority 36/46, 78.3%) could slightly, mostly or fully relate to the statement: “It is difficult for me to recognize the decisive facts during the informed consent discussion”  wished that the medical staff would take more time for them at the front desk. Furthermore, 54.3% (25/46) partly, mostly, or fully agreed with the statement: “I would wish that the physician would take more time for me in the conversation” Fig. . Less thTo ensure good quality of instruction, education, and counseling, the high prevalence of hearing impairment in cancer patients must be considered. If not specifically asked for, they otherwise might have been overlooked in everyday practice.A large proportion of our participants suffer from reduced psychological well-being. For these individuals, the indication for screening for depression would be given WHO . The lonDespite satisfaction with the hearing aid, the proportion of those who reported wearing it all day seems unsatisfactory. This finding matches with the survey of Bainbridge and Ramachandran . In thisBased on our findings, wearing a hearing aid does not guarantee fully restored hearing. Hearing aid users probably cannot act like normal hearing people in physician–patient conversations. For this reason, they should still be considered as a separate patient group. This seems to match with the results of Stengel et al.  who, in In our study, hearing aid users have more difficulties in physician–patient communication than those without hearing aids. This could mean that potential conversational difficulties are not automatically eliminated by simply wearing a hearing aid. This further reinforces our recommendation that physicians should continue to consider this group as handicapped compared to people with normal hearing. Patients with and without hearing aids appear to have similar wishes for physician–patient interaction. This may indicate that wearing a hearing aid improves communication and reduces desires regarding conversation. Also, the well-being of these two groups seems to be similar. This coincides with the finding of Mondelli and de Souza  who founIn our study, it could be found that hearing-impaired cancer participants had more problems and wishes when talking to their physicians compared to normal hearing participants. Even their well-being was worse. This again emphasizes the relevance of our study and thus the importance of focusing on cancer patients who are hearing-impaired.It seems that it is more difficult for the hearing-impaired to understand what the physician has said and that this involves a greater effort of concentration for them. Increased concentration while listening is one of the first steps in the development of unconscious compensatory strategies. This permanently increased concentration subsequently leads to increased listening effort. This may result in a reduced attention span and a premature concentration deficit in conversation  Well-Being Index (WHO-5) is a proven tool and can be used in daily practice.Hearing aid fitting itself does not guarantee normal hearing. Therefore, it may be necessary to continue to consider these individuals as handicapped in communication. However, if physicians get to know about a hearing impairment, they should actively suggest using a hearing aid in the conversation.Physicians should not rely on patients reporting about their hearing loss on their own initiative at the beginning of the conversation. The same applies if patients are actually aware of their hearing loss. For at least roughly verifying a suspected hearing loss that has not been clarified, developing shorter questionnaires constitutes an alternative. An example is the Mini Audio Test (MAT) from Löhler et al. . This shGuidelines on how to communicate with hearing-impaired patients should be followed. Even with normal hearing individuals, physicians should pay attention to better articulation and slower focused speech.Hearing-impaired patients were more uncomfortable asking for clarification if they did not comprehend facts. For this reason, it seems advisable to regularly inquire whether the patient has understood what has been said. In some cases, our participants seemed to have enormous problems in the physician–patient communication. Thus, the personal brief educational interview cannot always be a good and reliable basis for a self-determined decision for or against treatment. In consequence, further alternative offers should be created.


To compare the incidence of hearing loss among adults stratified by the occurrence of hypertension, and to investigate the association between hypertension and hearing loss.Estudo Longitudinal da Saúde do Adulto . Data from the first and second waves were analyzed, including information from audiological assessment and general health of the subjects. As outcome, we considered the presence of hearing loss (hearing thresholds above 25 dBHL at frequencies from 500 Hz to 8 kHz) and, as exposure variable, hypertension . As covariables for adjustment were considered: sex, age, education, race / ethnicity, income, smoking, diabetes, and occupational exposure to noise. Poisson regression analysis was conducted, estimating the crude and adjusted relative risks, with 95% confidence intervals, in order to assess the factors associated with hearing loss. Longitudinal observational study, part of the  In crude analyses, the incidence of hearing loss was higher for subjects with hypertension (9.7% versus 5.4%). The crude relative risks for hearing loss was almost double  for subjects with hypertension in the right ear. In the adjusted analyses, the relative risks was not significant for the hypertension variable . Being 60 years or older  showed a statistically significant association with hearing loss, indicating that older adults have higher relative risks for hearing loss. In the adjusted analyses controlled for multiple risk factors there was no association between hypertension and hearing loss. The dichotomous variable age (being 60 years or older), on the other hand, has shown a significant association with hearing loss. Hypertension is a circulatory disorder, considered chronic, asymptomatic, and of multifactorial origin, characterized by sustained rise in blood pressure levels2. It is estimated that about 600 million people worldwide live with hypertension, and a global growth of 60% of the cases is expected by 20253.In Brazil, hypertension affects 36 million adults, and more than 60% of the older adults4.The overall prevalence of moderate to severe hearing loss is estimated to increase with age, from 2% at age 20 to 12% at age 60 and to over 58% at age 90, with the vast majority of affected persons living in low and middle-income countries. It is worth mentioning that hearing loss is influenced by several determinants such as genetic factors, chronic diseases, environmental factors (noise and use of ototoxic medications) and lifestyle, and that it may entail several losses at economic, social, and quality of life levels5.Some authors also suggest that subjects with hypertension have a greater hearing impairment than subjects without this comorbidity7. Hypertension may also cause hearing loss because of ionic changes in cellular potentials7.One of the pathogenic mechanisms of hypertension which may be involved in hearing loss is the reduction in capillary blood flow due to increased blood viscosity, which may damage the integrity of oxygen and nutrient transport to the cells, causing tissue hypoxia and consequent hearing loss5. Some of these studies have observed the existence of a significant association between them8, while other studies have not found such association9.Many studies have been conducted about the association between hypertension and hearing loss, but results are controversialIt is worth mentioning that the aforementioned studies were generally developed in a shorter period, as they are cross-sectional studies, which limits possible conclusions about aspects that interfere in the development of hearing alterations. Longitudinal studies that approach hearing and its relation with chronic diseases are scarce, but may clarify many controversies regarding the influence of some of these risk factors on hearing loss, since we may identify the incident cases of hearing loss, as well as differences in the incidence rates in different groups based on certain exposures, adjusting these analyses for possible confounders.The objectives of the present study were thus to compare the incidence of hearing loss among adults stratified by the occurrence of hypertension, and to investigate the association between hypertension and hearing loss.Estudo Longitudinal da Saúde do Adulto  is a multicenter cohort study consisting of 15,000 employees, and conducted in six higher education and research public institutions in the Northeast, South, and Southeast regions of Brazil. All active or retired employees aged 35 to 74 years, of both genders, were eligible for the study. The design, objectives, and profile of the ELSA-Brazil cohort are detailed and published in a previous study12.The Estudo Longitudinal da Saúde Auditiva do Adulto  is part of the ELSA-Brazil research center in São Paulo. It was approved by the Ethics Committee of the institution (n° 883/09), and all participants signed the informed consent form.The ancillary study 13. As in the main study, participants are followed-up, and return for reevaluations in cycles of 3 to 4 years.The ELSA-Brazil research center in São Paulo has 5,061 participants, among which 901 subjects (wave 1) agreed to audiological monitoring as part of the evaluation, and are part of ELSA-A14.At each wave, volunteers answer a questionnaire about health and other personal details, and undergo a series of evaluations, laboratory tests and physical examinations13.Some of the procedures for audiological evaluation are: audiological anamnesis, meatoscopy, measurement of acoustic immitance, pure-tone audiometry, and speech audiometry15. The mean hearing thresholds by air conduction in the frequencies from 500 Hz to 8 kHz were calculated for each ear and for both ears.At ground zero (wave 1), we identified participants with no hearing loss (n = 676) among the 901 subjects who participated in ELSA-A. Hearing loss was considered as hearing thresholds above 25 dBHLOf the 676 participants, additional 81 subjects were excluded in wave 2 (n = 595), because there was no data from the audiological evaluation for various reasons .16.Hypertension, considered an exposure variable, was defined based on: report of a medical diagnosis of hypertension; and/or use of medications to treat hypertension; and/or systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg12.Covariates considered risk factors for hearing loss were included and adjusted in the analyses performed in the study: sex, age group , education , race/ethnicity , income , smoking , occupational noise exposure , and diabetes . Diabetes was defined by the presence of one of the factors: medical history of diabetes; reported use of medications to treat diabetes; fasting serum glucose ≥ 126 mg / dl; glycated hemoglobin level (HbA1c) ≥ 6.5%, or 2-h oral glucose tolerance test with 75 g glucose ≥ 200 mg / dl)Descriptive analysis was performed by calculating the prevalence of variables in wave 1, and the incidence for the outcome of interest.Analysis of losses (n = 81) was performed, and when compared to the follow-up subjects (n = 595), the proportions of the variables had no significant variation.To assess the unadjusted association of exposure with the outcome, crude relative risks were calculated.Three different models , using Poisson regression with robust variance, were used to calculate the relative risk estimates with respective confidence intervals (95%) for adjusted models between hearing loss and hypertension. Adjustments were performed with sociodemographic variables, and all analyses were stratified by left ear, right ear, and both ears.The significance level adopted was 5% (p < 0.05), and analyses were performed on the SPSS software version 21.0.Wave 1 included 676 subjects. Most subjects (75.9%) were between 40 and 59 years old, female (56.1%), and self-reported as white (57.5%). Regarding the level of education, 43.9% of the subjects had higher education, and income between USD 1245–3319 .As for general health characteristics, approximately 30% of the subjects had hypertension, and 13.3% had diabetes. Regarding smoking, 57.2% of the subjects had never smoked . In waveAs for hearing health, in waves 1 and 2 most subjects did not have hearing complaints . As for tinnitus, 36.7% of the subjects in wave 1, and 24.1% in wave 2 reported this symptom, and more than one third of the subjects reported noise exposure in both waves  .In the crude analysis for both ears the incidence of hearing loss was 6.7%, being higher for subjects with hypertension (9.7% versus 5.4%). The relative risk for hearing loss was almost double for subjects with hypertension for the right ear , and there was a trend toward statistical significance for both ears .In the multivariable model adjusted by the covariates age group, gender, education, income, race, hypertension, diabetes, smoking, and noise exposure, the dichotomous variable age (60 years or older) showed a statistically significant association with hearing loss , indicating that the older adults have a higher relative risk for hearing loss . After adjusting for covariates, there was no association between hypertension and hearing loss for any of the analyses .In the present study we sought to compare the incidence of hearing loss among adults with and without hypertension, and to check for an association between hypertension and hearing loss. The results of the four-year follow-up of ELSA-A subjects showed an incidence of hearing loss of approximately 7%. There was no association between hypertension and hearing loss after analyses adjusted for multiple risk factors recognized in literature. Older subjects (aged 60 years or more) showed a higher relative risk of hearing loss.17.Sociodemographic characteristics of the population studied showed that most subjects were younger adults, which is an advantage in longitudinal studies. The study of aging processes in younger cohorts may provide valid and important prospective measures of exposures, before damage to systems and organs is installed, and while the etiologic processes are developing18 reported that women typically use health services more than men, as they may be more concerned about their health.We also observed a higher number of women participating. A previous study20. A previous study on cardiovascular risk factors highlighted that subjects with higher education tend to be more aware about health, as well as healthier habits, besides having more timely access to health services21. Therefore, any considerations about health should take into account the education level observed in the sample.White race was self-reported by 57.5% of the participants, and 43.9% of the subjects had higher education. In both cases, the prevalence is above the national averages22. The higher prevalence of hypertension in wave 2, when compared to wave 1, probably may be explained by the increased age of participants between both waves, which may be a consequence of the aging process23.Regarding hypertension, wave 1 disclosed a prevalence of 29.9%, similar to the prevalence of hypertension described in a meta-analysis based on 10 Brazilian cross-sectional studies, which was 28.7%. However, the prevalence of wave 2 (35.8%) was higher than that same studyRegarding hearing health, less than half of the participants reported hearing complaints, tinnitus and exposure to noise, both in wave 1 , and in wave 2 . It is observed an increase in the prevalence of hearing complaints in wave 2, what did not occur with tinnitus and noise exposure.24.The increase in the occurrence of hearing complaints in wave 2 may be due to countless factors such as, for example, increase in the number of people with hypertension, aging of participants, and incidence of hearing loss between the two waves. Aging brings with it an increase in chronic diseases, being hypertension and diabetes the diseases with the highest prevalence and incidence in the world8.Studies have reported that these chronic diseases that affect subjects in aging may be related to hearing alterations stemming from ageper se causes a decrease in hearing thresholds, as well as impairment on central auditory processing. Thus, peripheral and central auditory alterations associated with age-related hearing loss may have a negative impact on the perception of verbal and non-verbal auditory stimuli25, which could cause an increase in hearing complaints in the second wave.Moreover, aging 26. In wave 1, the 36.7% prevalence of tinnitus even in the absence of hearing loss supports this statement. As for wave 2, a possible explanation for the reduced prevalence of tinnitus complaint, despite the existence of hearing loss in some subjects, is that some of them who had this symptom in wave 1 may not have participated in wave 2 or, in some cases, there may have been remission of the symptom27.As for tinnitus, it is known that this symptom often co-exists with hearing loss; however, tinnitus may also occur in people with normal hearing, and it may be an alert for the start of a possible hearing alteration28. For this reason, noise exposure was included as an adjustment covariate in the analyses performed in this study.More than one third of the subjects who participated in waves 1 and 2 reported exposure to noise. This is a known potential risk for hearing loss and tinnitus29. However, it should be stressed that this analysis disregarded the effect of covariates.In the crude analysis, the incidence of hearing loss was higher for subjects with hypertension when compared to subjects without hypertension. These findings suggest an increased RR of hearing loss associated with hypertension, in line with previous studies that found that people with hypertension have a higher risk for developing hearing loss30 and Samelli et al.11 who did not observe an association between hypertension and hearing loss.When investigating hearing loss in subjects with and without hypertension, it is necessary to consider the covariates, trying to exclude their effect on the outcome one intends to study. Thus, in the joint analysis with the possible confounders , there was no association between hypertension and hearing loss. These findings corroborate the studies by Lin et al.5, since it is the only variable that remained associated with hearing loss after joint analysis with the other confounders.However, still for the adjusted analysis, there was a significant association between being 60 years or older and hearing loss , suggesting that the older adults have an increased RR for developing hearing loss. These results suggest that age is the most important risk factor for hearing loss5. Several studies have shown the influence of age on hearing thresholds30.There is a consensus that age is a major contributor to hearing loss. Age-related hearing loss (or presbycusis) is a symmetrical sensorineural hearing loss that affects especially the higher frequencies, caused by the physiological aging of the cochlea, and the audiometric configuration of age-related hearing loss is similar to that of hypertension5.In fact, both chronic diseases and hearing loss increase with age, and all these conditions have an impact on the blood microcirculation of the cochlea, which may lead to hearing loss hardly associated specifically with a single risk factor. It is believed that physiological aging would cause hearing loss, and that chronic diseases, such as hypertension, may exacerbate this process30. For example, Reed et al.31 observed no association between hypertension and hearing loss in a cross-sectional analysis, but found an association between hypertension in middle age and hearing loss measured 25 years later, suggesting that the duration of illness may be another influencing factor. Lin et al.30 suggested that this inconsistency in the results of the various studies may be related to a weak association between cardiovascular risk factors with hearing loss. Therefore, effects would be masked by stronger risk factors such as age, especially in cohorts with older subjects.It should be stressed that variability in literature findings regarding the association between hypertension and hearing loss, including our study, may also be influenced by methodological aspects such as the measures used (self-reported versus objective), criteria adopted , populations assessed , the study design , as well as covariates incorporated into the analysesThe strengths of this study include: the longitudinal design, the systematic and objective methods used for hearing assessment, laboratory tests, and physical examination of subjects. However, one of the limitations of the study was the use of a self-reported variable for the disease duration, when diagnosed prior to the beginning of the ELSA-Brazil study. In the future, it is important to analyze data regarding the disease duration, checking the influence of time of the disease onset on the worsening of hearing thresholds, investigating whether subjects with longer time of diagnosis have greater hearing impairment.We emphasize that, despite the many controversies about the influence of hypertension on hearing, patients with this condition should be monitored because they are part of a population considered to be at risk for hearing loss. A better understanding of the relationship between hypertension and hearing loss, as well as the influence of other potentially modifiable risk factors, has important clinical implications, since early referral of adults with hypertension (or other chronic diseases) for audiological evaluation may become one of the first strategies to prevent hearing loss.In brief, the adjusted analyses controlled for multiple risk factors showed no association between hypertension and hearing loss. The dichotomous variable age (being 60 years or older) showed a significant association with hearing loss.