Dual sensory loss (DSL) has a negative impact on health and wellbeing and its prevalence is expected to increase due to demographic aging. However, specialized care or rehabilitation programs for DSL are scarce. Until now, low vision rehabilitation does not sufficiently target concurrent impairments in vision and hearing. This study aims to 1) develop a DSL protocol  which focuses on optimal use of the senses and teaches DSL patients and their communication partners to use effective communication strategies, and 2) describe the multicenter parallel randomized controlled trial (RCT) designed to test the effectiveness and cost-effectiveness of the DSL protocol.To develop a DSL protocol, literature was reviewed and content was discussed with professionals in eye/ear care (interviews/focus groups) and DSL patients (interviews). A pilot study was conducted to test and confirm the DSL protocol. In addition, a two-armed international multi-center RCT will evaluate the effectiveness and cost-effectiveness of the DSL protocol compared to waiting list controls, in 124 patients in low vision rehabilitation centers in the Netherlands and Belgium.This study provides a treatment protocol for rehabilitation of DSL within low vision rehabilitation, which aims to be a valuable addition to the general low vision rehabilitation care.NTR2843Netherlands Trial Register (NTR) identifier:  As a result of the aging of the Western population, impairments of hearing and vision caused by age-related degeneration of the senses (e.g. presbyacusis and macular degeneration) are expected to increase rapidly ,2. A relDSL has a detrimental effect on a patient’s health and well-being in relation to, for example, communication, social participation, depression, cognition, functional disability, health-related quality of life, self-rated health and mortality -5,13-22.Two main issues affect the lives of DSL patients. First, DSL impairs proper use of hearing aids. The complexity and small size of hearing aids makes handling and maintenance difficult for DSL patients. Examples of difficulties are inserting the hearing aid or ear mold in the ear, seeing the controls, or replacing batteries (glare from reflective surfaces may interfere with seeing the battery polarity) . TherefoSecond, DSL impairs communication as both good visual and hearing acuity enhance speech understanding. In DSL patients, age-related hearing loss reduces the ability to discriminate speech. In turn, a visual impairment reduces the perception of visual cues supporting speech understanding, such as looking at the speaker’s face/mouth and other bodily movements and gestures ,37-40. AAlthough DSL patients would benefit from rehabilitation to cope with these problems, integrated rehabilitation of DSL is scarce. In current practice, rehabilitation of sensory impairments in the aging population is divided into separate rehabilitation services for impairments in vision (low vision rehabilitation centers) and in hearing (audiology centers and hearing aid providers). Concurrent hearing impairment could affect the success of low vision rehabilitation  and viceThis paper reports on the development of a ‘Dual Sensory Loss-protocol’ (DSL protocol) designed for occupational therapists (OTs) working in the field of low vision rehabilitation, which focuses on maximal use of remaining hearing and vision. The protocol presents an integrated treatment of DSL for older adults within low vision rehabilitation. In addition, the design and methodology of a randomized controlled trial (RCT) to evaluate the effectiveness and cost-effectiveness of this protocol is described.In the development of the DSL protocol, literature was reviewed, and patients and professionals were consulted. First, the literature was reviewed on the topic of rehabilitation of DSL, and on existing interventions or recommendations on rehabilitation of DSL ,46,49-57However, because professionals may have some (work-related) bias, DSL patients and their communication partners were also consulted . Three DA draft of the DSL protocol was sent to all professionals involved; in two feedback rounds, they were asked to provide comments/suggestions on the draft.The DSL protocol provides information on DSL. However, because of the aim to implement the protocol in low vision rehabilitation centers, it also focuses on the gap in knowledge related to audiology and rehabilitation in that field.In the DSL protocol, rehabilitation is divided into three chapters . Chapter 1 of the DSL protocol includes information on audiology and the benefits/limitations of hearing aids, and also focuses on the proper use/maintenance of hearing aids. The chapter starts by informing the patient/communication partner about both vision and hearing loss to raise recognition, awareness, knowledge and understanding of sensory impairments. Patients/communication partners are informed about the benefits/limitations of hearing aids in order to develop realistic expectations and, for the communication partner to gain understanding of the situation. Note that care must be taken in addressing unrealistic expectations, as too low expectations could demotivate or discourage patients from using hearing aids .Then, the DSL protocol focuses on the proper and optimal use of hearing aids. Although correct use of hearing aids is a prerequisite, it cannot be presumed. Hearing aid users benefit from training ; traininIn the second chapter, the DSL protocol focuses on optimal use of the senses by improvement of the living environment in relation to lighting, acoustics and proximity, and the use of low vision and hearing assistive devices ,61,62. TCommunication and coping with DSL is the focus of the third chapter; it stimulates use of communication strategies (patients and communication partners) and social participation, it also discusses problems with energy/fatigue, and provides information on peer support. Communication difficulties and decreased social activity of DSL patients have a negative impact on wellbeing . Use of The protocol is divided into two parts: i) a comprehensive guidebook for the professional, and ii) checklists for each patient. The guidebook provides background information, materials and comments on each exercise. Materials include a CD, DVD, large printed handouts , information on patient organizations, a large printed picture of a loop system sign, information on financial compensation for assistive devices, a handout with instructions on hearing aid use and maintenance, and handouts with communication strategies for patient and communication partners.The second part of the protocol consists of checklists for each patient with exercises and instructions, which follow the three chapters of the guidebook. Items of the checklist are:Introduction1) Discuss goal and design of treatment2) Check severity of vision and hearing loss3) Check available low vision and hearing aids4) Check if the patient has comorbidity5) Create awareness with the patient of his/her dual sensory loss6) Create awareness of the communication partner about dual sensory loss (CD)Chapter 1: Hearing aids7) Give information on hearing aids and discuss realistic expectations8) Discuss experiences and problems with hearing aids9) Check working of hearing aid, batteries and tube10) Check amplification of hearing aid11) Check replacement of hearing aid and ear mold12) Check visibility of hearing aid, advise on use of low vision devices if necessary13) Check the possibilities of the hearing aid, such as settings/modes and programs14) Check skills in hearing aid use and manipulation of controls15) Check batteries and battery replacement16) Mark hearing aid17) Dry clean ear mold18) Wet clean ear moldChapter 2: Optimal use of the senses: living environment &hearing assistive devices19) Lighting for speech reading20) Advice on acoustics for speech intelligibility21) Use of loop systems in public buildings22) Use of subtitles and spoken subtitles23) Check whether the patient would benefit from other hearing assistive devicesChapter 3: Communication and coping with DSL24) Address problems related to fatigue and energy balance25) Use of communication strategies by the patient (handout)26) Use of communication strategies by communication partner (handout)27) Discuss the use of communication strategies on the basis of propositions28) Address DSL (vision and hearing impairment) to the speaker29) Ask speaker for clarification30) Discuss communication strategies using specific questions31) Provide information on patient organizations and peer groupsHome assignmenta) Watch the DVD ‘Hearing and being heard’ on the use of communication strategies, together with the communication partner. Discuss the situations on the DVD using questions.b) Attend a social activity, to apply the new skills and communication strategies.The OT will go through the checklist in 3–5 sessions at the patient’s home; participation of the communication partner is strongly recommended. The sessions are divided in two parts of 30 minutes each, separated by a break of 15 minutes. This takes into account, the length of the sessions, as well as the rapid fatigue and decreased ability of older adults with DSL to concentrate for longer periods of time. The exact number of sessions needed to go through the checklist depends on the abilities/needs of the individual patient. We anticipate the  participation of communication partners, since communication is interactive and relies on the conversational abilities of both communication partners.To use the DSL protocol, OTs need training. For the current RCT to test the effectiveness of the DSL protocol, OTs from two participating rehabilitation institutions were offered a one-day training in the DSL protocol on October 18th, 2011. The first part of the training was provided by an audiologist and involved background information on audiology. Subsequently, a hearing aid provider gave instructions on the use and maintenance of hearing aids, exercises on hearing aid use, and gave information and a demonstration on hearing assistive devices. In the second part of the training, a speech therapist taught the OTs how to teach patients and proxies to use adequate communication strategies, e.g. with the use of role play. In role play, special glasses and earmuffs were used to simulate vision and hearing loss of DSL patients. The training was filmed and later on three other OTs were later trained with using this film as part of their training.In a limited pilot study (before the start of the RCT) OTs went through the DSL protocol with a DSL-patient in a real-life situation. The results of this pilot study were evaluated in three meetings with the OTs and, subsequently, a few clarifying adaptations were made to the protocol.A two-armed international multicenter parallel RCT will be conducted to evaluate the health effectiveness and cost-effectiveness of the DSL protocol from a societal perspective in low vision multidisciplinary rehabilitation institutions in the Netherlands and Belgium. The design of the trial is shown in Figure http://www.trialregister.nl, identifier: TC = 2843).The study is approved by the Medical Ethical Review Committee of the VU University Medical Center (the Netherlands) and the Ethical Committee of University Hospitals UZ/KU Leuven (Belgium) according to the principles of the Declaration of Helsinki. The trial is registered at the Netherlands Trial Register  who received low vision rehabilitation between January 1 and October 31, 2012. Addresses were derived from the patient information databases of the rehabilitation institutions. After two weeks, patients who did not fill in the questionnaire were telephoned about the questionnaire and in case the patient was not able to fill in the questionnaire due to low vision, the questions were administered orally by telephone. More details on the screening and the results of the screening are published elsewhere .Patients who experience hearing problems and are in the possession of a hearing aid will be invited to participate in the RCT. Hearing aid owners will be invited to participate because hearing aids, and making optimal use of hearing aids, are an important part of the DSL protocol. In addition, by selecting hearing aid owners with hearing problems by using information from the questionnaire, patients with both objective hearing loss (reimbursement of hearing aids from a hearing loss of at least 35 dB) and self-reported hearing disability will be selected; these patients are expected to be motivated and the most suitable for rehabilitation . MoreoveWritten information will be sent to eligible patients and informed consent will be signed prior to inclusion. It is expected that about 1500 patients need to be screened to include 124 eligible participants in the trial. Patients who are unable to comprehend or respond to questions due to cognitive impairment, or have insufficient knowledge of the Dutch language, will be excluded from the study. Table After baseline measurements, participants will be randomly allocated (stratified by therapist) to either the intervention or control group, by means of computer-generated tables. Trained OTs employed by the participating low vision multidisciplinary rehabilitation institutions in the Netherlands and in Belgium will provide therapy for older adults with DSL and their communication partner (i.e. the intervention group) according to the newly developed DSL protocol. To prevent unequal distributions of participants in the control and intervention groups among OTs, participants will be stratified within working areas of OTs before randomization resulting in eight strata, one for each of the eight participating OTs . Block randomization will be performed in blocks of two to ensure equal group sizes in each stratum. Randomization will be performed by an independent researcher using a computer-generated allocation scheme so that the researcher who will analyze the data is blinded . All participants will be informed about the allocation. In case a participant is allocated to the treatment group, an email will be sent to inform the designated OT. Treatment will take place in the participant’s home in 3–5 appointments, depending on the individual needs of the participant and/or proxy. All participants have received low vision rehabilitation and hearing aid fitting before entering the study. Using a waiting list procedure, participants in the control group will be offered treatment after 3-month follow-up measurements.Measurements will include face-to-face structured interviews and will be performed by trained research assistants in a quiet room in the home of the participant at baseline and at 3-months follow-up. Data collection will take about two hours per measurement. The software program Blaise Enterprise 4.7  will be used to directly enter data into laptop computers. Communication partners will be asked to fill in a written questionnaire at baseline and at 3-months follow-up. To measure the ability of understanding speech in noise (speech-reception-threshold in noise), a speech-in-noise test developed by Smits et al. (2013) will be included in the baseline measurements . In the Three months after data collection, all participants (including non-compliant participants) will be approached for follow-up measurements.The effects of the intervention will be evaluated in terms of hearing aid use and satisfaction, communication (primary outcomes), coping, psychosocial health and perceived quality of life (secondary outcomes) using several validated questionnaires Table .Difficulties with hearing aid use and maintenance will be measured with questions on problems with hearing aid use and maintenance, e.g. “How difficult is it for you to insert your hearing aid?” or “How difficult is it for you to change your hearing aid batteries?”. Questions on hearing aid fitting, hearing aid use and satisfaction will be based on the Questionnaire for evaluation of hearing aid fitting, e.g. hours of hearing aid use, use of hearing aids in different situations, and appreciation of hearing aids [Self-reported change from hearing aids is measured with the Dutch version of the widely used International Outcome Inventory for hearing aids (IOI-HA) [Communication (coping behavior in communicative situations) and consists of three subscales: ‘Maladaptive Behavior’; ‘Verbal Strategies’ and ‘Non-verbal Strategies’ [Self-reported change from communication strategies reported by the participant is measured with the Dutch version of the International Outcome Inventory for alternative strategies (IOI-AI) [ing aids . Self-re(IOI-HA) ,66,85. T(IOI-HA) . The ‘Coategies’ . Self-re(IOI-AI) . Both me(IOI-AI) ,48).adjustment to hearing loss and consists of three subscales: ‘Self-Acceptance’, ‘Acceptance of Loss’ and ‘Stress & Withdrawal’ [vision-related quality of life outcomes of participants [Health was measured with an item on subjective health and with the Euroqol 5 Dimensions (EQ-5D) questionnaire to measure health status [Fatigue is assessed with the Fatigue Assessment Scale [participation, a number of items of the Dutch ICF Activity Inventory will be selected from the participation domain ‘Interpersonal interactions and relationships’, e.g. with regard to communication and understanding of DSL [Autonomy problems will be assessed with the 9-item version of the Patient Autonomy Questionnaire (PAQ) [emotional and social loneliness will be measured with the 11-item Loneliness Scale [Secondary outcomes will be coping, quality of life, health, fatigue, loneliness, participation and autonomy. First, the domain ‘Personal Adjustment’ of the CPHI will be used to assess change in hdrawal’ . Second,icipants ,71. The h status . Fatiguent Scale . To measg of DSL . Furtherre (PAQ) . Feelingss Scale . Examplepatient and disease characteristics will be assessed. Information on age, gender, education level, living arrangement , comorbidity, eye condition , ear condition  and hearing acuity  will be collected by research assistants. Visual acuity and other relevant data, such as the eye condition, will be obtained from the patient’s files at the low vision rehabilitation centers with the patient’s consent. Cognitive impairment is assessed with the six-item screener derived from and comparable to the full Mini-Mental State Examination (MMSE) [depressive mood, is used to assess the presence of depressive symptoms, which may influence the outcome of the study [In addition, n (MMSE) . Finallyhe study . Particicoping with hearing loss[Self-reported change from hearing aids and self reported change from communication strategies reported by the communication partner will be measured with the Dutch versions of the International Outcome Inventory for hearing aids (IOI-HA-SO) and the International Outcome Inventory for alternative strategies (IOI-AI-SO) [Health was measured as subjective health and with the EuroQol 5 Dimensions (EQ-5D) [Evaluation of the DSL protocol with questions: “Are you satisfied with the advice of the OT?”, “Are you satisfied with the treatment?”, and ”Are you satisfied with the results?”. Chronic fatigue was assessed with the Fatigue Assessment Scale (FAS) [Self-efficacy is measured with the General Self-Efficacy Scale (GSES) divided in three subscales: Initiative, Effort and Persistence [Depressive symptoms will be assessed with the Dutch version of the Center for Epidemiological Studies-Depression scale (CES-D) [The HHDI ‘reactions of others’ scale assesses attitudes towards the hearing impaired partner and has been used to measure ring loss. Self-reI-AI-SO) . Health  (EQ-5D) . Evaluatle (FAS) . Self-efsistence . Depress (CES-D) .In a bottom-up price calculation all costs  will be calculated for both the intervention and control group. Intervention costs include participation of the OT , participation of the communication partner . Healthcare costs include costs of medication and consultations of health care providers. The volume of will be measured with the iMTA Medical Consumption Questionnaire (iMCQ)  and costData will be analyzed according to the intention-to-treat principle. Linear mixed models for continuous outcomes and generalized linear mixed models for counts and categorical outcomes will be used to assess treatment effects with respect to primary and secondary outcome measures. Treatment effects will be assessed according to the analysis strategy as described by Winkens et al. -89 and iFor participants who are not treated according to the protocol, intention-to-treat analyses will be compared to per-protocol analyses. Data will be analyzed using the software package SPSS 20 for Windows.Power calculations are based on expected progress in use of communication strategies , which has been the primary outcome of previous studies in persons with hearing loss . In a prIn addition to the RCT, an economic evaluation will compare costs and consequences from a societal perspective of an intervention group receiving the DSL protocol compared with a waiting list control group. Therefore, all costs and consequences of the DSL protocol will be taken into account for patient, communication partner and society. The incremental cost-effectiveness ratios (ICER) will be calculated; the difference in mean costs between intervention and control group will be divided by the difference in outcome measures between the two groups. Because costs data are generally skewed, non-parametric bootstrapping with 5000 replications of both intervention and control group will be used to derive 95% confidence intervals for the ICER. Bootstrapped cost-effectiveness pairs will be plotted in a cost-effectiveness plane and cost-effectiveness acceptability curves will be estimated .Especially among visually impaired elderly, dual sensory loss (DSL) is highly common. Of all the related difficulties, communication is perhaps the most challenging and it may negatively affect a patient’s health and wellbeing. We expect the newly developed DSL protocol to reduce these difficulties. This may lead to better hearing aid use, improved use of effective communication strategies and hence, better quality of life, health and wellbeing. This paper describes the ‘Dual Sensory Loss-protocol’ and the design of a multicenter international RCT to determine the effectiveness and cost-effectiveness of the DSL protocol.In the development of the DSL protocol, designed for OTs working in low vision rehabilitation, we obtained information from the literature, which we complemented with interviews and discussions with patients and professionals (working in ear and eye care). The trial will test the effectiveness of the additional DSL protocol compared to a waiting list control group on use and maintenance of hearing aids; communication; coping with a dual sensory impairment; social participation and quality of life of the patient and communication partner; and cost-effectiveness from a societal perspective.The development of the protocol and design of the RCT required decisions as to which professionals would be most suitable to perform the protocol, and which DSL patients should be included in the trial.Firstly, the DSL protocol consists of three chapters suitable for different rehabilitation professionals. On the one hand, the first two chapters of the DSL protocol focus on maximizing use of the senses with the use of hearing aids; other assistive devices; and minor adaptations to the living environment; these are considered highly suitable topics to be handled by OTs. On the other hand, the last chapter focuses on psychosocial issues: it discusses communication difficulties, psychosocial problems, coping with dual sensory impairment, and also teaches communication strategies; some consider that these topics are more suitable for social workers. To be able to build a relationship of trust, the patient can best be handled by one professional, and we decided OTs are the most competent. Secondly, we decided to recruit DSL patients who already received usual low vision and audiology care, i.e. patients who possess hearing aids and who have received low vision rehabilitation. This allows us to investigate the added value of the DSL protocol compared to a waiting list control group .Several studies have aimed to meet the urgent need for evidence-based protocols and interventions in rehabilitation -94. HoweHowever, there are limitations to the study concerning both the protocol and the RCT. First, the DSL protocol was developed for patients with some residual vision and hearing, which concerns the vast majority of DSL patients , and focSecond, due to budgetary restrictions it was not possible to provide information on the long-term effects. Third, blinding of participants and OTs is not possible since no placebo treatment is included in the study to account for the placebo effect. Participants may report change as a result of simply meeting with an empathetic professional each week to discuss problems. Therefore, the effect of the DSL protocol is the total difference between groups, including both treatment and associated placebo effects. This has both advantages and disadvantages: a disadvantage is that the pure effect of the DSL protocol’s content remains unclear whereas, on the other hand, reality is best reflected. This pragmatic trial provides the best reflection of the likely rehabilitation outcome in actual practice.This study provides useful information on DSL. Also, if the trial shows the DSL protocol to be effective, this will allow multidisciplinary low vision rehabilitation centers to provide an evidence-based treatment protocol for DSL patients. The DSL protocol will be an important tool for OTs to assist their older patients with DSL in the use of hearing aids, to maximize use of the senses, and to teach patients and/or communication partners specific skills to improve communication.However, DSL needs more attention in other care settings (besides low vision rehabilitation), such as nursing homes and audiology rehabilitation. It is estimated that about 2% of the elderly who consult a hearing healthcare professional experience such visual impairment to such extent, that it limits the perception of facial cues for communication . AlthougBesides special treatments for DSL, there is a need for more collaboration between low vision and audiology rehabilitation by, for example, making greater use of referrals . To faciIn conclusion, until now, insufficient attention has been paid to the problems of elderly with DSL. However, the development of this DSL protocol represents an important step to improve the health and quality of life of DSL patients.DSL: Dual sensory loss; HA: Hearing aid; OT: Occupational therapist; RCT: Randomized controlled trial.The authors declare that they have no competing interests.RvN conceived and designed the study and GvR, JF SK and DL advised on the study and its design. HV developed a draft of the DSL protocol and GvR, SK, JF RvN helped to draft and revise it. DL performed the power calculation of the RCT and HV conducts the trial. HV drafted the manuscript, which was revised by all other authors. All authors have read and approved the final version to be published.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2318/13/84/prepub


A3A genes across a wide range of 12 primates including New World monkeys, Old World monkeys and Hominids. Sequence variation was observed in exons 1–4 in all primates with up to 31% overall amino acid variation. Importantly for 3 hominids codon M1 was mutated to a threonine codon or valine codon, while for 5/12 primates strong Kozak M1 or M13 codons were found. Positive selection was apparent along a few branches which differed compared to positive selection in the carboxy-terminal of A3G that clusters with A3A among human cytidine deaminases. In the course of analyses, two novel non-functional A3A-related fragments were identified on chromosome 4 and 8 kb upstream of the A3 locus. This qualitative and quantitative variation among primate A3A genes suggest that subtle differences in function might ensue as more light is shed on this increasingly important enzyme.The APOBEC3 gene cluster encodes six cytidine deaminases  with single stranded DNA (ssDNA) substrate specificity. For the moment A3A is the only enzyme that can initiate catabolism of both mitochondrial and nuclear DNA. Human A3A expression is initiated from two different methionine codons M1 or M13, both of which are in adequate but sub-optimal Kozak environments. In the present study, we have analyzed the genetic diversity among  The A3A gene is missing in the Rhesus macaque assembly, while the marmoset locus doesn't exist per se, sequences being distributed over numerous contigs. As the A3 locus shows signs of extensive gene conversion, the apparent gaps might reflect assembly problems.Even though a number of primate genomes are available, only the chimpanzee locus is colinear. For the orang-utan the A3A genes across a wide range of primates including New World monkeys, Old World monkeys and Hominids. There is variation among the Kozak motifs with the M1 initiator methionine being absent for chimpanzees, bonobos and gorillas. Some, but not all, A3A lineages show positive selection suggesting that A3A enzymes may not be truly orthologous.We have analyzed the genetic diversity among C. guereza, C. aethiops and C. neglectus  and synonymous (dS) nucleotide substitutions per site and dN/dS ratios over the twelve primate species using the Hyphy package and FEL and REL methods A3A and A3Gc cytidine deaminases are different, a good example being the New World monkey lineage.A phylogenic tree for the complete sequence of A3A was constructed using BioNJ . The rednSCX2C motif similar to that for all A3 deaminases (HAEXnPCX2–4C) (When performing Blat searches for this study (UCSC Genome Bioinformatics), we identified a segment of 288 bp on human chromosome 4 with strong homology to exon 3 of the A3A/A3Bc/A3Gc cluster  which wiPCX2–4C) . While tPCX2–4C) .A3A gene. The construct was cloned in pcDNA3.1 TOPO resulting in addition of the V5 tag. When transfected into HeLa cells and stained with FITC-conjugated anti-V5 antibody the construct was viable and strongly nuclear, more so than hA3A indicating that residues impacting A3A localization lie in exon 3  for the HBV X gene segment analysed is 91.8°C . When copΨA3chr4 , suggestA3A-related fragment was identified ∼8 kb upstream of the human A3A gene in the same orientation as the entire A3 locus. For comparison, the A3A-A3B intergenic region is ∼19 kb. The fragment comprises 104 bp (37%) of intron 4, exon 5 and downstream sequences. Overall it shows 96% nucleic acid homology to hA3A. As such it must represent a vestige of prior gene conversion. Indeed, the sequence is surrounded by repeat elements, some of which are found surrounding the hA3A and hA3B genes. This A3A remnant is found in the chimpanzee, orang-utan and rhesus macaque genomes.Finally, an additional ∼1.1 kb A3A gene shows considerable qualitative and quantitative genetic variation, with up to 31% amino acid variation. Translation initiation sites vary there being at least four different configurations  and chimpanzees (Pan troglodytes troglodytes) in Cameroun with permission of the Cameroonian Ministries of Health, Research and Environment and Forestry and Wildlife, and from bonobo (Pan paniscus) in the Democratic Republic of Congo with the permission of the Ministries of Science and Technology and Forest Economy Colobus guereza) and mandrills (Mandrillus sphinx), DNA was extracted from whole blood on samples that were collected on primate bushmeat with permission from Cameroonian Ministries of Health, Research and Environment and Forestry and Wildlife, as previously reported Pongo pygmaeus) that died of natural causes while housed at the Wanariset orang-utan Reintroduction Center in East Kalimantan, Indonesia Hylobates lar, ATCC 57763) respectively, while samples of rhesus monkey , vervet monkey , and necropsy tissue samples from a squirrel monkey (Saimiri sciureus) and cotton-top tamarin (Sanguinus Oedipus) that died of natural causes while kept in a zoo have been already described Cercopithecus neglectus) came from an animal that died of natural causes while housed at the zoo de la Palmyre (France).Faecal samples were collected from wild non-habituated western gorilla  in a final volume of 50 µL. PCR products were purified from agarose gels  and ligated into the TOPO TA cloning vector . After transformation of Top10 electrocompetent cells (Invitrogen), up to 15 clones were picked. Sequencing was outsourced to GATC biotech. All mutations were confirmed by inspection of the chromatogram. The pΨA3chr4 insert was synthetized by GeneCust and cloned into the pcDNA3.1 TOPO-V5 vector (Invitrogen).Hot start PCR was performed with corresponding primers . The fir5 QT6 cells (ATCC CRL 1708) were cotransfected with 1 µg of pΨA3chr4 plasmid DNA along with 1 µg pCayw, a plasmid encoding an infectious molecular genome of hepatitis B virus (HBV) using FuGENE 6 (Roche). Total DNA was extracted using the MasterPureTM complete DNA and RNA purification kit (Epicentre). QT6 cells were maintained in HAM's F40 medium, supplemented with 1% chicken serum, 10% FCS, 5% tryptose phosphate, 2 mM L-glutamine, 50 U/ml penicillin and 50 µg/ml streptomycin Briefly, 105 cells per dish HeLa cells (ATCC CCL 2) were grown to a density of 5.10http://phylogeny.fr. The final output was edited using Treeview Sequences were aligned using the MUSCLE program, and neighbor-joining trees were obtained using BioNJ as implemented in We used the genetic algorithm (GA-Branch) method available in HyPhy Colobus guereza (JN177339), Cercopithecus aethiops (JN177340), Cercopithecus neglectus (JN177341), Mandrillus sphinx (JN177342), Macaca mulatta (JN177343), Hylobates lar (JN177344), Gorilla gorilla (JN177345), Pongo pygmaeus (JN177346), Pan paniscus (JN177347), Pan troglodytes troglodytes (JN177348), Saguinus oedipus (JN177349) and Saimiri sciureus (JN177350).Accession numbers were deposited at GenBank:


Rhizopus sp. is the most frequent pathogen and infection occurs almost exclusively in immunocompromised patients. We describe the first case of intestinal mucormycosis occurring after a Streptococcus pyogenes toxic shock syndrome in a previously healthy patient caused by Rhizopus microsporus var. azygosporus.Mucormycosis is an uncommon opportunistic infection and the gastrointestinal form is the rarest.  Streptococcus pyogenes toxic shock syndrome (TSS). This is to our knowledge the first case of mucormycosis occurring after a S. pyogenes TSS.Mucormycosis is an infection caused by members of the order Mucorales. Relatively uncommon, it is one of the most rapidly fatal infections known to man . The gasS. pyogenes necrotizing pneumonia with TSS and transferred to our institution. Upon admission, she was found to have multiorgan failure with acute respiratory distress syndrome and immediately required intubation and vasopressors. She also received IV penicillin, clindamycin, immunoglobulins, activated C-protein, and three days of corticosteroids at physiological dose. Over the following week, the shock resolved and her respiratory parameters improved.A previously healthy 53-year-old woman, who had been complaining of respiratory tract symptoms and fever for 3 days, was diagnosed with a Bacteroides distasonis. The following day, a second-look laparotomy confirmed the absence of additional necrosis or ischemia and the wound was closed. The patient remained clinically stable and afebrile, but the leukocytosis progressed. Preliminary results of the peritoneal fluid cultures showed gram-negative rods and hyphae compatible with those of the Mucorales, the latter being initially considered a probable laboratory contaminant given the favorable clinical evolution of the patient at this point.However, on day 10 her condition critically deteriorated, vasopressors were resumed and piperacillin-tazobactam was administered. On physical examination, proctorrhagia and abdominal distension were noted, and she developed leukopenia . AbdominOn day 15 (five days postoperatively), the patient became unstable again, with a concomitant rise in lactate and white cell count. With the ileostomy tip and wound borders blackish, a diagnosis of intestinal mucormycosis was suspected. Liposomal amphotericin B was started at 5 mg/kg daily. An abdominal CT scan documented a lack of enhancement of the distal portion of the small bowel, including the ileostomy, compatible with ischemia . Numerouμm in length, spherical sporangia, ovoidal sporangiospores 4–7 μm long, occasional chlamydospores, and numerous pale to dark brown azygospores . R. azygosporus is now considered a variety within R. microsporus. However, the ITS sequence does not allow discrimination of the varieties which are still assigned by morphology. The isolate was deposited at the Laboratoire de santé publique du Québec under accession number LSPQ-00966. The in vitro susceptibility of the isolate to antifungal drugs was determined using the Clinical and Laboratory Standards Institute's broth microdilution method M38-A2 [A culture of peritoneal fluid on Sabouraud dextrose agar revealed a rapidly growing grayish cottony colony following incubation at 30°C for 3 days. The organism was thermophilic, displaying good growth at 45°C. Microscopic examination revealed large and mostly nonseptate hyphae, rhizoids, short unbranched and brown sporangiophores up to 500 gospores . From th Micafungin was added to the therapeutic regimen because of a possible synergistic effect with amphotericin B against mucoraceous fungi. Daily laparotomies with broad resections of the necrotic tissues were performed. An immunology consultation did not establish an immune deficit, but immunoglobulins and interferon-gamma were administered nonetheless to optimize the phagocytic function of leucocytes.Unfortunately, even after eight interventions , mucormycosis continued to progress relentlessly over surgical margins. On day 27, it was decided to cease treatments. The patient died a few hours later.The main protagonists of host defense mechanisms in mucormycosis are mononuclear and polymorphonuclear phagocytes, both of which are impaired in most of the clinical settings associated to the previously mentioned risk factors. In the normal host, phagocytes kill the fungus by generating oxidative metabolites and cationic peptides defensins . In vitr Clinical presentation depends on the predisposing conditions and the route of infection, resulting in either cutaneous, rhinocerebral, pulmonary, gastrointestinal (GI), or disseminated mucormycosis . AngioinMucorales species from clinical specimens in the United States revealed that 22% were R. microspores [R. microsporus var. azygosporus. This organism has been very rarely implicated in human disease. To our knowledge, this case is the fifth described in the literature. R. microsporus var. azygosporus was previously reported as the causative agent of three fatal cases of gastrointestinal infection in premature babies [A recent study of 190 isolates of molecularly identified rospores . None wee babies  and in oe babies .Our case is intriguing because this patient developed intestinal mucormycosis despite the lack of any immunosuppression prior to streptococcal TSS and of any of the other classical predisposing factors. She was HIV-negative, and no cellular or humoral defects were elicited. It is unlikely that the short course of corticosteroids impaired her immune response. Consequently, could the streptococcal TSS have predisposed her into developing this rare form of mucormycosis?Patients with diabetic ketoacidosis are at high risk of developing rhinocerebral mucormycosis , 13 becaStreptococcal pyrogenic exotoxins cause a transient decrease in RNA synthesis in Kupffer cells, which in turn alters the reticuloendothelial system function . In our Rhizopus spp. have been described following the use of wooden tongue depressors [R. microsporus. Moreover, during the subsequent year, no other case of mucormycosis was identified in our center, and no R. microsporus was isolated in any clinical specimen. As fungi of the order Mucorales are ubiquitous in the environment, it seems likely that she was colonized with the fungus prior to her hospital admission and became infected after multiple invasive procedures.It remains unclear how the fungal pathogen was introduced into her GI tract. This is generally attributed to the ingestion of contaminated foods or the use of contaminated instruments . For exapressors . Similarpressors . EnvironBecause of its vascular tropism, rapid diagnosis of mucormycosis is essential to lower mortality , which cImaging findings of GI mucormycosis have rarely been reported in the radiological literature. In early-stage GI mucormycosis, CT may show nonspecific bowel wall thickening, with or without target sign, and decreased bowel wall enhancement, representing bowel ischemia. When the involved bowel segment becomes frankly necrotic, the bowel wall is thinned or even disappears, as in our case . Timely Successful treatment requires a combination of aggressive surgical removal of necrotic tissues along with long-term administration of intravenous antifungal therapy. A recent study showed that susceptibility of Mucorales to antifungals differs according to family, genus, and species . The mosS. pyogenes TSS. The diagnosis of mucormycosis is rarely suspected in patients without any known risk factor and isolation of a mucoraceous fungus in these circumstances is often considered nonsignificant. This delay in diagnosis will further worsen the prognosis. TSS may induce a state of reticuloendothelial dysfunction and altered iron metabolism which predisposes to mucormycosis. In summary, this is to our knowledge the first case of intestinal mucormycosis occurring after a


The STET trial is a two-centre open RCT comparing morbidity and healthcare resource use when off-pump coronary artery bypass surgery is carried out via a left anterolateral thoracotomy incision (ThoraCAB) or via a conventional median sternotomy incision (OPCAB). It was hypothesised that post-operative recovery would be faster with ThoraCAB.Post-operative hospital stay is a commonly used measure of recovery. However, in an open surgical trial, where the decision to discharge the patient from hospital lies with the surgeon, post operative hospital stay is susceptible to bias. For the STET trial we developed an objective measure of recovery. Recovery time was defined as the time from surgery until the patient was considered fit for discharge. Patients were classified fit (a) when the x-ray was clear ; (b) there was no suspected systemic, lower respiratory tract or wound infection; (c) routine blood results and temperature were normal and (d) when physically mobile . These recovery criteria were monitored daily until discharge.184 patients were recruited . In the OPCAB group 77% were classified fit at or before discharge versus 68% in the ThoraCAB group. For the remainder, the recovery time was censored because discharge occurred before all the criteria were met. Insufficient mobility accounted for the majority of censored observations. The median recovery time was 6 days, IQR  in the ThoraCAB group versus 5 days, IQR  in the OPCAB group (Time ratio (ThoraCAB/OPCAB) 1.03 . In contrast, the median time to discharge was 5 days in the ThoraCAB group versus 6 days in the OPCAB group.The anticipated faster recovery with ThoraCAB was not found and a significant proportion of patients were discharged before all the recovery criteria were met. The results from the STET trial illustrate the bias associated with clinical decision making in an open RCT. The measure of recovery time (with slightly modified criteria) is being used in other cardiac surgery trials.


Tinnitus, a phantom auditory sensation, is associated with hearing loss in most cases, but it is unclear if hearing loss causes tinnitus. Phantom auditory sensations can be induced in normal hearing listeners when they experience severe auditory deprivation such as confinement in an anechoic chamber, which can be regarded as somewhat analogous to a profound bilateral hearing loss. As this condition is relatively uncommon among tinnitus patients, induction of phantom sounds by a lesser degree of auditory deprivation could advance our understanding of the mechanisms of tinnitus. In this study, we therefore investigated the reporting of phantom sounds after continuous use of an earplug. 18 healthy volunteers with normal hearing wore a silicone earplug continuously in one ear for 7 days. The attenuation provided by the earplugs simulated a mild high-frequency hearing loss, mean attenuation increased from <10 dB at 0.25 kHz to >30 dB at 3 and 4 kHz. 14 out of 18 participants reported phantom sounds during earplug use. 11 participants presented with stable phantom sounds on day 7 and underwent tinnitus spectrum characterization with the earplug still in place. The spectra showed that the phantom sounds were perceived predominantly as high-pitched, corresponding to the frequency range most affected by the earplug. In all cases, the auditory phantom disappeared when the earplug was removed, indicating a causal relation between auditory deprivation and phantom sounds. This relation matches the predictions of our computational model of tinnitus development, which proposes a possible mechanism by which a stabilization of neuronal activity through homeostatic plasticity in the central auditory system could lead to the development of a neuronal correlate of tinnitus when auditory nerve activity is reduced due to the earplug. Tinnitus is a phantom auditory sensation, the perception of a sound in the absence of a corresponding sound source. In most cases, tinnitus is associated with hearing loss Computational modelling studies have recently illustrated how cochlear damage might lead to the development of increased spontaneous neuronal activity as observed in animal models of tinnitus It has been long known that complete auditory deprivation can induce tinnitus-like phantom sounds in healthy, normal-hearing volunteers 3. All equipment was calibrated to accepted standards.This study was approved by the ethics committee of the University of Manchester, and all participants gave written informed consent. The investigation of phantom sounds after earplug usage was embedded in a study on changes in acoustic reflex thresholds and perceived loudness through earplugs . 18 volunteers  were recruited into the study. Participants were required to have normal hearing, i.e. thresholds of <20 dB HL from 0.25 kHz to 8 kHz, and no asymmetry >10 dB between ears at any frequency. A short health questionnaire was used to screen for other conditions, and persons reporting tinnitus were excluded from the study. Pure tone audiometry was performed with an Aurical clinical audiometer and TDH-39 supra-aural headphones. Hearing thresholds were tested at 0.25, 0.5, 1, 2, 4 and 8 kHz. Normal middle ear function was ensured through tympanometry using a GSI TympStar middle ear analyser; participants were required to have middle ear pressure between +50 and −50 daPa and middle ear compliance of 0.3 to 1.6 cmParticipants wore a silicone putty ear plug in one ear for 7 days. Each participant was randomly assigned to plug either the left or the right ear, and the participants were instructed to wear the earplug continuously. Sound attenuation of the earplug i.e., the difference in ear canal sound level with and without the earplug in situ, was measured using a clinical probe tube microphone system and a broadband signal of 75 dB SPL. This method was also used to confirm that participants fitted the earplug with a maximum attenuation difference of 3 dB at 1 kHz and 2 kHz when fitting it themselves. At the end of the session, participants were given an “earplug logbook” to record earplug usage . They were also told that there might be a possibility of experiencing phantom sounds during earplugs usage, and they were asked to take a note about their occurrence in the logbook. We deliberately did not mention tinnitus in all explanations about phantom sounds to avoid this strongly suggestive term.All participants who perceived a phantom sound on day 7 underwent a characterisation of the phantom sound using a modified version of the tinnitus spectrum approach To model the development of phantom sounds after earplug-induced auditory deprivation, we employed a computational model of tinnitus development comprising the first stages of auditory processing The effects of sound attenuation through an earplug providing The central auditory system stage of the model is based on the circuit that has been proposed for the dorsal cochlear nucleus Homeostatic plasticity was implemented in the model by simultaneously scaling the strength of the excitatory and inhibitory synapses onto principal neurons in opposite directions Data analysis and model simulations were performed using MATLAB . All error bars are given as ± s.e.m.18 participants with normal hearing  in the central auditory system were stabilized by homeostatic plasticity. After the model’s ear had been plugged, homeostatic plasticity thus tried to compensate for the decrease in PN activity by increasing excitation and decreasing inhibition. When homeostasis restored the mean activity of the PNs in the model cochlear nucleus to the healthy target level . Such hyOur results demonstrate that unilateral auditory deprivation similar to a mild high-frequency hearing loss is sufficient to induce phantom auditory sensations in healthy normal hearing subjects without tinnitus. This suggests that auditory deprivation (not necessarily involving cochlear damage), and the concomitant reduction of auditory nerve activity, could be the dominant factor for the development of phantom sounds. The characteristics of the phantom auditory sensations perceived by our participants were very similar to tinnitus: Firstly, the descriptions of the phantom sounds resembled those of tinnitus sounds given by tinnitus patients The participants in our study wore earplugs in one ear only. Bilateral earplugs were not tested due to ethical considerations, as plugging both ears could increase the probability of dangerous situations, e.g. in traffic. Thus, the phantom auditory sensations perceived by our participant could have developed in reaction to decreased input from the ipsilateral ear, the imbalance between the ears, or both. Given that binaural deprivation in a sound-proof booth also gives rise to phantom sounds In the recruitment information sheet for the study, our participants were informed that they might experience phantom sounds while their ear was plugged, and this suggestion itself might have increased the incidence of phantom sounds, e.g. by focussing attention. One way of addressing this problem would be to use a control group wearing non-attenuating earplugs. However, a non-attenuating earplug can be easily recognized by the wearer. Alternatively, a future study could employ earplugs with different degrees of attenuation to study whether the occurrence of phantom sounds depends on the degree of attenuation, which was beyond the means of our current study. Moreover, it also remains to be shown if a similar relation between phantom sound characteristics and attenuation profile can also be obtained when only low frequencies are attenuated, which would support a true frequency-specific adaptation effect. However, we believe that the fact that the phantom sounds were stable enough to run a full tinnitus spectrum characterisation in 11/18 participants, that their pitch generally matched the attenuation characteristics of the earplugs, and that the phantom sounds disappeared in all participants after removing the earplug, already support a causal relation between plugging the ear and the occurrence of phantom sounds.Several mechanisms might contribute to the occurrence of phantom sounds while the ear is plugged: Firstly, an intrinsic tinnitus could have been unmasked through the reduction of AN input caused by the earplug. However, as the earplug does not change the spontaneous activity of the auditory nerve, and thus not the neural activity coding for silence, changes in the central auditory system would still be required to give rise to a conscious tinnitus percept. Secondly, the neuronal response gain in the central auditory system could have been increased in response to the auditory deprivation. The resulting over-amplification of spontaneous activity in this scenario could account for the occurrence of phantom sounds. It has been shown recently that earplug-induced unilateral auditory deprivation lowers the acoustic reflex threshold in the ipsilateral ear, a physiological change indicative of increased gain in the auditory brainstem Homeostatic plasticity is also a key factor in our computational model for the development of tinnitus When auditory nerve activity was ‘renormalized’ by removing the earplug, the phantom auditory sensations disappeared in all participants. This is consistent with the mechanism of activity stabilization in our model. Thus, one might conclude that tinnitus (occurring in association with hearing loss) could be decreased by renormalizing or simply increasing AN activity through increased acoustic stimulation, delivered for example through a hearing aid. However, there are technical and biological limitations for the renormalization of auditory nerve activity after cochlear damage. Firstly, the limited frequency range of current ear-level devices restricts the frequency range where AN activity can be increased through amplification, and we have shown recently that this factor influences the effectiveness of tinnitus management through hearing aids and noise generators


Retinitis pigmentosa is characterized by the sequential loss of rod and cone photoreceptors. The preservation of cones would prevent blindness due to their essential role in human vision. Rod-derived Cone Viability Factor is a thioredoxin-like protein that is secreted by rods and is involved in cone survival. To validate the activity of Rod-derived Cone Viability Factors (RdCVFs) as therapeutic agents for treating retinitis Pigmentosa, we have developed e-conome, an automated cell counting platform for retinal flat mounts of rodent models of cone degeneration. This automated quantification method allows for faster data analysis thereby accelerating translational research.An inverted fluorescent microscope, motorized and coupled to a CCD camera records images of cones labeled with fluorescent peanut agglutinin lectin on flat-mounted retinas. In an average of 300 fields per retina, nine Z-planes at magnification X40 are acquired after two-stage autofocus individually for each field. The projection of the stack of 9 images is subject to a threshold, filtered to exclude aberrant images based on preset variables. The cones are identified by treating the resulting image using 13 variables empirically determined. The cone density is calculated over the 300 fields.rd1 mouse was found to be equivalent to the decrease determined by stereological counting. We also studied the spatiotemporal pattern of the degeneration of cones in the rd1 mouse and show that while the reduction in cone density starts in the central part of the retina, cone degeneration progresses at the same speed over the whole retinal surface. We finally show that for mice with an inactivation of the Nucleoredoxin-like genes Nxnl1 or Nxnl2 encoding RdCVFs, the loss of cones is more pronounced in the ventral retina.The method was validated by comparison to the conventional stereological counting. The decrease in cone density in The automated platform ℮-conome used here for retinal disease is a tool that can broadly accelerate translational research for neurodegenerative diseases. Becausenit gene . Initialnit gene . We subsnit gene ,6. One onit gene . The vianit gene ,7. Interdiseases . This nof oxygen . We have, RdCVF2 . The admrd1 retina measured using our platform to that measured by standard stereological counting. In parallel, we developed an automated, operator-independent stereological method that was also evaluated for accuracy. The automated platform scanned the whole surface of the flat-mounted retina allowing the user to evaluate the local density of cones as demonstrated by the pattern of S-cones in the rd7 retina. We studied the spatiotemporal pattern of cone loss in the rd1 retina as well as the loss of cones in the nucleoredoxin-like gene knock-out mice Nxnl1-/- and Nxnl2-/-, revealing a more pronounced loss in the ventral region of the retina. The development of the platform ℮-conome, as validated in the experiments reported here, will accelerate the translational research required to evaluate RdCVF as a therapeutic agent for cone degeneration in RP.Whatever the delivery system used--be it protein injection, viral vector delivery or even by reactivation of the RdCVF promoter in neighboring cells ,11,12 --ad-libitum access to food and water. The two congenic C3H lines [rd1/rd1 and C3Hwt/wt) were re-derived and maintained at Charles River. The rd7 colony was obtained from Jackson Laboratories, (USA). The homozygous knockout mice Nxnl1 and their controls are described in [Nxnl2 line is described in Jaillard et al. (manuscript in preparation). All three lines have a pure BALB/c background. Day of birth was designated postnatal day 0 (PN0).All procedures were in compliance with the Association for Research in Vision and Ophthalmology Statement for the use of Animals. The protocols approved by the National Eye Institute Animal Care and Use Committee. Animals, mixed gender were housed under a 12 hours light/12 hours dark cycle and given 3H lines  (C3Hrd1/ribed in . The Nxnrd1/rd1 eyes aged PN15 to 90 days. All the right eyes of each genotype (n = 7) per age  were analyzed by automated counting and the left eyes by stereological counting. We then replicated the experiment by inverting eye polarity. Animals were sacrificed by decapitation. The orientation of the eyes was marked on the limbus at 12 O'Clock position before enucleating. Neural retinas were dissected in phosphate-buffered saline (PBS) at room temperature from the posterior eyecup followed by immersion in cold 4% paraformaldehyde (PFA) in PBS at pH 7.4. For cryosectioning, eyes were fixed in cold PFA 4% in PBS overnight after puncturing the cornea then left 1 hour in 10%, 11/2 hour in 20% and 3 hours in 30% sucrose then quickly embedded in 4% gelatin with liquid nitrogen. The section plane was extended along the vertical axis from the optic nerve head in the posterior retina to the cornea.Retinal tissues were obtained from C3Hwt/wt and C3Hrd7 retina (not shown).A peptide corresponding to the second extracellular loop of mouse short wave opsin (CGPDWYTVGTKYRSE) was synthesized and coupled to ovalbumin and injected into two New-Zealand rabbits. The specificity of the polyclonal antibodies was confirmed by immunohistochemistry and compared with the pre-immune serum on rd1/rd1) in PBS containing 0.1% Triton X-100, followed by incubation 1 hour in blocking buffer PBS containing 1% of bovine serum albumin (BSA), 0.1% Tween-20 and 10% normal goat serum (NGS). After washing, retinas were labeled for 3 hours at room temperature or overnight at 4°C with Alexa Fluor 594-coupled peanut agglutinin lectin from arachis hypogae (PNA) [Fixed retinas were rinsed with PBS three times, before permeabilization   , covering the entire surface of the retina . Two incremented stages of autofocus were executed to recover the focal plane for each individual plane (~300) on the overall retinal surface. The first stage scans six different planes within the depth of the retina with an increment of 60 μm approaching the focal plane. The second stage is a fine adjustment from this position using 8 planes with a lower increment of 15 μm. Centered on this focal position, a stack of nine images per field distanced by 0.7 μm were acquired in the Z-direction  was equipped with a mercury super high pressure lamp, a computer driven motorized stage , an optical filter switch  for two excitation filters (485 and 520 nm) and two emission filters (520 and 635 nm), a shutter driver (JML Direct Optics), two objectives 4X  and 40X , and a CCD camera . The pieces of equipment were connected . A virtual eye fundus representation was designed to visualize the data. The value X and Y were used to calculate the position of the optic nerve and the local density of cones in 9 rows taken from this centre are projected on the disk annulus by annulus. To represent the amount of cones in each segment, a color scale was applied using multiples of 45 .p < 0.05 considered significant. Unpaired Student's t-test was used to compare density of cones levels in rd1 at different ages with a Welch's correction. In figure Nxnl+/+ (n = 10), Nxnl1-/- (n = 7) and Nxnl2-/- (n = 8) mouse. To compare the means S-cone density (S-opsin) from the same retina of the dorsal and ventral region for Nxnl+/+ (n = 5) and Nxnl2-/- (n = 5) mouse.Statistical analyses were performed with GraphPad Prism5.0, with rd1 mouse model [rd1 (C3Hrd1/rd1) and wild-type (C3Hwt/wt) maintained on identical genetic background [rd1 retinas   on flat-se model . For botckground , the rigckground . The eyes Figure . PNA label [rd1 CHrd1/rd1 % Figure  versus 3% Figure , which drd1 retinas, while the overall densities were slightly reduced  distributed over the surface of the retina. We expected that the automated identification of cones from these reduced fields would be facilitating the recognition of cones by the software Figure . When th pixels dy Figure . Howevery Figure . This inrd7 retina. The rd7 mouse carries a recessive mutation in the orphan nuclear receptor Nr2e3 causing a developmental defect that results in an excess of S-cones [rd7 retinas and similarly localized to the ventral part of the retinal explant . In this representation, S-cones are concentrated in the ventral region of the rd7 retina . We have reported a reduction of 17% in cone number in the Nxnl1-/- mouse at 15 weeks of age [Nxnl2-/- mouse, the gene encoding the paralogue RdCVF2 [et al., manuscript in preparation). At 8 months of age the cone density was found to be 34% reduced as compared to controls on identical genetic background. The distribution pattern of this decrease in cone density is not homogenous, with an apparent higher deficit in the ventral region of the Nxnl2-/- retina, compared to the Nxnl1-/- mouse  at ventral and dorsal locations  using parameters whose values have been empirically set-up. The trophic effects of RdCVF proteins formulated for clinical trial or of AAV-RdCVF ,12 can nI3Kinase . We alsond cones .The quantification of neuron survival and neuropathological lesions in neurodegenerating tissues is essential for the development of therapeutic strategies relying on the delivery of trophic factors . With reNxnl2-/- retina proceeds from the ventral part. The automated platform used here for retinal disease could accelerate translational research for neurodegenerative diseases more broadly.In summary, e-conome provided an accurate platform to measure the density of the cones. In addition we show that the spatiotemporal pattern of cone loss in the Nxnl1: Nucleoredoxin-like 1 gene; Nxnl2: Nucleoredoxin-like 2 gene; PBS: Phosphate-buffered saline; PFA: Paraformaldehyde; PN: Post-Natal day; PNA: Peanut agglutinin lectin from arachis hypogae; RdCVF: Rod-derived Cone Viability factor; TUNEL: Terminal UTP nick end labelingBSA: Bovine serum albumin; DMEM: Dulbecco's Modified Eagle Medium; NGS: Normal goat serum; T.L. and J-A.S. are patent-holders on the use of RdCVF and RdCVF2 for the treatment of neurological disease.EC conceived, carried out experiments, analyzed the data and wrote the manuscript. NW analyzed the data and designed the regionalization. SMS analyzed the data and advised on stereology. OP conceived the regionalization tool. J-AS conceived the experiments. TL conceived, carried analyzed the data and wrote the manuscript. All authors read and approved the manuscript.EC, Research Engineer Inserm, NW Assistant Professor U. Strasbourg, SMS, Associate Professor UPMC, OP Research Director CNRS, JAS, Professor UPMC and TL Research Director Inserm.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2415/11/38/prepub℮-CONOME journals. (a) ACQUISITION.JNL. (b) COUNTING.JNL. Bold words correspond to recorded journals. All the numbered lanes designate building functions use by the journals. Italic words indicate assigned variables of the journals. Green words in italic are not used in the ℮-CONOME application.Click here for fileIllustration of the image processing: (a) before processing. (b) after processing. The yellow squares indicate the cones. The parameters for counting are indicated in green.Click here for fileCounting of cones. (a) Stereological method: serial 1. (b) Stereological method: serial 2. (c) Global automated method: serial 1. (d) Global automated method: serial 2. (e) Automated stereological method.Click here for fileComparison of the three methods of counting before normalization (BN) and after (AN). (a) Stereological method. (b) Global automated method. (C) Automated stereological method.Click here for fileSections of the C57BL/6@N retina at PN 35 after labeling with S-opsin antibodies (green). PNA, red, DAPI, blue. (a) dorsal. (b) ventral. Notice that labeling was made with a different aliquot of the S-opsin antibodies as compared to figure 6. Scale bar 25 μm.Click here for file


Resveratrol is a polyphenolic compound produced in some plants in response to stress, such as injury or infection  and is p+, the cofactor for Sirt1, as well as Sirt1 activity [The controversy regarding the mechanism of action for resveratrol arose when a series of papers demonstrated that it activated Sirt1 only if the substrate is attached to a fluorophore or a bulky amino acid -7. Howevactivity ,12. ConsOne of the proposed mechanisms by which resveratrol activates AMPK is inhibition of ATP production. However, except at high concentrations of resveratrol (>100 μM), ATP levels do not decrease in the time frame of AMPK activation ,14, suggSince there are 11 PDE family members, each with different properties and tissue expression patterns, it would be impossible to mimic all of resveratrol effects with just one PDE inhibitor. However, PDE4 is the predominant PDE activity in skeletal muscle, the tissue where the metabolic effects of resveratrol are best elucidated. We found that the PDE4 inhibitor rolipram was sufficient to activate AMPK and Sirt1 in myotubes and to reproduce, at least qualitatively, the metabolic effects of resveratrol in skeletal muscle, as well as to improve glucose tolerance in obese mice . It is uOne area where we lack understanding is the intracellular concentration of resveratrol. The serum level of unmodified resveratrol is low (submicromolar to low micromolar) because most resveratrol in serum is present in the conjugated form (e.g. glucuronide). However, tissues such as skeletal muscle have glucuronidases, which can potentially removed the conjugate and increase the intracellular levels of unmodified resveratrol far above those in the serum.The mechanism by which novel chemical entity (NCE) STACs activate Sirt1 in vivo is also under question because like resveratrol, they do not activate Sirt1 against native substrates in vitro, suggesting that they may activate Sirt1 indirectly in vivo ,7. InterIn addition to resveratrol, other natural compounds that have been identified as STACs such as butein, fisetin and quercetin have also been identified to be PDE inhibitors ,17. ThisWhether resveratrol can activate Sirt1 directly in addition to activating it indirectly (via PDE inhibition) remains to be seen. Even if resveratrol can activate Sirt1 directly in vivo, it is not clear how much this effect will add to the well-known anti-inflammatory and antidiabetic effects produced by PDE4 inhibitors alone (e.g. the FDA-approved PDE4 inhibitor roflumilast) . This quIn conclusion, the discovery of the resveratrol-PDE link suggests that PDE4 inhibitors, possibly in combination with other PDE inhibitors, may be useful for mimicking CR and for treating aging-related diseases.


Mucorales have been increasingly reported as cause of invasive fungal infections in immunocompromised subjects, particularly in patients with haematological malignancies or uncontrolled diabetes mellitus and in those under deferoxamine treatment or undergoing dialysis. The disease often leads to a fatal outcome, but the pathogenesis of the infection is still poorly understood as well as the role of specific virulence determinants and the interaction with the host immune system. Members of the order Mucorales are responsible of almost all cases of invasive mucormycoses, the majority of the etiological agents belonging to the Mucoraceae family. Mucorales are able to produce various proteins and metabolic products toxic to animals and humans, but the pathogenic role of these potential virulence factors is unknown. The availability of free iron in plasma and tissues is believed to be crucial for the pathogenesis of these mycoses. Vascular invasion and neurotropism are considered common pathogenic features of invasive mucormycoses. Mucorales, which is the core group of the traditional Zygomycota [Mucoromycotina of the Glomeromycota phylum of the kingdom Fungi [Zygomycota, because the authors consider the phylum polyphyletic, indeed the name zygomycosis, which encompassed infections caused by members of Mucorales and Entomophthorales, has become obsolete [Mucorales are characterized by aseptate (coenocytic) hyaline hyphae, sexual reproduction with the formation of zygospores, and asexual reproduction with nonmotile sporangiospores. They are ubiquitous in nature, being found in food, vegetation, and soil [Mucoraceae family, and the resulted disease is called mucormycosis [The gomycota –3, have om Fungi . This neobsolete . The Mucand soil –3. The mrmycosis –3, 5–7. rmycosis , 8. Riskrmycosis . Limitedrmycosis , 10. ThiMucorales  spp. rank as second and/or third cause [Mucorales [A few members of the ucorales  are ablence 1885 . They fonce 1885 . More rence 1885 . The majnce 1885 . Rhizopurd cause –9. Althord cause . They weucorales . In immuucorales .Mucormycosis can be classified in rhinocerebral, pulmonary and disseminated, abdominal-pelvic and gastric, and cutaneous or chronic subcutaneous diseases. Common features of rhinocerebral, pulmonary, and disseminated diseases include blood vessel invasion, hemorrhagic necrosis, thrombosis, and a rapid fatal outcome. Rhinocerebral mucormycosis is more often associated with uncontrolled diabetes mellitus and ketoacidosis than malignancies or deferoxamine therapy. Inhaled spores colonize at first the upper turbinates and paranasal sinuses and cause sinusitis. Depending on the underlying disease, the fungus can rapidly invade the central nervous system, causing symptoms like an altered mental state, progression to coma, and death within a few days –3, 5–11.Pulmonary mucormycosis is commonly seen in patients with leukemia, lymphoma, solid organ or bone marrow transplantation, and diabetes but is occasionally reported also in apparently healthy subjects. Disease manifestations vary from a localized nodular lesion to cavitary lesions and dissemination; in the latter case, massive hemoptysis generally occurs. Crude mortality is lower (60%) in cases of isolated lesions than in severe pulmonary (87%) and disseminated 95%) diseases [5% diseasGastrointestinal disease is a rare manifestation of mucormycosis, and it is mainly associated with malnutrition in presence of predisposing factors, especially in children with amoebic colitis, typhoid, and pellagra . In the Cutaneous mucormycosis may be a primary disease following skin barrier break or may occur as a consequence of hematogenous dissemination from other sites, and the outcome of the disease is strictly dependent on the patients' conditions. Primary cutaneous mucormycosis can involve the subcutaneous tissue as well as the fat, muscle and fascial layers . in vitro susceptibility testing for amphotericin B gives a broad range of values according to the genus and the species. With the exception of posaconazole, the azole derivatives show a limited in vitro activity against Mucorales, and the echinocandins have a limited activity against these fungi [in vitro combination of posaconazole with amphotericin B showed synergistic effects against hyphae of some species [Treatment of mucormycosis combines surgical intervention and antifungal therapy. Liposomal amphotericin B is the drug of choice for the therapy of mucormycosis. The se fungi . Studies species . In addi species , 16–18.  species –23. Pati species , 21. A p species –11, 24, Quantitative and qualitative measures of virulence vary as a function of host factors, microbial factors, environmental factors, social factors and interactions amongst them”. This concept is especially true if we consider opportunistic microorganisms such as fungi. Macrophages and neutrophils play the major role in immune defence against agents of mucormycosis. Prolonged neutropenia is thus the main risk factor for developing the disease. Moreover, therapeutic interventions , that cause functional defects in macrophages and neutrophils, represent additional risk factors for mucormycosis. Diabetes itself can impair the function of neutrophils contributing to the severity of the mucormycosis in patients with ketoacidosis [Mucorales either enhancing their growth and hyphal development in vitro or increasing their pathogenicity in vivo [Mucorales use DFO as a xeno-siderophore, being capable to detach iron from DFO in a very efficient manner. More recently, other investigators confirmed the importance of iron in the pathogenicity of Mucorales by studying the expression of the FTR1 (high-affinity iron permease of R. oryzae) gene and its product [R. oryzae, which was unable to acquire iron in vitro and showed a reduced virulence in mice. Consistently, anti-Ftr1p antibodies protected mice from R. oryzae infection [Mucorales [Rhizopus oryzae. This study demonstrated that in the presence of high iron and glucose concentrations, such as in diabetic subjects, there is a direct relationship between an increased expression of GPR78 and an increased damage to endothelial cells in diabetic mice [Mucorales are capable to gain access to the central nervous system (CNS) by local vessels invasion or direct extension from paranasal sinuses [Mucorales, in particular of Rhizopus species—the most common etiological agents of disseminated mucormycosis—is a possible involvement of endosymbiotic bacteria in the pathogenesis of the disease [Rhizopus species to live with endosymbiotic toxin-producing bacteria [Mucorales could be proteolytic, lipolytic, and glycosidic enzymes as well as metabolites like alkaloids or mycotoxins as agroclavine. However, their direct involvement in human cases of mucormycosis has been still to be documented [According to Casadevall and Pirofski : “Quantiacidosis . An impoacidosis . Iron is in vivo . Hemodia in vivo  reported in vivo , 29 was  product . The autnfection . Angioinnfection . Specifiucorales . More reucorales  demonstrtic mice . Involve sinuses , 5–11. A sinuses . By eval disease . The autbacteria  and of tbacteria , 37. Othβ-1–3 glucan detection is not useful in this kind of infection due to the extremely low content of this molecule in the Mucorales [Histology and culture are still the most important diagnostic approaches for mucormycosis because of the lacking of molecular diagnosis methods standardized or commercially available. Moreover the ucorales , 39. Timucorales .Mucorales have been involved in the pathogenesis of the infection as potential virulence factors, but a trait that can be considered a specific determinant of virulence has not been defined yet. Angioinvasion, neurotropism, and iron uptake are common characteristics of Mucorales that trigger diseases in humans. Many open issues remain to be clarified on the interaction between members of the Mucorales order and the host immune response. Different therapeutic approaches, especially the combination therapy, seem to have a promising impact on the clinical outcome of this infection. However, the development of the most severe forms of mucormycosis and the subsequent outcome is strictly dependent on the efficiency of the host immune system. Invasive mucormycosis is an important cause of morbidity and mortality in patients with impaired immune defence and severe underlying diseases. In immunocompromised or debilitated patients, the disease is rapidly progressive, refractory to antifungal therapy, and often cause of death. Several characteristics of


The identification and discrimination of timbre are essential features of music perception. One dominating parameter within the multidimensional timbre space is the spectral shape of complex sounds. As hearing loss interferes with the perception and enjoyment of music, we approach the individual timbre discrimination skills in individuals with severe to profound hearing loss using a cochlear implant (CI) and normal hearing individuals using a bone-anchored hearing aid (Baha). With a recent developed behavioral test relying on synthetically sounds forming a spectral continuum, the timbre difference was changed adaptively to measure the individual just noticeable difference (JND) in a forced-choice paradigm. To explore the differences in timbre perception abilities caused by the hearing mode, the sound stimuli were varied in their fundamental frequency, thus generating different spectra which are not completely covered by a CI or Baha system. The resulting JNDs demonstrate differences in timbre perception between normal hearing individuals, Baha users, and CI users. Beside the physiological reasons, also technical limitations appear as the main contributing factors. The perception of music is an important feature of everyday life improving life quality and is also a prerequisite to discriminate speech prosody and speakers. In individuals with hearing loss or deafness, the ability to perceive music is reduced or lost , 2. To eOne prevalent factor for music perception is the ability to perceive and discriminate timbre. However, timbre appears as a psychoacoustical attribute of complex tones comprising all acoustical attributes that are not exclusively assigned to the perception of pitch, loudness, and subjective duration , 4. ThusPrevious work used complex tones recorded by natural instruments or sound generated by a synthesizer as stimuli to measure timbre discrimination –9. As thTo contribute to a more systematically evaluation of the ability to rehabilitate music perception, our study investigates the individual timbre discrimination skills of individuals with severe-to-profound hearing loss using a cochlear implant (CI) and normal hearing individuals using a bone-anchored hearing aid. A cochlear implant which is applicable for adults and children with severe-to-profound deafness transforms the incoming sound signal to a digital signal by a coding strategy, wherewith the auditory nerve fibers are stimulated. Therefore electrical pulses are delivered by electrodes which are spread along the cochlea. Despite in the majority of cases a sufficient speech intelligibility can be enabled or restored by using recent devices, CI users still report an insufficient perception of music which becomes apparent by a reduced discrimination or recognition of melodies .Factors contributing to a reduced music perception in CI users basically are technical parameters of the CI devices. For example, the number of electrodes 12–22) limits the spectral resolution within the cochlea and thus affects the  pitch discrimination . Further2–22 limiPatients suffering from moderate hearing loss may benefit from hearing aids. Beside the differentiation between external, semi-implantable, and fully implantable hearing aids, the devices can also be distinguished by the transmission pathway of the sound to the cochlea. So the direct stimulation of the cranial bone overcomes a conductive hearing loss. The most prominent device is the bone conduction hearing aid (Baha) comprising an implantable titanium screw placed to achieve osteointegration, a percutaneous coupling, and an electromechanical processor. With this a vibration of the cochlea fluid is evoked by a vibrator , 20. ForFor testing the performance and the individual outcome of the Baha device, a temporary transcutaneous coupling of the device is provided by the Baha test device and the Baha softband (Cochlear Ltd.). With this, the Baha sound processor is connected to a special adapter and pressed onto the patients' skin. The resulting hearing thresholds and the speech development with the Baha softband are almost equal to them achieved with a conventional bone conductor , 24. As A further aspect concerning the ability to discriminate spectral differences is the limited bandwidths of the electrical devices . Thus, low-frequency and high-frequency portions of the respective stimulus spectrum are not transmitted by the hearing devices. However, recent investigations exploring the audibility of sound within a frequency spectrum from 500 to 4000 Hz  or the aIn this study, we investigate the individual spectral shape JND for complex tones in cochlear implant users compared to normal hearing listeners using a Baha or not. To explore the differences in timbre perception abilities caused by the hearing mode, the sound stimuli were varied in their fundamental frequency, thus generating different spectra which are not completely covered by a CI or Baha system.Twelve normal hearing adults  between the ages of 21–71 years participated in the study. All participants passed a hearing screening (pure tone thresholds of 10 dB HL or better from 250 to 4000 Hz in both ears) and had no reported history of hearing or neurological problems. For the second part of the experiment, these patients were fitted with a bone-anchored hearing aid . The vibrator was connected to the right mastoid using the Baha softband .Ten adults  using a unilateral Nucleus CI  or an unilateral MED-El CI  with no residual hearing (pure tone threshold >80 dB HL from 250 to 4000 Hz) on the other side were enrolled in the study. Subject demographics are shown in All participants were assessed for their musical experience. They gave informed consent after the procedures were explained to them, in accordance with the ethical guidelines of the Martin-Luther-University Halle-Wittenberg, where the study was conducted. The procedures conform to the Code of Ethics of the World Medical Association (Declaration of Helsinki).f0 of 65.5, 131, 262, 524, or 1048 Hz. With each of the five fundamental frequencies, ten harmonics were added with 50% of the fundamental frequency amplitude, thus covering a frequency range from 2 × f0 to 11 × f0. For each of the five fundamental frequencies, a standard and a probe stimulus was calculated. At maximal spectral shape difference, the amplitudes of the odd harmonics were set to zero for the standard stimuli and the amplitudes of the even harmonics were set to zero for the probe stimuli. Thus, a combshaped amplitude spectrum occurred for the different tone sets  could not be used as a cue for the discrimination of the sounds. The sound pressure level of the stimuli was calibrated using a sound level meter . An external soundcard  with a resolution of 24 Bits was used as D/A converter and connected to the stimulation computer. A Power amplifier  and a free field studio loudspeaker  with a distance of 1 m in front of the listener were used to present the stimuli in free field conditions in an acoustically shielded room.The stimulus duration was 700 ms containing 75 ms of rise and fall time periods. The amplitudes of the resulting waveforms were scaled to achieve a sound pressure level of 65 dB. To assure a constant loudness of all used stimuli, the sound pressure level of the stimuli with a reduced spectral difference was measured exemplary for spectral differences of For the Baha users, the sound signals were delivered directly to the line input of the Baha processor. The opposite ear canal was closed with a wax ear plug  to avoid an influence of the sound signal emitted by the Baha on the psychoacoustical task. The program switch of the Baha Intenso was set to “external”, and the gain control was set to its middle position which provided a linear I/O function of the sound intensity level up to 60 dB HL. As the Baha modifies the sound intensity level, the calibration of the sound intensity was done by a psychoacoustical procedure before running the experiment. Therefore, the participants were simultaneously using a headphone and the Baha. Alternating to the sound delivered electrically to the external audio port of the Baha Intenso a calibrated signal (65 dB HL) was presented by the headphone. Comparing the perceived sound intensity levels, the volume switch of the Baha was adjusted until the perceived sound level intensities were rated as equal. This resulted in a volume value of “2” for every subject. To avoid low-frequency artifacts but ensure the transmission of the used stimulus frequencies, the tone control of the Baha Intenso was adjusted to the middle position.All participants performed a psychoacoustically test protocol. For each of the five fundamental frequencies, a timbre discrimination test was performed. The resulting five conditions were run in a quasirandomized order. All normal hearing participants repeated this protocol using the bone-anchored hearing aid. In this test, the conditions were again pseudorandomized.α(0 ⋯ 1), representing the amplitude difference between the odd and even harmonics for both the standard and the probe stimuli, was initially set to α = 1. At this maximal superthreshold spectral shape difference, the amplitude of the even harmonics of the standard was 1 and the amplitude of the odd harmonics was zero. At maximal cross-fading (α = 0), the stimuli were equal in their spectral shape with an amplitude of the harmonics of 0.5  paradigm. In every trial, two standard stimuli and one probe stimulus were presented subsequently in a randomized order. The participants' task was to listen carefully to the three subsequent stimuli. They were informed that one of three stimuli will differ in timbre. Thereafter the participants were asked to decide which one of the preceding stimuli was different and to press the respective button. The cross-fading parameter  0.5 see . The speα represents a linear measure of the amplitude differences of the odd and even harmonics between the standard and the probe stimuli. As the JND refers to the level of a sensory stimulus, the individual spectral shape JND was calculated by logarithmizing the cross-fading parameter α to refer the JND to the sound pressure level difference between the respective harmonics.The cross-fading parameter t-tests between the normal hearing participants and the CI users. For all participants, a two-way analysis of variances (ANOVA) with factors of hearing mode  and condition  was performed on the resulting cross-fading parameter α (JND). Resulting effects were specified post hoc with t-tests and Bonferroni-corrected probabilities.For every stimulus condition, the individual JNDs were compared by independent f0 = 65.5 Hz condition. Here, no timbre differences were perceived at all. Two normal hearing participants  did not agree to the Baha testing. All except of one CI user (CI6) who could not complete the f0 = 65.5 Hz condition completed the timbre discrimination test. α, values between 0.012 and 0.938 were measured. Thus, no ceiling effect occurred for all the CI users and the normal hearing participants if using the Baha or not.All normal hearing participants completed the timbre discrimination test. f0 = 65.5 Hz, 131 Hz, 262 Hz, 524 Hz, and  1048 Hz) was performed on the resulting cross-fading parameter α (JND).The results show that the main effect of the hearing mode significantly affected the individual JND, F = 58.67, P < 0.001. Bonferroni post hoc tests revealed that the JND in cochlear implant users was significantly poorer compared to normal hearing participants and the Baha users (both Ps < 0.05).All participants reported none ore school-level musical education. Thus the influence of musical experience was neglected and a two-way ANOVA  = 6.58,  P < 0.001). Bonferroni post hoc tests revealed that the JND with complex tones based on a fundamental frequency of f0 = 1048 Hz was significantly poorer compared to complex tones with f0 = 524 Hz, f0 = 262 Hz, and f0 = 131 Hz. Further, the JND with f0 = 65.5 Hz was poorer than the JND with the f0 = 524 Hz tones .The main effect of the condition was also significant, indicating that the individual JND was elicited differently by the different stimuli spectra  = 2.87,  P < 0.01). Post hoc comparisons revealed a better JND with f0 = 65.5 Hz, f0 = 131 Hz, f0 = 262 Hz, and f0 = 1048 Hz conditions in normal hearing participants compared to the CI users. The JND in Baha users was significantly better than in CI users only for fundamental frequencies of f0 = 131 Hz and f0 = 262 Hz. Also in the f0 = 1048 Hz condition the JND was significantly better in normal hearing participants compared to using a Baha. No significant different JNDs were found between the normal hearing participants and the CI users in the f0 = 524 Hz condition, between normal hearing participants and Baha users in the f0 = 131 Hz, f0 = 262 Hz, and f0 = 524 Hz conditions, and between Baha users and cochlear implant users in the f0 = 524 Hz and f0 = 1048 Hz conditions.The condition × hearing mode interaction was significant, indicating that the influence of the stimuli spectra was different between the hearing modes  or not measurable f0 = 65.5 Hz as compared to the conservative listening without the Baha. In the high-frequency condition (f0 = 1048 Hz), the poorer JNDs might have been induced in the Baha users as the spectrum of the f0 = 1048 Hz stimulus exceeds the high cutoff frequency of the Baha system (see f0 = 65.5 Hz, condition the first harmonic has a frequency below the low-frequency cutoff frequency of the Baha processor. Obviously this harmonic is of significant interest for the discrimination of timbre.In normal hearing individuals, the JND distributions are comparable between using a Baha or not. Only with the low-frequency and high-frequency stimuli the JND if using a Baha is poorer (stem see . In thisf0 = 131 Hz, f0 = 262 Hz, and f0 = 524 Hz conditions, no significant difference was observed between the JNDs in normal hearing participants if using a Baha or not. Here, the sound transmission of the Baha obviously completely recovers the spectral shape as the relevant features of the stimuli to discriminate timbre. However, the stimulation was different between the Baha hearing mode and the normal hearing mode as the Baha was connected only monaural, whereas the stimuli were delivered binaurally to the participants in free-field conditions. Comparing the monaural Baha stimulation and the binaural free-field stimulation, no significant different JNDs were observed. Thus, an improved pitch perception by binaural stimulation [In the mulation , 28 coulThe observed timbre discrimination skills measured as JND by changing the spectral shape of complex tones demonstrate differences in music perception between normal hearing individuals, Baha users, and CI users. Beside the physiological reasons, also technical limitations appear as the main contributing factors. However, all measured individuals could discriminate the spectral shape. Further investigations will extend these findings by changing the spectral fluctuation and the rise time of the tones to assess further dimensions of timbre.The music perception is limited by the technical parameters of the respective hearing aid or neuroprosthesis. This is important for the creation of individual training tools in the audioverbal therapy for the hearing impaired individuals.