The purpose of this cohort study is to compare newborn hearing screening (NHS) results between healthy newborns and neonates who were admitted to the neonate intensive care unit (NICU) for more than 5 days based on the national database for 9 years. Ultimately, we’ve tried to analyze the associated factors necessary to manage the national NHS program according to the group, which would help to establish policy to effectively detect and support hearing impaired children and which would help to control qualities.The Ministry of Health and Welfare (MHW) introduced a nationwide coupon-mediated program for the low-income class since 2009. The coupon consisted of two parts, the screening part and the confirming parts with the same unique number, and the MHW supported the cost of one screening test and one diagnostic auditory brainstem response (ABR) test for infants who did not pass from the screening test. We have analyzed the screening test performing rate, the referral rate according to the screening methods or institutions, the prevalence of hearing loss, and the average age of hearing loss diagnosis. Hearing loss was defined as any hearing impairment either unilateral or bilateral with the hearing threshold ≥ 40 dB nHL on the diagnostic ABR test, irrespective of its etiology.A total of 524,371 newborns were enrolled in the study, and 506,634 (96.6%) neonates were in the “well-baby group (WBG)”, while 17,737 (3.4%) were in the “high-risk group (HRG)”. The referral rate of the screening test was 1.5% in average, 1.3% in the WBG, and 7.5% in the HRG. The referral rates varied according to the screening methods and screening institutions. The adjusted prevalence of HL was 5.6/1,000 in average, 4.6/1,000 in the WBC, and 28.8/1,000 in the HRG. The screening tests were performed 4.3 ± 6.7 days after birth and the diagnostic tests were done 62.7 ± 37.5 days after birth in WBG. In HRG, dates were 17.7 ± 19.3 days and 97.6 ± 51.4 days, respectively.The prevalence of hearing loss in infants who were hospitalized in NICU for more than 5 days was about seven times higher than that in healthy newborns. However, different referral rates were noted depending on both institutions and the screening methods. These differences need to be addressed in order to improve our program and ensure that all neonates with hearing loss, especially neonates with high risk factor, are detected and appropriately referred for the treatment. Hearing is important for the development of language and communication skills , 2. SincIn South Korea, the government recognized the significance of NHS and had initiated NHS pilot programs since 2007, and the Ministry of Health and Welfare (MHW) started a nationwide coupon-mediated NHS program through 2009 to 2018, primarily for newborns of low-income families. Newborns who were born in the households with a median income of 72% or less, which included both all low-income class (less than 50% of median income) and some of the middle-income class (from 50% to 72% of median income) were supported with the nationwide coupon-mediated NHS program in these periods [From 2010 and on, the nationwide coupon-mediated NHS program collected data from enrolled newborns and identified details whether they were admitted to NICU for more than 5 days, which is one of the high-risk factors for HL according to JCIH 2007. The referral rate is mentioned to be much higher in NICU neonates 2.8–9.2%) –9, and t.2% –9, aSo, the aims of this study were to compare NHS results between healthy neonates and neonates who were admitted to the NICU for more than 5 days based on the national database for 9 years, and to assess the referral rate according to the types of screening methods or institutions, the prevalence and severity of hearing loss, and the average age of HL diagnosis in both healthy and NICU neonates. Ultimately, we have tried to analyze the associated factors necessary to manage the national NHS program by separating the NICU and the healthy newborns, which would help to establish policy to detect and support children with hearing loss effectively and to control qualities of NHS program.We analyzed the records of the national pilot newborn hearing screening (NHS) database from January 2010 through September 2018. In this period, a total 524,371 newborns were registered in this database. The national coupon-mediated pilot NHS project for mainly low-income families was implemented in 255 public health centers nationwide, and dozens of public health centers conducted the projects for all newborns in their area.The coupon consisted of a screening part and a confirming part with a same unique number not related to personal information. The screening part contained the blanks to fill for the data of (1) the birth of neonate, (2) the type of screening clinic or hospital, (3) NHS performed date, (4) screening methods (either with AABR or (automated) otoacoustic emissions ((A)OAE), (5) screening test results, and (6) whether neonates were admitted to the NICU for more than five days. The coupon for the confirming part was for neonates who have not passed the NHS test and had to perform a follow-up diagnostic auditory brainstem response (ABR) test; it had blanks to fill in for (1) the birth of neonate, (2) results of NHS, (3) the type of hospital performing the diagnostic test, (4) the ABR date, and (5) the hearing threshold. The pregnant woman in the family received a NHS coupon at her residential public health center before childbirth, and when she gave birth, she submitted the coupon to designated NHS hospital for her newborn to undergo hearing screening test. Designated hospitals filled out the information on the screening coupon and submitted it to the MHW and charged for the test fee. The parents or caregivers of the newborns were instructed to visit the designated clinics or hospitals within 1 month of age for AABR or (A)OAE screening test. However, if the newborn stayed at the NICU for more than 5 days as a high-risk group, the screening tests were supported even after 1 month of age. The outcomes of NHS were presented as either “pass” or “refer”. The Ministry of Health and Welfare collected all national coupons and built a NHS database.We categorized the all newborns into two groups, the ‘well-baby group (WBG)” who was born healthy or admitted to the NICU less than 5 days and the ‘high-risk group (HRG)’ who was hospitalized in NICU for more than 5 days. The number of newborns screened and referred, the prevalence of hearing loss and test performed dates after birth were investigated. Hearing impairment was defined as any hearing loss either unilateral or bilateral with the hearing threshold ≥ 40 dB nHL on the diagnostic ABR test, irrespective of its etiology.The study protocol was approved by the institutional review board of Hallym University Kangnam Sacred Heart Hospital (IRB no. HKS201910020) and waved to inform the consent by the Institutional Review Board because of retrospective database study nature.p < 0.05. Statistical significance was assessed by Pearson chi-square or Fisher’s exact test, with Bonferroni correction of p values for multiple comparisons.Statistical analyses were performed using SAS 9.2 Version . Statistical significance was set to A total of 524,371 newborns were enrolled in the study, and 506,634 (9.6%) neonates were in the WBG, while 17,737 (3.4%) were in the HRG . During When we analyze the NHS results by the screening methods, WBG was screened with AABR in 448,709 cases (88.6%) and with (A)OAE in 57,837 cases (11.4%). In HRG, the screening was performed with AABR in 14,793 cases (83.6%) and with (A)OAE in 2,903 cases (16.4%). We’ve identified that AABR screening methods (88.4%) were preferred than (A)OAE methods (11.6%) during the 9-year NHS pilot program . The refp<0.0001). The referral rate was 0.9% for WBG and 3.6% for HRG in maternity clinics (p <0.0001)Then we analyzed the NHS results by the screening hospitals. WBGs were distributed with different percentages among hospitals; 93.7%  were screened in the maternity clinics, 4.3%  were screened in the ENT department of general hospitals and 1.9%  were screened in various local clinics . HRGs we clinics . The refThe total identified number of HL infants was 667  . The WBGp = 0.6025)Then we analyzed the distribution of HL severity by the ear. We defined 40–55 dB nHL as moderate HL, 56–69 dB nHL as moderate to severe HL, 70–89 dB nHL as severe HL, and 90 dB nHL or higher as profound HL. In WBG, total of 724 ears had hearing loss; 351(49%) ears had moderate HL, 146(20%) ears had moderate-severe HL, 82(11%) ears had severe HL and 145 (20%) ears had profound HL . In HRG,p<0.0001). The diagnostic test dates were also significantly longer in HRG (p = 0.0102)  .There have been studies comparing NICU and healthy neonates in several countries and reporting associated risk factors. But few studies have been conducted in a large population with national database as this study, and a total of 524,371 newborns  was enrolled , 13–15. The mean referral rate of total enrolled newborns was 1.5% but the annual referral rate was not even in HRG in our study . The incWhen we identified the referral rate according to the group, it was 1.3% for WBG and 7.5% for HRG. Although a referral rate of less than 4% for overall newborns is recommended for NHS program quality control such as JCIH and other guideline , 18–20, In this study, the referral rate differed with the screening methods and screening hospitals. The NHS tests were performed with AABR in 88.4% and (A)AOE in 11.6%. Also, NHS tests were conducted mostly in maternity clinics (91.4%) followed by ENT department of general hospitals (6.7%) and other local clinics (1.9%). The distinct characteristic of Korea is that the hearing screening tests were started by maternity clinics in the beginning and AABR devices were widely spread by instrument corporations in 1990s. However, since there was lack of a quality control, ENT departments in general hospitals and university hospitals began to educate hearing specialists by offline workshops from early 2000, published guidelines and position statements (2010 and 2018); and these endeavors initiated a national NHS pilot program since 2007 [In a systemic review of 53 articles, the average dropout rate which is loss to follow up after screening test was 20% in single-center studies and 21% in multiple-center studies. Reasons of a high dropout rate were the educational disparity, lack of adequate knowledge of parents, and lack of an adequate data management system which is the most important strategy to decrease the dropout rates during follow-up period after screening [When we analyzed the distribution of hearing loss severity by the ear, WBG had high proportion of moderate hearing loss (49%) and had 31% of severe or profound hearing loss which would require surgical interventions. Meanwhile, HRG had less percentage of moderate HL (38%) and higher proportion of moderate-severe, severe and profound hearing loss, but there was no significant difference between two groups. We should consider the possibility of middle ear effusion and resolution of the middle ear status for moderate degree HL, since otitis media with effusion is a common cause of failed infant hearing screening test , 22.The JCIH has recommended the ‘1-3-6’ guidelines for the EHDI for children who have deaf or hard of hearing , 4. In oThere are some factors or limitations and need-improvements in our national NHS program. First, the diagnostic ABR performing rates should be increased. Second, as mentioned above, it is mandatory to have a quality control tailored to the type of screening hospitals. Third, it is required to adopt AABR as one of screening methods in HRG. Fourth, national NHS program should focus on the hearing rehabilitation of individuals through national registries and database. Finally, HRG should be managed and tracked separately, because they have higher chances of delayed hearing loss or auditory neuropathy. That is, to detect the false negative, delayed or progressive hearing loss, it is necessary to perform audiologic evaluations and continuous surveillances and management of the HRG.The prevalence of hearing loss in infants who were hospitalized in NICU for more than 5 days was about seven times higher than that in healthy newborns. However, different referral rates were noted depending on both institutions and the screening methods. These differences need to be addressed in order to improve our program and ensure that all neonates with hearing loss, especially neonates with high risk factor, are detected and appropriately referred for the treatment.S1 Checklist(DOC)Click here for additional data file.


Sixteen percent of chronic inflammatory demyelinating polyneuropathy (CIDP) patients may present acutely like acute idiopathic demyelinating polyneuropathy (AIDP) the demyelinating form of GBS, developing in <8 weeks 2. This entity is classified as acute‐onset CIDP (A‐CIDP) which presents overlapping clinical and electrophysiological findings with GBS during early stages of disease, but followed with a chronic course beyond 2 months. Also, those who have three or more treatment‐related fluctuations (TRF) are included under this term.Distinguishing between acute‐onset chronic inflammatory demyelinating polyneuropathy (A‐CIDP) and acute idiopathic demyelinating polyneuropathy (AIDP) may be difficult during early stages but is crucial in order to guide treatment strategies without delay. These two forms share some overlapping clinical and electrophysiological findings, including some severe clinical features such as cranial nerve and respiratory tract involvement making the diagnosis of A‐CIDP more difficult. Distinguishing between acute‐onset chronic inflammatory demyelinating polyneuropathy (A‐CIDP) and acute idiopathic demyelinating polyneuropathy (AIDP) may be difficult during early stages but is crucial in order to guide treatment strategies without delay. These two forms share some overlapping clinical and electrophysiological findings, including some severe clinical features such as cranial nerve and respiratory tract involvement making the diagnosis of A‐CIDP more difficult.Neurology, 74, 2010 and 1680). This entity is classified as acute‐onset CIDP (A‐CIDP) which presents overlapping clinical and electrophysiological findings with GBS during early stages of disease, but followed with a chronic course beyond 2 months. Also, those who have three or more treatment‐related fluctuations (TRF) are included under this term.Sixteen percent of chronic inflammatory demyelinating polyneuropathy (CIDP) patients may present acutely like acute idiopathic demyelinating polyneuropathy (AIDP) the demyelinating form of GBS, developing in <8 weeks (Ruts et al  However, it has been reported that a significant number of patients with CIDP (16%) may present with an acute clinical onset reaching a nadir within the first 8 weeks and a subsequent chronic progression sharing similar clinical and electrophysiological findings, during early stages of disease, with the AIDP, the demyelinating variant of Guillain‐Barré syndrome (GBS). These patients are classified as acute‐onset CIDP (A‐CIDP)2A 59‐year‐old man, without any particular medical history, presented at our department of neurology at the military hospital with a progressive clinical picture, 10 days following a flu, made of initial ascending paresthesia attending rapidly the upper limbs in <24 hours followed after 2 days by weakness in the lower then the upper limbs, and a discrete dysphagia with frequent choking to liquids. He was admitted to our hospital 8 days after the beginning of the symptoms on 11 April 2016. During hospitalization, he developed 3 days after his admission, respiratory weakness with worsening of the dysphagia, and facial diplegia on the 14th day of evolution. No autonomic dysfunction was noted. Physical examination showed flaccid tetraplegia graded 3 in upper limbs and 2 in lower limbs according to MRC scale, with absence of all reflexes, hypoesthesia in glove and stocking distribution, a positive Romberg sign, and facial diplegia. The EMG  or to plasmapheresis, with only 8 to 16% patients presenting treatment‐related fluctuations (TRF), during which secondary deterioration lasting <8 weeks is observed after treatment by immunoglobulin.The aim of this study is to highlight some clinical and evolutive particularities of A‐CIDP especially the respiratory tract involvement and bulbar signs which are rarely described in this particular subtype of CIDP making the diagnosis more difficult in early stages.4Acute‐onset chronic inflammatory demyelinating polyneuropathy is a particular CIDP subtype. It presents 16% of CIDP and is characterized by an acute‐onset resembling GBS at early stages, developing in <8 weeks but followed with a chronic course beyond 2 months. Cranial nerves and respiratory tract involvement in this form are rare but have been described. Further studies need to be conducted in order to better characterize this different single entity.None declared.MM: Conceptualization, Resources, Investigation, Methodology, Validation, Visualization, Supervision. AO: Investigation, Formal analysis, Data curation, Writing ‐ review & editing, original draft, Visualization. IB: Investigation, Formal analysis, Visualization. AK: Formal analysis, Visualization. JZ: Validation, Supervision, Project administration. RM: Validation, Supervision, Project administration.


Long-standing chronic otitis media (COM) may lead to sensorineural hearing loss (SNHL). The present study aimed to evaluate the factors affecting the sensorineural component to counsel patients regarding the risk of SNHL at the event of untreated COM.A time-bound cross-sectional study was conducted in the Department of Otorhinolaryngology at a tertiary care hospital. The study population included the study group comprising 137 patients with chronic suppurative otitis media (CSOM) and the control group which consisted of 137 individuals with the same age range and gender as the case study group. Moreover, the hearing was assessed using a pure tone audiogram and special tests of hearing.Based on the findings of the present study, the SNHL was found in 71.4% of CSOM cases with an ear discharge duration of more than 5 years. The SNHL occurred in 55.2% and 44.7% of the cases with pars flaccida and of pars tensa perforations, respectively. In the case of pars tensa perforation, greater perforation size resulted in a steady increase in the odds of developing SNHL. Patients with subtotal and total perforations were at higher risk of developing SNHL. Patients with longer duration of disease, squamous type of disease, and larger size of pars tensa perforation had greater susceptibility to develop SNHL. Therefore, eradication of the disease from the middle ear and early reconstruction of the hearing mechanism during the course of the disease result in reducing the burden of SNHL. Chronic suppurative otitis media (CSOM) is defined as a chronic inflammatory process that involves the middle ear cleft with recurrent episodes of ear discharge through a perforation in the tympanic membrane. It follows an episode of acute otitis media or may develop as a sequel of secretory otitis media . HearingPrevious studies have reported that inner ear is involved in middle ear inflammatory disease leading to sensorineural hearing loss (SNHL); therefore, proper treatments and follow-ups are recommended. The present study aimed to investigate the occurrence of SNHL in CSOM and find the correlation between SNHL and various factors, such as type and duration of the disease.A prospective observational cross-sectional study was carried out in the ear, nose, and throat diseases (ENT) department of a tertiary care hospital over a period of 18 months starting from October 2013. Clearance was obtained from the University's Ethics Committee. Patients who visited the ENT out-patient department with predominant signs and symptoms of CSOM and who had already been on medical treatment for the same were entered into the study. An equal number of volunteers of the same age and gender as the study group were enrolled as the control group. A detailed history was taken and a clinical examination was performed. Investigations, including complete blood count, erythrocyte sedimentation rate, and random blood sugar were conducted depending on the history and clinical examination. The sample size consisted of 274 individuals who were equally assigned to the study and control groups. Informed consent was obtained from all participants. Convenience sampling was employed for the selection of the participants.Studygroup selectionThe study group included individuals of both sexes between 11 to 45 years of age, with predominant symptoms and signs of CSOM. Pregnant women, patients aged less than 11 years, those with previous tympanomastoid surgery, those on ototoxic medication, those with history of head injury, those with history of meningitis or syphilis, those suffering from systemic diseases that may affect normal hearing (like Diabetes Mellitus), uncooperative patients, those with Hereditary/Familial hearing loss, post traumatic perforation of tympanic membrane and those with history of occupational noise exposure were excluded from the study.Control group selectionA total of 137 volunteers with the same age and gender as the study group, who showed no signs and symptoms of chronic otitis media (COM) and did not undergo medical/surgical treatment for the same disease entered into the control group. Those with conditions mentioned in the exclusion criteria for the study group were excluded.All the enrolled subjects underwent the following investigations:Pure-toneaudiometry, namely high-frequencyaudiometry Pure tone audiometry was performed in an anechoic chamber with the help of the calibrated Interacoustics Clinical audiometer-AC-40 (Denmark). The obtained thresholds were used to quantitatively assess the degree of hearing loss using Clark’s (1981) modification of Goodman classification of severity of hearing loss (1965)  test started. Around 20 such 1 dB increments were given and the subjects had to indicate each time they heard the increment. If 5 or more increments were heard consecutively, then such increments would be deleted. This would ensure that the response was to the change in intensity not to the time interval. If the subject did not respond to many consecutive increments, the size of the increment would be raised followed by a proper hearing test in order to retrain the patient. Consequently, false negative and false positive results were avoided.Shortincrementsensitivityindextest variants:There are five variants as follows:Classical SISI-A high score of 1 dB increments at 20dB sound level- is suggestive of a cochlear lesion. A low score of 2 to 5 dB increments at 20 dB sound level -is suggestive of a retrocochlear lesion.A low score of 1 dB increments at high sound levels 75dB-is suggestive of a retrocochlear lesion. A lower score in one ear than the other with their thresholds being almost equal, when increment size varied from 1-5 dB at 20 dB sound level-is suggestive of a central lesion opposite the ear with the lower score. The difference in the rate at which scores increase when 1 dB increments are made at sound levels ranging from 20 dB to high levels (about 75dB) in 10 dB steps for both ears – is suggestive of a retrocochlear lesion. The location of the lesion would be on the same side as the ear which did not show normal increases in intensity  of which were in the study group and the remaining 50% (n=137) in the control group. Out of 274 subjects, 46% (n=126) were female and 56% (n=148) were male. A total of 194 ears were included in the study group. Of these 59.2% (n=115) ears developed COM mucosal disease and 40.7% (n=79) ears had COM squamosal disease. Among the study group, conductive hearing loss (CHL) was observed in 47.3% of the subjects and mixed hearing loss was detected in 52.4%. While in the control group, the CHL and SNHL were observed in 5% and 5.1% of the subjects, respectively .Mixed hearing loss was detected in 70% of patients with disease duration ranging within 4-5 years. This shows that with longer duration of the disease, the incidence of the mixed hearing loss increases .Around 73% of patients with large perforation had moderate mixed hearing loss, while 62.9% had mild mixed hearing loss .Patients with marginal perforation had a higher occurrence of mixed hearing loss. Around 36.8% had moderate mixed hearing loss, while 42.1% had mild mixed hearing loss .Cochlearinvolvementin chronic otitis media patientswithmixedhearinglossOut of the 194 ears included in the study, 102 had mixed hearing loss. About 45.0% (n=46) had mild mixed hearing loss and of these 93.4% (n=43) were SISI positive. Moderate mixed hearing loss was observed in 54.9% (n=56) ears, of which 94.6% (n=53) were SISI positive. Of the patients with mixed hearing loss, 94.1% (n=96) were SISI positive.Cochlearinvolvementinthe controlgroup In the control group, the SNHL was observed in 5.1% (n=10) cases. Of these individuals, 40% (n=4) had cochlear involvement.Comparisonof the cochlearinvolvementin chronic otitis media patientsand the control groupMixed hearing loss was observed in 52.5% (n=102) ears of COM, of which 94.1% (n=96) had positive SISI. The SNHL was noted in 5.1% (n=10) ears in the control group, of which 40% (n=4) had positive SISI. The CSOM is a common condition in ENT practice. Conventionally, the CSOM has been associated with the conductive component of hearing loss. The current study was conducted to evaluate the presence of a sensorineural element in hearing loss associated with CSOM. The present study was conducted on 237 subjects with the age range of 11-45 years, consisting of 148 (56%) males and 126 (46%) females. The occurrence of SNHL in CSOM is a well-established fact . In order to rule out the possible effects of presbycusis, patients with the age > 45 years were excluded. Longer duration of ear discharge resulted in a steady increase in the SNHL incidence. Around 71.4% of patients with ear discharge for more than 5 years developed SNHL.In addition, no patient with ear discharge of less than 1 year developed SNHL. There was no significant correlation between the development of SNHL and the use of topical ototoxic ear drops. Patients with pars flaccida perforation were found to have higher chances of developing SNHL (55.2%) than patients with pars tensa perforation (19.7%). It was found that 52% of the patients, who had the mucosal type of disease, had developed SNHL and it was more frequently observed in patients with sub-total and total perforations. In addition, with an increase in the perforation size, the susceptibility to develop SNHL steady increases. It can be concluded from the present study that with an increase in the duration of the disease, there is a prolonged exposure of the inner ear to toxins that diffuses through the round window membrane; therefore, resulting in the development of the SNHL. Patients with mucoid ear discharge develop CHL probably due to a lesser amount of microtoxins. However, there was no statistically significant difference in the susceptibility to develop CHL or SNHL in patients with mucopurulent or purulent ear discharge. Pars flaccida perforation was more frequently associated with cholesteatoma and active middle ear disease was associated with low pH around the round window membrane which facilitates the passage of microtoxins into the inner ear. As the size of perforation increases, more amounts of microtoxins penetrate the inner ear damaging the hair cells, especially at the basal turn of the cochlea which leads to developing SNHL.According to the findings of the present research, patients with a longer duration of disease were more likely to develop SNHL. In the case of the mucosal disease, patients with larger perforation size suffered from more severe SNHL. In addition, the occurrence of the SNHL was observed to be higher in patients with the squamosal disease. This could be attributed to the prolonged exposure of the inner ear to toxins that enter via diffusion through the round window membrane. These microtoxins damage the hair cells, particularly the basal turn of the cochlea, resulting in the development of the SNHL. Therefore, it is suggested that patients should be counseled early early regarding the need for surgery to prevent from developing irreversible hearing loss. Furthermore, eradication of the disease from the middle ear and early reconstruction of the hearing mechanism during the course of the disease would reduce the burden of SNHL.Longer duration of middle ear disease results in a higher risk of developing SNHL. The SNHL occurrence is higher in the squamosal and mucosal diseases with larger perforations. Early eradication of the middle ear disease by surgical intervention can prevent irreversible hearing loss.


We investigated the regulatory and cell specific expression for these loci by generating mRNA-seq, ATAC-seq, and single-cell RNA-seq from cells in the mouse cochlea. Risk-associated genes were most strongly enriched for expression in cochlear epithelial cells, as well as for genes related to sensory perception and known Mendelian deafness genes, supporting their relevance to auditory function. Regions of the human genome homologous to open chromatin in epithelial cells from the mouse were strongly enriched for heritable risk for hearing difficulty, even after adjusting for baseline effects of evolutionary conservation and cell-type non-specific regulatory regions. Epigenomic and statistical fine-mapping most strongly supported 50 putative risk genes. Of these, 39 were expressed robustly in mouse cochlea and 16 were enriched specifically in sensory hair cells. These results reveal new risk loci and risk genes for hearing difficulty and suggest an important role for altered gene regulation in the cochlear sensory epithelium.Age-related hearing impairment (ARHI), one of the most common medical conditions, is strongly heritable, yet its genetic causes remain largely unknown. We conducted a meta-analysis of GWAS summary statistics from multiple hearing-related traits in the UK Biobank  and identified 31 genome-wide significant risk loci for self-reported hearing difficulty (p < 5x10 The genetic architecture of age-related hearing impairment (ARHI), a strongly heritable condition, has not been well studied. We present a systems genetics analysis of risk loci for ARHI. We performed a joint GWAS analysis of four hearing related traits from the UK Biobank and identified 31 genome-wide significant risk loci for hearing difficulty, eight of which have not been previously reported. By integrating these risk loci with transcriptomic and epigenomic data from the mouse cochlea, we discovered that risk loci are strongly enriched at genes and open chromatin regions that are active in cochlear sensory epithelial cells. Our results suggest an important role in ARHI for altered gene regulation in cochlear hair cells and supporting cells. Age-related hearing impairment (ARHI) is characterized by a decline of auditory function due to impairments in the cochlear transduction of sound signals and affects approximately 25% of those aged 65–74 and 50% aged 75 and older. Causes TRIOBP, a gene associated with prelingual nonsyndromic hearing lossTRIOBPPlease let us know if you have any questions while making these revisions.Yours sincerely,Susan H. Blanton, PhDGuest EditorPLOS GeneticsScott WilliamsSection Editor: Natural VariationPLOS GeneticsReviewer's Responses to QuestionsComments to the Authors:Please note here if the review is uploaded as an attachment.Reviewer #1: The authors have put together a comprehensive manuscript describing their GWAS using the UKBB questionnaire-based information on hearing. To my knowledge there exists no prospective data set of individuals appropriately screened and tested for ARHI that would provide the power necessary for significance. These authors, utilizing this database, have displayed a powerful tool for GWAS and have identified and replicated several genomic regions associated with ARHI. Furthermore, these authors demonstrate the homology to our best genetic model thus far, the mouse. I think this is a meaningful paper that will serve hearing research well.Reviewer #2: Kalra et al. use bioinformatics approaches in an attempt to identify genetic loci that are associated with hearing deficits in humans. They conduct a meta-analysis of GWAS summary statistics from the UK Biobank and report the identification of previously known and 8 new putative risk loci in humans. Using mouse tissue they then carry out a variety of omics studies to identify cells in the inner ear expressing the genes, open chromatin regions, and epigenetic marks associated with the disease. The authors conclude that hearing loss in the adult is genetically complex and likely involves altered gene regulation in the cochlear sensory epithelium.The work is generally carried out at a high standard but I am a bit conflicted how far the study advances the field conceptually. GWAS studies (at least one using the same data set) have already identified many loci associated with hearing difficulties in the adult and are replicated here. The current analysis adds genes to the list without substantially changing the overall picture. The contribution of each locus to phenotype is small, which is in agreement with earlier findings. Perhaps one of the most interesting parts of the paper is the attempt to link omics studies in mice with mapping data in humans to begin a functional characterization of the putative risk loci. Based on these data, the authors conclude that many of the genes linked to hearing loss are apparently expressed in the inner ear and in sensory structures. This is also in agreement with previous studies indicating that genetic forms of hearing loss frequently affect genes expressed in sensory structures of the inner ear. While the datasets are certainly of value for the community and worthwhile reporting, functional validation is largely missing. This is further confounded by limitations of the study. Hearing phenotypes were self-reported without quantitative assessment. Most of the identified loci have not been replicated in independent cohorts. The authors also point out that the data are a ‘best guess’ and need additional validation. Thus, while the data are certainly interesting, I find they fall short of the kind of advance expected for PLOS Genetics.**********Have all data underlying the figures and results presented in the manuscript been provided?PLOS Geneticsdata availability policy, and numerical data that underlies graphs or summary statistics should be provided in spreadsheet form as supporting information.Large-scale datasets should be made available via a public repository as described in the Reviewer #1: YesReviewer #2: Yes**********what does this mean?). If published, this will include your full peer review and any attached files.PLOS authors have the option to publish the peer review history of their article , and click on the Fetch/Validate link next to the ORCID field.  This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager.In the meantime, please log into Editorial Manager at If you have a press-related query, or would like to know about one way to make your underlying data available , please see the end of this email. If your institution or institutions have a press office, please notify them about your upcoming article at this point, to enable them to help maximise its impact. Inform journal staff as soon as possible if you are preparing a press release for your article and need a publication date.Thank you again for supporting open-access publishing; we are looking forward to publishing your work in PLOS Genetics!Yours sincerely,Susan H. 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Hearing loss becomes increasingly common with age and affects quality of life. Recently, scientists have published articles about the relationship between metabolic disease and hearing loss. Metabolic disease was previously found to be highly related to an increase in alkaline phosphatase. Thus, there may be an indirect relationship between alkaline phosphatase (ALP) and hearing loss. In this paper, we will demonstrate the relationship between ALP and hearing loss. We included 3877 National Health and Nutrition Examination Survey (NHANES) participants, who represent the noninstitutionalized civilian population in the United States from age 20 to age 69, and examined the association between ALP and frequency distributions of pure-tone air-condition (PTAC) thresholds. After adjusting for pertinent variables, the subjects who belonged to the higher quartiles of ALP tended to have worse hearing thresholds (pure tone average at high and low frequencies) than the first quartile of ALP (p < 0.001). The results showed a positive correlation between ALP and hearing loss, in both males and females (p < 0.001) and in subjects whose body mass indices (BMI) were less than 30 (p < 0.001). In conclusion, ALP may play a role in detecting hearing loss. About 28.8 million of them could benefit from wearing hearing devices3. However, only approximately 16 percent of adult aged 20–69 have ever used the hearing devices, based on the manufacturers’ voluntary reports of registered devices to the U.S. Food and Drug Administration, 2012. Therefore, strategy to postpone the onset of hearing loss is needed in order to improve quality of life and reduce medical expenses4. There are a myriad of intrinsic and extrinsic factors concerning hearing loss issues, such as age6, gene polymorphism6, noise and digital music exposure7, poor nutrition and lifestyle6, current ototoxic drugs used6, and secondhand smoke8. In addition to these factors, over 50% of patients with hearing impairment have previously unrecognized underlying diseases, such as hypertension9, diabetes mellitus (DM)10, metabolic syndrome11, osteoporosis13 and Paget disease14.The United States government has paid more attention to auditory healthcare recently due to the prevalence of adult hearing loss between ages 20 and 69. Approximately 37.5 million of American adults aged 18 and over have suffered hearing loss in the national health interview survey in year 201215. Recently, researchers have noticed asymptomatic elevated ALP values in normal individuals14. In patients with chronic kidney disease, elevated serum ALP levels affect the inflammatory responses and are directly associated with erythropoietin stimulating agent-resistant anemia16. A chronically elevated ALP level in a normal person may imply presence of a disease, including hearing dysfunction.Osteoporosis is a metabolic disease that raises alkaline phosphatase (ALP) levels. ALP, a homodimeric enzyme of 86 kilodaltons, plays a vital role in metabolism within the liver and bone. Clinicians use bisphosphonates to reduce the level of ALP, thus preventing a further decrease in bone mineral density. In addition, bisphosphonates also lower the level of ALP in Paget diseaseDue to the lack of literature concerning the relationship between ALP and frequency distributions of pure-tone air-conduction (PTAC) thresholds to date, our study was designed to provide insight into this issue. Therefore, we investigated the association between ALP and hearing loss using the National Health and Nutrition Examination Survey (NHANES) data from the year 1999 to 2004.We included 3877 NHANES participants who represented noninstitutionalized civilian population. The characteristics of the study population are presented in Table Table Table We performed a quartile-based analysis by dividing ALP into quartiles, as shown in Table By evaluating representative data for the US population, we discovered the fourth quartile of ALP was highly related to high-PTA when we weighed the differences between the first, second and third quartiles’ ALP levels. This connection was found not only in obese (BMI>30) individuals but also in underweight, normal weight, and overweight (BMI<30) individuals.17. ALP has been found at higher levels in osteoporotic postmenopausal women due to high bone turnover rate12. In addition, high bone turnover states are known to raise plasma lead levels. A high turnover rates in women who had a higher bone lead level in Q2 and Q3 of ALP compared to Q1 in peri- and postmenopausal women18. Therefore, the association between high ALP and high BLL in postmenopausal women in their study corresponds to a worse hearing threshold of low-PTA in low BMI women in our study.Our results showed a worse hearing threshold in low-PTA was not only observed in women with BMI less than 30 but also in men. As far as we know, women who have low body mass indices are at risk for osteoporosis19. In addition, osteoporotic men trended to have lower free testosterone, higher levels of ALP and sex hormone-binding globulin than osteopenic and normal bone mineral density groups. This finding also supports the correlation between hearing loss and ALP in men, although the association is weak20.In recent years, scientists have recognized osteoporosis in men. Men suffer from osteoporotic fractures and have twice the 1-year fatality rate of women due to decreased lower body strength21. The mechanism is related to the intense metabolic activity such as infection and inflammation, which drive the formation of free radicals and inflammatory cytokines, in both healthy and disease25. The elevated serum ALP is associated with C-reactive protein (CRP), which indicates ALP level may be a marker of low-grade chronic inflammation26. Chronic TNF-alpha release that enters the inner ear may cause bone conduction threshold elevation at the high frequencies27. In addition, otitis media-related inflammation also increased air conduction and bone conduction thresholds during childhood and adults stages28. While bacterial infection, eosinophilic inflammation, and chronic otitis media deteriorated bone conduction threshold29. The increases in stiffness and in mass of the ossicular chain affect bone conduction threshold shifts, which are less likely to accompany aging than are changes in air conduction thresholds30. The temporal bone houses the structures of the auditory system31. The malleus, incus, and stapes bones are the ossicles, which function to mechanically convert the vibrations into the inner ear. While ALP activity was detected in the ganglion cells and near the temporal bone31. Therefore, temporal bone and the ossicles, which contain the ALP activity in the ear, may take part in bone conduction threshold shift32.Age-related hearing loss is one of the most common conditions affecting older adults. However, hearing loss is also found in younger people without evidence of hair cell loss or absence of auditory nerve synapses in their temporal bones33. In addition, vascular calcification raised ALP concentration asymptomatically. A statistically significant correlation between insulin resistance and serum bone ALP levels in vascular calcification, and ALP can be a predictor of cardiovascular events and mortality in patients with DM34. Moreover, ALP is capable of dephosphorylating nucleotide phosphatase and lipopolysaccharide to reduce inflammation and coagulopathy, as it shares a similar amino acid sequence with von Willebrand factor and collagen35. The positive correlation between inflammation and ALP level mostly presents in healthy elderly people with unrecognized Paget’s disease5, osteoporosis17, and presbycusis5. The sensorineural hearing loss in Paget disease includes a variety of cochlear lesions36 and inferior cochlear vein occlusion that lead to pathologic changes in the stria vascularis and spiral ligament37. Based on the findings of Nomura et al., ALP shows strong activity in spiral ligament and stria vascularis, and the microcirculatory disturbance in the stria prominence, causes the impaired function in hearing38. As previously mentioned, the increased in ALP was parallel to the hearing loss due to the evidence of ALP activity in the temporal bone and cochlea.The mechanism of hearing loss in regard to the increment of ALP remains an uncertainty. To date, ALP with reactive oxygen species (ROS), inflammation, and insulin resistance are possible mechanisms of hearing loss, subsequent to the disturbance of microcirculation in the cochlea. Scientist have established the role of the ROS signaling pathway in osteoblast (OB) differentiation. They demonstrated that the activation of NADPH oxidase was the key reaction to initiate ALP expression. The ROS system therefore produces oxidative stress and induces mitochondrial morphological transitionOur study had a few limitations. First, the cross-sectional study design with data captured from a single point in time for ALP and hearing loss was a limitation of our study design compared to hearing threshold shift in longitudinal study designs. Second, the self-reported questionnaire of inherited genetic defects and past medical history may have introduced recall bias. Third, the NHANES data only provided the current use of ototoxic medication, instead of hormonal drugs, antidepressants, and anti-inflammatory medicine.We concluded that a positive relationship between bone ALP and hearing loss does exist for the general population. For an individual with a BMI<30 and hearing that has remained within the normal range, bone ALP levels seem to be a tool for detecting hearing loss. Because the causal mechanism associated ALP and hearing loss remains unclear, further research should be carried out in order to achieve a better understanding of the underlying pathophysiology of hearing loss.The NHANES data were adequately secured and approved by the National Center for Health Statistics Institutional Review Board. Informed consents for all eligible subjects were obtained before the start of a series of surveys with physical and laboratory examination. All methods were performed in accordance with the relevant guidelines and regulations of NHANES.We included 3877 NHANES participants from ages 20 to 69 who represented the noninstitutionalized civilian population in the United States. This population were enrolled from NHANES from the period between 1999 and 2004 and had undergone a series of household interview surveys, physical examinations, and laboratory tests at a mobile examination center (MEC).39. We averaged the thresholds at 3,000, 4,000, 6,000, and 8,000 Hz for the high-PTA while the thresholds at 500, 1,000, and 2,000 Hz were included in the low-PTA, according to NHANES data40. In the regression model, we chose the pure-tone thresholds of the worse ear for analysis.Half of our target populations had undergone audiometric testing randomly after a series of surveys with physical and laboratory tests. Subjects who could not tolerate auditory headphones in MEC sound-isolated rooms were excluded. The test was performed by technicians who had received training from the National Institute for Occupational Safety and Health. They used an AD226 audiometer, TDH-39P headphones and EARTone 3 A earphones for both ears and recorded threshold values from −10 dB to 120 dB. According to the American Speech Language Hearing Association (ASHA), the normal range for hearing thresholds is −10 to 15 dB and the abnormal hearing thresholds (worse ear) is ≥26 dB. The frequency distributions of PTAC thresholds is 0.25–8 Hz2). BMI>30 was referred to as obese. The self-reported questionnaire contained questions about present medical illnesses that had ever been diagnosed by a physician, such as DM, heart disease and stroke, and the current use of ototoxic drugs.We collected age, sex and race  as our demographic data. BMI was calculated as weight divided by the square of the height .42. We used the Statistical Package for the Social Sciences version 18.0 to analyze our data. We set two-sided alpha values, with values less than 0.05 as our significant p-values. The dependent variables were the normalized hearing thresholds (high-PTA and low-PTA), which were transformed using the logarithm function. Moreover, we further divided the serum ALP into quartiles as follows: Q1 <10.6 ug/L, 10.6 ug/L ≤ Q2 <13.8 ug/L, 13.8 ug/L ≤Q3 <18.2 ug/L and Q4 ≥ 18.2 ug/L. In the multivariate regression models, we adjusted for age, gender and race for model 1; age, gender, race, BMI, LDL-C and uric acid for model 2; and age, gender, race, BMI, LDL-C, uric acid, stroke, tympanometry status, ear condition, DM status, histories of heart disease, and ototoxic status for model 3.The study used sample weights to account for the complex sampling design and to allow approximations of the United States population, following guidelines of National Center for Health Statistics. The NHANES 1999 to 2004 sample weights adjusted for the differential probabilities of selection and nonresponse in the survey sample. The weight represented the number of individuals in the target population each sample participant was estimated to represent


Predicting hearing outcomes in idiopathic sudden sensorineural hearing loss (ISSNHL) is still challenging. We hypothesized that assessment of the semicircular canal (SCC) function via the video head impulse test (vHIT) might provide prognostic information. The medical records of patients diagnosed with ISSNHL from January 2015 to December 2018 were retrospectively reviewed. The prognostic values of the vHIT and other previously known factors in predicting hearing recovery were analyzed using a logistic regression model. A total of 148 patients with normal contra-lesional hearing were analyzed. Fifty-seven patients exhibited low gain (<0.7) on the vHIT in at least one SCC, more than the number of patients complaining of dizziness. Multivariable analysis revealed that non-recovery of normal hearing was associated with older age (OR 1.040), worse canal paresis on the caloric test (OR 1.023), worse initial hearing thresholds (OR 1.045) and abnormal vHIT result in the posterior SCC (OR 3.670). Low vHIT gain in the posterior SCC had specificity of 94.4% and positive predictive value of 85.7% in predicting non-recovery of normal hearing. In conclusion, abnormal vHIT gain in the posterior SCC appears to be a specific prognostic factor for incomplete hearing recovery in ISSNHL. In the majority of patients there is no specific identifiable cause of the hearing loss, and these cases are classified as idiopathic SSNHL (ISSNHL)1. Various etiologic backgrounds have been proposed, such as viral infection, vascular insufficiency and immunologic reaction4. ISSNHL has been treated with empirical therapies such as high dose steroid, antivirals, hyperbaric oxygen, etc5. Even if managed promptly, the outcomes of ISSNHL vary from non-recovery of previous hearing to complete recovery.Sudden sensorineural hearing loss (SSNHL) is defined as sensorineural hearing loss of 30 dB or more over at least three consecutive frequencies occurring within 72 hours1. The prevalence of dizziness or imbalance in SSNHL has been reported to be about 30%, and is related to poor prognosis4. Because vertigo is a subjective symptom, unlike the other indicators, a variety of studies have been performed to elucidate the clinical significance of vestibular function tests in SSNHL. Previous reports have focused on the value of the caloric test and vestibular evoked myogenic potentials (VEMP), which reflect the functioning of the horizontal semicircular canals (SCC) and otolith organs9. Theoretically, however, various types of vestibulocochlear involvement can be expected in ISSNHL. In terms of anatomic position, the closest vestibular organ from the cochlea is the saccule. The endolymphatic fluid spaces of cochlea and saccule are connected via ductus reunions, and their innervating nerve fibers are close together , bi-thermal caloric test and air-conducted cervical VEMP. The aim of the study was to evaluate the clinical significance of SCC involvement, as assessed by the vHIT, in predicting hearing outcomes of ISSNHL.Accordingly, we aimed to evaluate localized dysfunction of the vestibular organ in ISSNHL. We hypothesized that each of the components of the vestibular organ, especially the SCCs, can be involved variously in ISSNHL and might have distinct prognostic implications. Since subjective symptoms are not always correlated with objective vestibular function test results12. At the time of diagnosis, otoendoscopic examination, audiometry and vestibular function tests including the caloric test, vHIT and cVEMP, were routinely performed in all patients. Subjects with pre-existing hearing loss in the contra-lesional normal ear exceeding 25 dB HL were excluded to avoid possible debate about the assessment of outcomes. Those with retrocochlear pathology or other ear diseases - vestibular schwannoma, Meniere’s disease, inner ear anomaly, perilymphatic fistula, conductive hearing loss, or AICA infarction on MRI - were also excluded.The medical records of patients diagnosed with unilateral ISSNHL from January 2015 to December 2018 were retrospectively reviewed. The diagnosis of SSNHL was based on sudden hearing loss of more than 30 dB at a minimum of 3 consecutive frequencies over a period of 72 hours or lessAccording to the uniform treatment protocol, patients were initially treated with high dose oral steroid (prednisone 1 mg/kg daily for 7 days followed by 4 days of tapering). Thereafter, salvage intratympanic dexamethasone (5 mg/mL) injections (4 times/2 weeks) were performed in those whose hearing thresholds did not reach serviceable level (<40 dB HL) within a week.13. Complete recovery was defined as a final hearing threshold <25 dB HL. Partial recovery was defined as a final hearing threshold of 26–45 dB HL and >15 dB of hearing gain. Slight improvement referred to a final hearing threshold >46 dB HL and <than 15 dB of hearing gain, and no improvement meant a final hearing threshold >76 dB HL or <15 dB of hearing gain.Recovery of hearing was determined at 3 months from onset according to Siegel’s criterion, which is widely used to report hearing gain in SSNHLIn this study, the complete recovery group according to Siegel’s criterion, namely patients with final hearing threshold <25 dB HL, was the group of interest. The other groups were combined as the incomplete recovery group.This investigation was approved by the ethics review board of Hanyang University Guri Hospital (IRB #2019-11-016) and performed in accordance with the Declaration of Helsinki and good clinical practice guidelines. Informed consent was waived because of the retrospective nature of the study, and the analysis used anonymous clinical data after approval of ethics review board of Hanyang University Guri Hospital.14. Head impulses were given at least 10 times at the low amplitude of 10 degrees and a consistent peak velocity (100–300/second). Eye and head velocities were recorded. A calculated VOR gain of <0.7 was considered abnormal.The video head impulse test (vHIT) was performed at presentation to evaluate the high-frequency vestibulo-ocular reflex (VOR) in each SCC plane, using an ICS Impulse . To enhance test reliability, two experienced examiners performed the test, using the standard protocol proposed by Halmagy16. The induced nystagmus was recorded by video-nystagmography  until it had decayed to the null position. The maximum slow phase velocities of the corresponding stimuli were assessed and the asymmetry of vestibular function was calculated using Jongkees’ formula17. Canal paresis >25% was defined as horizontal semi-circular dysfunction18.The bi-thermal caloric test was performed using binaural alternative instillation of 8 liters of cold (24 °C) and warm (50 °C) air for 60 seconds20. Using a tone-burst sound stimulus of 500 Hz and 90 dB nHL via an EA-3 insert ear phone, the amplitudes of evoked potentials (P13-N23) on the same side of the sternocleidomastoid muscle were recorded20. cVEMP abnormality was defined as an asymmetry ratio of p13-n23 amplitude >35%, or no significant P13-N23 waveform21.The cVEMP test was performed with a Biologic Navigator Pro . The reference electrode, ground electrode and two active electrodes were placed at the sternoclavicular notch, center of the forehead and the middle third of each sternocleidomastoid muscle, respectivelyData were analyzed with IBM SPSS Statistics, version 24.0 for Windows . Descriptive data are expressed as means and standard deviations. A logistic regression model was used to evaluate the effects of prognostic factors on incomplete hearing recovery. Each parameter was assessed by univariable logistic regression analysis, and statistically significant factors were included in a subsequent multivariable analysis. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the vHIT for predicting non-recovery of normal hearing – incomplete recovery – were calculated. P values <0.05 were considered to indicate statistical significance. Figures were drawn with Microsoft Powerpoint 2016 MSO .A total of 148 consecutive patients (mean age 49.7 ± 13.9 years) with ISSNHL were analyzed. The average initial hearing threshold was 62.2 ± 29.5 dB HL  Table . Hearing4.5% TablUnivariable analyses showed that abnormal vHIT results in the horizontal SCC (P = 0.031) and posterior SCC (P < 0.001) were significantly related to poor recovery Table .In a multivariable analysis including the objective clinical factors that were statistically significant in the univariable analysis, significant predictive indicators for incomplete recovery were age , poorer initial hearing level , canal paresis on the caloric test  and abnormal vHIT gain in the posterior SCC   Various patterns of vHIT abnormality with SCC involvement were observed with or without subjective dizziness, (2) Multivariable analysis showed that incomplete recovery of hearing was significantly associated with decreased vHIT gain in the posterior SCC , worse initial hearing level at onset , age at onset , and canal paresis on the caloric test , (3) In our preliminary data, decreased vHIT gain in the posterior SCC had specificity of 94.4%, sensitivity of 31.2%, PPV of 85.7% and NPV of 56.7% in predicting incomplete recovery.22. The video method of examination, vHIT, is a noninvasive and quantitative method assessing each of the six SCCs individually14. In the vHIT, the adequacy of the VOR is usually measured by the gain, the ratio of the area under the eye velocity curve to the area under the head velocity curve during small, fast, passive unpredictable head impulses14. A VOR gain of <0.7 is usually considered as identifying a deficient SCC14. The vHIT has been widely applied to evaluate SCC function, especially in peripheral vestibular disorders and some central lesions28. In this study, we used it to assess vestibular involvement in ISSNHL.Since its introduction in 1988 by Halmagyi and Curthoys, the head impulse test has been used to evaluate the functioning of SCCs29. The well-known factors include age at onset, severity of initial hearing loss and time to initial treatment1. In our study, older age and poor initial hearing level were significantly associated with incomplete recovery of hearing  and saccule (cVEMP) was an important factor for hearing recovery, and that the extent of vestibular damage was related to the prognosis of hearing loss30. In addition, Fujimoto et al. reviewed the results of vestibular function tests in ISSNHL patients with vertigo to assess the extent of vestibular lesions7. They showed that the vestibular end organs close to the cochlea tended to be preferentially affected: there was involvement of saccule in 64%, of the horizontal SCC in 52% and of the utricle in 43% of the cases7. In our study, about 2/3 of the patients gave abnormal results in vestibular function tests. As in previous reports, the saccule was most often affected  followed by the horizontal SCC, based on abnormal caloric responses   Table . Among tIn terms of the inflammatory origin of ISSNHL, the involvement of adjacent vestibular organs can be explained by the flow of endolymphatic fluid within the inner ear, as well as the proximity of the vestibulocochlear nerve, and vestibular involvement can vary between individual patients. Empirical corticosteroid therapy may be expected to play a crucial role in such cases, as well as where viral infection and autoimmunity are implicated.9. Rambold et al. described a subgroup of patients with a distinct lesion pattern specifically involving the posterior SCC and cochlea9. In our study, twelve patients  showed this pattern (Fig. 32, the vulnerability of the cochlea to ischemia might offer a possible explanation for this outcome.It has also been suggested that certain patterns of vestibular involvement point to a vascular etiology for ISSNHL, as opposed to an inflammatory cause. In particular, compromise of the common cochlear artery can induce sudden hearing loss with isolated posterior SCC hypofunction Fig. 9. Rambolern Fig. . To compern Fig. , a post-In the present study, multivariable analysis showed that risk factors for incomplete recovery were older age, low initial hearing level, canal paresis on the caloric test and abnormal vHIT gain in the posterior SCC Table . PosteriTo the best of our knowledge this is the first study assessing the prognostic value of SCC involvement in ISSNHL using the vHIT. We assessed all ISSNHL patients, regardless of subjective dizziness. In addition, the inclusion criteria included normal contra-lesional hearing to alleviate possible debate about outcome determination. The evaluation of vestibular function, including each SCC, provided distinctive results pointing to a new prognostic indicator of hearing recovery. Unfortunately, oVEMP, which assesses utricular function, was not included in our analysis due to a lack of reliable data. Although we reviewed consecutive ISSNHL patients who were managed with a uniform treatment protocol during the enrollment period, there remains a possibility that biases may have arisen from the retrospective nature of the study. Hopefully, a future prospective study including all available vestibular function tests in a large number of patients will give further insight into the role of vestibular function in ISSNHL. Apart from providing prognostic information, we expect future studies to help develop individual treatment strategies to improve outcomes in ISSNHL.Abnormal vHIT gain in the posterior SCC is probably a specific prognostic factor indicating incomplete hearing recovery in ISSNHL.


Hearing loss/deafness is a common otological disorder found in the Pakistani population due to the high prevalence of consanguineous unions, but the full range of genetic causes is still unknown.A large consanguineous Pakistani kindred with hearing loss was studied. Whole-exome sequencing and Sanger sequencing were performed to search for the candidate gene underlying the disease phenotype. A minigene assay and reverse transcription polymerase chain reaction was used to assess the effect of splicing variants.OTOF  cosegregated with the disease phenotype in this Pakistani family. The substitution of a single base pair causes the deletion of 10 bp (splicing variant 1) or 13 bp (splicing variant 2) from exon 27, which results in truncated proteins of 1141 and 1140 amino acids, respectively.The splicing variants of OTOF splice-site variant as pathogenic for profound hearing loss in this family.Our findings reveal an  Nongenetic factors such as congenital cytomegalovirus, toxoplasmosis, asphyxia, and exposure to noise or ototoxic drugs can also cause hearing loss. A variety of genes are implicated in hearing loss, such as the gap junction protein2 (GJB2), the potassium voltage-gated channel subfamily Q member 4 (KCNQ4) and OTOF [OTOF gene, located on chromosome 2p23.3, measures 90 kb and contains 48 coding exons [OTOF, is a Ca2+-binding transmembrane protein of synaptic vesicles which play a crucial part in maintaining exocytosis and vesicle priming at the ribbon synapses of cochlear inner hair cell [OTOF mutations, affecting the function of hair cell in the inner ear and the neurotransmission of auditory signal [OTOF mutations were the genetic cause in 13 (2.3%) of 557 Pakistani families with hereditary deafness [OTOF mutations was responsible for moderate to severe hearing loss in 4.4 percent of people in Pakistan [OTOF gene splicing acceptor site (NM_194248): c.3289-1G>T mutation that caused profound hearing loss in a large consanguineous Pakistani family.Hearing loss is characterized by any degree  of loss of the ability to hear that can occur at any stage of life , 2. Congand OTOF . The OTOair cell . DFNB9  staining, after which Sanger sequencing was performed. Sequence traces were visualized with CodonCode Aligner (Version 7.1.2) and SeqMan (Lasergene).Primers were designed with Primer3 to validate the selected variant (NM_194248: c.3289-1G>T) from WES data through Sanger sequencing. The primer sequences were as follows: forward, 5′-cgtggtccttagggggttt-3′; reverse, 5′-gagtgcgacttggtgcagat-3′. PCR amplification was performed with these primers for all available individuals by using the GeneAmp PCR system 2720 . The PCR mix consisted of 5 μl of premix ExTaq Polymerase , 30 ng of DNA, 50 ng of primers, and ddHOTOF , and the sequences were as follows: forward, 5′-TTGGCGCGCCCTCTGGCTTTGAGAGCACCAG-3′; reverse, 5′-ATAAGAATGCGGCCGCAGCCTGACTGGACAGATGGAT-3′. The genomic DNA (gDNA) of the unaffected heterozygous individual IV-16 was amplified using Phanta Max Super-Fidelity DNA polymerase  with the appropriate primers and then introduced into the pCAGGS-IRES-green fluorescent protein (GFP) vector by Sgsl and NOT1 . The plasmid was used to transform E. coli DH5α . Ten positive clones were selected on Luria–Bertani (LB) plates, and the genotypes of the clones were confirmed by Sanger sequencing. After sequence alignment, wild-type and mutant plasmids were selected to transfect cell lines.A minigene splicing assay was performed as previously described . In ordeTOF Fig. a. The pr2 atmosphere. Wild-type and mutant plasmids in an otherwise similar construct were transfected into HEK 293 cells and HeLa cell using Lipofectamine 3000 reagent .Human embryonic kidney (HEK) 293 cells and HeLa cells were maintained in DMEM  containing 10% fetal bovine serum (FBS) (Gibco-BRL Life Technologies). Cells were grown in 24-well plates at 37 °C in a 5% COAfter 24 h, RNA was extracted from the cells using the FastPure Cell/Tissue Total RNA Isolation Kit . cDNA was generated from 500 ng of total RNA using a RevertAid First Strand cDNA Synthesis Kit . The primer sequences were as follows: forward, 5′-GTGCTGAATGAGACCCTGTG-3′; reverse, 5′-CCGTGGTGTTCCAGCTGGGG-3′. PCRs were generated using Phanta Max Super-Fidelity DNA polymerase . The amplification was performed for 35 cycles of 72 °C for 1 min, 62 °C for 30 s, and 72 °C for 1 min.The final product was introduced into the plasmid vector pMD19-T using a DNA ligation kit . Then, the plasmid was used to transform DH5α cells . The positive clones were selected by blue/white screening on Luria–Bertani (LB) plates; ten successful clones from HEK 293 cells and ten from HeLa cells were confirmed by Sanger sequencing.The ages of the seven affected subjects ranged from 1 to 28 years, and these subjects presented congenital, symmetrical bilateral hearing impairment. No malformation of any other organ system was evident in the fourth or fifth generation of the pedigree  is 0.000004  according to the GnomAD databases. Sanger sequencing was implemented to validate the variant in all family members; the variant was found to cosegregate with the phenotype of hearing loss in the pedigree   of cases in the study population [OTOF mutations cause mild, moderate, or profound hearing loss [According to the guidelines in the ACMG , all patpulation . Wang etOTOF by Naz et al. 2017 and was predicted to cause skipping of exon 27 [Aberrant transcript splicing represents a common class of mutations in hearing loss. The splicing mutation NM_194248:c.3289-1G>T has been reported in  exon 27 . This mu2+ sensor to set the rates of primed vesicle fusion to replenish the presynaptic plasma membrane and synaptic vesicle pool in the active zone of IHCs [https://www.ncbi.nlm.nih.gov/clinvar/), there are 18 known C2F mutations that cause hearing loss. Our study demonstrates that the splice-site mutation produced a truncated mature otoferlin protein lacking the C2E and C2F domains, which suggests that the truncated protein could not coordinate between vesicle fusion and synaptic vesicle pool replenishment and could not function as a Ca2+ sensor in IHCs, which eventually disrupted the temporal precision of IHC activity and thus produced the phenotype in this pedigree.Otoferlin plays a major role in sustaining exocytosis and vesicle priming at the synapses of cochlear inner hair cells (IHC) , 10. Oto of IHCs . C2E and of IHCs . This suAccording to ACMG standards and guidelines for the interpretation of sequence variants, this variant met the PVS1 (null variant splice site), PS3 (established by in vitro studies to have a damaging effect on the gene), PM2 (extremely low frequency if recessive), and PP1  criteria for pathogenicity , thus quOTOF that causes profound hearing loss; now that this splice-site variant has been implicated as pathogenic for hearing loss, the results provide evidence that that these findings will facilitate the diagnosis of deafness/hearing loss in future studies.The present study, through WES, Sanger sequencing, and minigene approaches, describes a splice acceptor site mutation (NM_194248: c.3289-1G>T) in Additional file 1. Clinical tests performed for patients. (A). Pure-tone audiometry for IV-4, IV-5, IV-9, V-2, and V-11; BERA test for V-10. (B). Tympanometry for IV-2, IV-4, IV-5, V-2, and V-11.


Low pathogenic avian influenza (LPAI) virus of subtype H9N2 is the most frequently detected subtype among domestic poultry and is a public health concern because of its zoonotic potential. Due to the multiple and complex routes of LPAIV H9N2 between geographic regions, little is known about the spatial diffusion of H9N2 virus to, within, and from Egypt, where it is endemic among poultry since 2011. Using close to 800 publicly available hemagglutinin (HA) segment nucleotide sequences, associated location and temporal data, we conducted a Bayesian discrete phylogeographic analysis. Here, we reconstructed and traced the origin, spread and principal transmission routes of H9N2 across large geographical regions, in addition to the transmission between Egypt and the rest of the world and between different Egyptian governorates. Our analysis suggests that during the last few decades, H9N2 has been introduced back and forth continuously between the countries where it is endemic. Amongst these regions, Saudi Arabia, United Arab Emirates and Iraq act as main distribution hubs and drive the viral migration worldwide, with bi-directional and long-distance diffusions. It is noteworthy that H9N2 was introduced once to Egypt via Israel in mid 2009, and that the descendants of the Egyptian LAIVs H9N2 were back-transmitted to Israel in 2015. Additionally, governorates in middle Egypt  are major hubs in the LPAIV H9N2 transmission network in Egypt. This knowledge highlights that H9N2 is both a global and a national concern and can aid in updating the surveillance program and vaccine strain selection. Low pathogenic avian influenza virus (LPAIV) of subtype H9N2 is a subtype of influenza A viruses that circulate among different bird species and possess a public health concern because of its zoonotic potential . Based oIn particular, Egypt has experienced incursion of LPAI H9N2 viruses of the G1-like clade in late 2010 . Since tUnderstanding virus spread and migration patterns could aid in better preparation for epidemics and provide useful guidelines for virus control. In this study, we conducted a phylogeographic analysis of LPAIVs H9N2 obtained from our institutional repositories and public databases, including >700 viruses from 1997–2018, to illustrate the dissemination of LPAIVs H9N2 from far Asia to the Middle East and North Africa, in addition to uncovering the transmission pathways of LPAIVs H9N2 in Egypt. The findings of this study should contribute to the strategic surveillance and targeted planning of control and prevention activities of not only LPAIVs H9N2 but also other subtypes co-circulating in Egypt.Initially, the genetic sequence data of more than 3,500 HA segments of global H9N2 viruses in 1997–2018 were retrieved from GenBank and Global Initiative on Sharing All Influenza Data (GISAID) platforms. To reduce the dataset size, several steps were taken. Initially, identical sequences were removed by keeping the sequence with the earliest date. Secondly, a maximum-likelihood tree was computed using PhyML v.3.0 , employiTo investigate the main global-level spatial diffusion routes between 1997 and 2018, locations were assigned to different regions: Middle East 1 , Middle East 2 , North Africa , China, Iran and South Asia  . In a paIn total 97 out of 171 available Egyptian sequences had known governorate information and were used to reconstruct the diffusing pattern within Egypt . By usinOur reconstruction of the H9N2 transmission pathways shows that the propagation network of H9N2 is highly structured, with significant inter-regional expansions with distinct source-sink dynamics . AmongstThere is a distinct spatial viral diffusion structure within Egypt, including both intra- and inter-area transmission pathways . Intra-aIn Egypt, LPAIV H9N2 continues to cause a significant impact on poultry production industry since its introduction in 2010 ; in addiWe find a hierarchical viral propagation network of LPAIV H9N2 being active since the past twenty years. Overall, there is a strong evidence of geographically structured viral diffusions both at the global and the regional scale. Saudi Arabia, United Arab Emirates and Iraq are likely to have played a dominant role in driving the global diffusions of LPAIV H9N2, which was supported by its highest probability as being the transmission sources and multiple transmission events to the rest of the world. This predominant role may potentially be due to its specific location, i.e., in the intersection of the Central Asian and Black Sea-Mediterranean flyways . It mighThe LPAIVs H9N2 isolated in North Africa has been demonstrated to share a close genetic relationship with those sampled from the Middle East . NotablyConsidering our analysis span more than 20 years of global H9N2 evolution, i.e., 1997–2018, the inferred transmission pathways and sources for the explored regions and time periods should more so be seen as a general pattern for the time-period as a whole. However, although we have subsampled all of the available H9N2 HA genetic diversity, it is important to note that reporting LPAIVs H9N2 varies between different countries our analysis is just reflecting the currently available data. Previous studies have shown extensive expansions to the Middle East after its first emergence in Asia, forming a close genetic linkage between two regions . FurtherFrom this study, it is observed that Egyptian LPAIVs H9N2 have evolved into three major groups  and was Taken together, our study showed the transmission of H9N2 influenza viruses to, in and from Egypt, is part of the complex migration network from far Asia to the Middle East to Africa. Data generated on LPAIVs H9N2 on the transmission patterns in our study can be informative for AIV control strategies for the local administrative authorities. Note that This inferred transmission pattern of HA gene should not be projected to other gene segments, given the different evolutionary and transmission dynamics. Continuous monitoring and characterization of AIV in Egypt is recommended to fully understand the transmission patterns of this virus.The datasets generated for this study can be found in the GenBank , Global Initiative on Sharing All Influenza Data (GISAID) platforms.RL, JP, and MN conceived the study, produced, analyzed, and interpreted the phylogeographic data. AA, JB, and JP provided the epidemiological data and performed the viruses sub-sampling. RL and MN drafted the manuscript. All authors critically analyzed and revised the manuscript, and provided final approval.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Hearing loss is the third most prevalent health condition in older age. In recent years, research has consistently reported an association between hearing loss and mental health outcomes, including poorer cognitive performances. Whether treating hearing loss in elders improves cognition has been directly or indirectly addressed by several studies. This review aims at providing a synthesis of those results. Regarding the literature on hearing aids’ use and cognition, although the lack of interventional studies has to be underlined, observational data suggest that hearing aids positively impact long-term cognition, even though more research is necessary to ascertain this statement and provide information on the length or frequency of use required in order to observe benefits. Regarding cochlear implants in elders experiencing more severe auditory deprivation, the literature is scarcer. The available studies have many limitations and do not allow the drawing of clear conclusions. Taken together, the results are encouraging. Nevertheless, because hearing loss is suspected to account for 9% of dementia cases, and also because hearing loss is one of the few potentially modifiable factors from a dementia prevention perspective, the need to stimulate research to have clearer knowledge of the benefits of treating hearing loss on cognitive outcomes is urgent. The global increase in life expectancy is obviously one of the major health achievements of the past 150 years, since, for the first time in history, most people worldwide can expect to live into their sixties and beyond. The now well-known counterpart of this is that the number of age-related chronic conditions that negatively affect independence and life participation has also substantially increased, contributing to a pessimistic picture of old age. The challenge is not only to live longer, but to live longer with no or little incapacities. Among the numerous conditions which affect the independence and life participation of older adults, hearing loss is one the most common. Age-related hearing loss, also called presbycusis, is a progressive, bilateral and symmetrical multifactorial disorder of hearing sensitivity due the consequence of the aging auditory system, including peripheral and central hearing ,3. In reBeyond well-being and psychosocial outcomes, another major domain of mental health suspected to be impacted by hearing loss is cognitive functioning. There is now strong and consistent evidence that older adults experiencing hearing loss present a poorer cognitive performance. Not only have cross-sectional associations between hearing loss and low cognitive scores been reported ,12,13 buTo explain the relationship between hearing loss and cognitive impairment, the literature has proposed several potential mechanisms. Two recent articles ,37 offerA first, relatively practical, explanation is that hearing impairment may bias the cognitive testing procedure, often involving verbal tests or orally provided test instructions. For instance, if a list of to-be-remembered words is orally given to a participant with hearing loss, the participant may require additional effort to accurately perceive the words, with less cognitive resources being available for encoding/learning processes. Future studies should make use of assessment tools suitable for people with a hearing impairment. It is noteworthy that two such tools have been recently developed: the Repeatable Battery for the Assessment of Neuropsychological Status for Hearing-Impaired individuals (RBANS-H)  providinA major potential explanation relies on what is known as the “deprivation hypothesis” ,40. AccoAn alternate view postulates that hearing loss may have a link with cognition because it leads to reduced physical activity, lower mood and poorer engagement in social and leisure activities. As shown by two studies ,44, the One mechanism that has been hypothesized to underlie the link between hearing loss and cognitive decline is related to the “cognitive load hypothesis” . In the Finally, the “common cause hypothesis” assumes the existence of a common factor that is responsible for the progressive degradation in physiological systems with aging. Cognitive as well as non-cognitive changes with advancing age are the result of multiple dysfunctions which are partly distinct and partly entangled. According to this hypothesis, both hearing loss and cognitive impairment are caused by common underlying processes such as generalized effects of the aging brain or age-related cerebrovascular disease. In its original view, the hypothesis stated that sensory acuity (including hearing and vision acuity) could be markers of global physiological integrity of the brain .Although presented as alternatives, the different hypotheses proposed to explain the hearing–cognition relationship may not be mutually exclusive. On the contrary, it is more than likely that several mechanisms, or all of them, act in conjunction.As mentioned above, hearing impairment is not only very frequent in older adults, it also has significant consequences on cognitive and mental health. Despite this, hearing loss in elders is largely underdiagnosed, and thus undertreated. Indeed, almost two-thirds of older people exhibiting hearing impairment do not use hearing aids . There iOne of the first studies addressing this question was conducted within the Health, Aging and Body Composition  cohort study , a US prAn ancillary study was conducted in a subsample of the ARIC study, a prospective population-based cohort study of 15,792 participants recruited in 1987–1989 from four US communities and involving repeated measures of cognitive function including tests of episodic memory , language skills (word fluency test), and processing speed/attention (digit symbol substitution test). In this ancillary study on hearing impairment, audiometric testing, in addition to cognitive testing administered three times, was offered to 253 participants with an average age of 77 . The maiA cross-sectional analysis conducted within the English Longitudinal Study of Ageing (ELSA) population-based study supported the hypothesis of a positive impact of hearing aids’ use on cognition . The stuA single-arm interventional study was conducted in 34 older adults with hearing impairment who completed a depression scale  as well as the mini mental state examination (MMSE) test assessing general cognitive functioning before receiving hearing aids and 3 months after . After 3Based on these promising, although not fully convincing, results—due to lack of statistical significance , very liInterestingly, in a subsequent study conducted within the same population-based cohort , these results were replicated on the risk of developing dementia . AdjustiIt is worth mentioning one study which reported slightly different results . In an eTherefore, before building a clear conclusion on the effect of hearing aids’ use on cognitive decline, it is important to underline three important caveats: (1) the scarce number of studies, in particular longitudinal ones; (2) one study providing contrasting results; and (3) the absence of results gathered from interventional clinical studies, in particular randomized controlled trials providing a full demonstration. Nonetheless, the available data globally support the hypothesis that hearing aids have a positive impact on long-term cognition in older adults suffering from hearing loss.With a more severe to profound degree of hearing loss, conventional hearing aids may increase sound detection without substantially improving speech perception in communication due to central auditory processing deficits. Cochlear implantation may be a therapeutic option for older adults with severe to profound hearing loss who continue to experience poor word discrimination despite appropriately fitted hearing aids . NonetheStudies looking at the effects of cochlear implantation on cognitive outcomes in elders are very few  on reducing cognitive decline in older adults with hearing loss . AwaitinBy highlighting the limitations of the existing literature, this review will hopefully stimulate more necessary research, as preventing cognitive decline and dementia is undoubtedly a major challenge for our society, and treating hearing loss is a promising and “accessible” strategy that should be seen as a component in multidimensional interventions. Indeed, even though this review was intentionally limited to the benefits of treating hearing loss, interventions addressing a wider range of risk factors, such as lifestyle factors and nutrition , should