Introduction: The objective of our study was to evaluate musical perception and its relation to the quality of life in patients with bimodal binaural auditory stimulation.Materials and Methods: Nineteen adult patients with a cochlear implant (CI) for minimum 6 months, and moderate to severe contralateral hearing loss with a hearing aid (HA), and 21 normal hearing adults were included in this prospective, cross-sectional study. Pure-tone and speech audiometry, musical test evaluating sound perception characteristics and musical listening abilities, Munich questionnaire for musical habits, and the APHAB questionnaire were recoded. Performance in musical perception test with HA, CI, and HA + CI, and potential correlations between music test, audiometry and questionnaires were investigated.Results: Bimodal stimulation improved musical perception in several features  in comparison to unimodal hearing, but CI did not add to HA performances in texture, polyphony or musical emotion and even appeared to interfere negatively in pitch perception with HA. Musical perception performances  appeared to be correlated to hearing-related quality of life (APHAB RV and EC subdomains) but not with speech performances suggesting that the exploration of musical perception complements speech understanding evaluation to better describe every-day life hearing handicap.Conclusion: Testing musical sound perception provides important information on hearing performances as a complement to speech audiometry and appears to be related to hearing-related quality of life. Binaural hearing is essential in everyday life since it reduces head-shadow effect, enhances speech discrimination in noise and provides sound localization capabilities . BinauraIn an implanted cochlea, the number of functional channels (stimulated nerve endings producing a distinctive pitch) are dramatically reduced in comparison to a normal ear, and each electrode codes for a large frequency band . Hence, While CI is effective for speech perception , the quaThe link between musical perception and quality of life has been investigated through validated questionnaires. Although quality of life is significantly improved after implantation, the quality of musical perception is generally degraded. At the same time, patients with better musical perception are found to have a better quality of life , b. HoweThe objective of our study was to further analyze the contribution of acoustic and electric hearing to different aspects of musical perception and their possible relation to the quality of life.We conducted a prospective cross-sectional study on patients with unilateral profound hearing loss implanted with a CI for more than 6 months and a moderate  to severe (71–90 dB) contralateral hearing loss  fitted wWe collected patient data including duration of profound hearing loss, etiology of hearing loss, age at implantation and CI brand. Audiometric data were also collected . When SRT could not be reached, level of maximum word score (dB) was indicated. The study received the approval of the local ethical research committee (CPP Est III). An informed consent was signed by all patients.Thirty-six patients currently followed-up in our center and who met these criteria were contacted. Among these patients, 17 (47%) declined to participate in the study. Finally, 19 adult patients were included. The group was composed of 12 women and seven men. Their average age was 61.2 ± 4.02 years (range: 19–78). Among patients, the hearing loss etiology was advanced otosclerosis in four (21%), sudden deafness in three (16%), congenital deafness in three (16%), Meniere’s diseases in two (10%), toxic in one (5%), and unknown in six (32%). The duration of profound deafness was 10 ± 2.8 years (range: 0–45), and the time between implantation and inclusion was 32 ± 6.5 months (range: 6–110). The mean duration of hearing aid usage was 29 ± 4.3 years (range: 3–56).Patients were equipped with Cochlear® CI 522® implant and Nucleus 6® processor in seven cases (37%), Advanced bionics® HiRes Ultra® implant and Naida CI Q90® processor in four (21%), Oticon Medical® Neuro ZTI® implant and Neuro 2® sound processor in four (21%), and Medel® Synchrony® implant and Sonnet® sound processor in four (21%) patients. Contralateral hearing aids were systematically reviewed for optimization within the 3 months period before inclusion. This included a technical check-up by the audiologist to verify that the hearing aid is correctly functioning, a free-field audiometry with the evaluation of the audiometric gain, and eventual fitting.A control group of 21 adults was also tested. This group comprised eight men, and 13 women with a normal hearing tested by pure-tone audiometry. The mean age in this group was 60.9 ± 4.14 years (range: 19–88).1) includes three main categories: sound, syntax and music sense. Each category includes four different test series, each with three subtests for the sound and syntax categories and two subtests for the music sense category. In this test material, we selected eight trials with a level of difficulty that could be adapted to CI patients. The sound material was prepared from musical samples that were systematically modified with a signal processing software . A laptop interface provided the information on the screen, an example for each test, and the response buttons on which the participant had to click in order to register his/her response. The required response was a forced choice between two propositions or a selection among a list (instruments). Each sound sample lasted 10 s. and could be listened ad lib. The recordings were played in an audiometric booth, by two loudspeakers  placed frontally at 1 m in a silent environment. The sound level was adjusted to an intensity considered comfortable for the patient, defined before the test. The test was performed once with the HA alone, a second time with the CI alone , and with the HA + CI. The learning effect was minimized by hiding the responses from the patient. Test order was not randomized because test items concerned unrelated sound or music qualities. Exposing the subject to one test could not enhance the performance to other items. Moreover, items were not compared to one another. The trial was short (approximately 30 min.) to avoid the fatigue effect. Score for each trial was recalculated to provide a mark out of 10.The ‘‘BbMAT’’ musical perception test,  where exercises consisted in distinguishing between two risings or falling notes sang by a professional female singer . The instrument recognition trial included nine tests with musical excerpts where the patient had to recognize which instrument was playing from a list of nine illustrated instruments . The timbre recognition trial included sound brightness, roughness, and clarity with six tests for each characteristic. In each test two samples were compared, and participants had to indicate which sample was brighter, rougher or more clear (sharper attack).The latter trial focused on three sound dimensions :-Brightness pertains to the spectral envelope of the sound. High energy in high-frequency spectrum is defined by a bright sound.-The roughness corresponds to the spectral flux (spectrum instability in time). Higher flux corresponds to a rougher sound.-The clarity is related to the attack curve of the sound. A direct attack causes a steep slope of amplitude in the temporal envelope and a clear sound.We evaluated the capacity to recognize musical lines in the same sound sample (polyphony). The subject had to indicate whether one or more instruments were playing at the same time (eight tests). We also evaluated the perception of sound texture in a trial. A sound sample was presented, and the examinee had to choose between “dense” or “airy sound” (six tests).In the music sense trial (six tests), we tested the emotional information provided by the music. The participant had to recognize the emotion reflected by selecting between “calm,” “fear,” and “anger.” In addition, a commentary box was provided to type general impressions for this task.Patients completed a questionnaire on musical habits, specifically the Munich music questionnaire (MMQ) developed by S. J. Brockmeier . It inclWe also asked participants to complete a quality of life questionnaire, APHAB (Abbreviated Profile of Hearing Aid Benefit). It includes 24 questions about different everyday life situations on hearing comfort. They are divided into four categories:-Ease of communication (EC): effort to communicate under relatively favorable conditions.-Reverberation (RV): communication in rooms with high reverberation.-Background noise (BN): communication in environments with high background noise.-Aversiveness (AV): unpleasant or disturbing aspect of the surrounding sounds.For each question, the patient had to quantify the frequency at which he or she was exposed to the situation. Each frequency corresponds to a percentage: always (99%), almost always (87%), generally (75%), half the time (50%), sometimes (25%), rarely (12%), and never (1%). It reflects the percentage of difficulties experienced: the lower the percentage, the better the hearing comfort. The percentages were then grouped by category to calculate the average score for ease of communication, reverberation, background noise and aversiveness. Each item was evaluated before and after cochlear implantation.p-values based on familywise error rates were reported. To compare different hearing conditions for each test item, a non-parametric Kruskal–Wallis test was used. This analysis was corrected for multiple comparisons by Dunn’s method and adjusted p-values were reported. APHAB scores passed D’Agostino and Pearson’s normality test. A 2-way ANOVA followed by Sidak’s multiple comparisons test was conducted and adjusted p-values are reported. The global APHAB scores were evaluated by a paired t-test.Graphpad Prism software  was used for statistics. The quantitative descriptive variables were described as means and standard error of the mean (SEM), and the qualitative descriptive variables by frequencies and percentages. The music test scores did not have a normal distribution for all test items (D’Agostino and Pearson’s test). Consequently, a non-parametric Wilcoxon signed-rank test was employed to compare scores vs. random level. This was followed by a Bonferroni correction for multiple comparisons, and the adjusted The ipsilateral PTA before and after implantation were 101 ± 4.8 dB and 30 ± 1.5 dB, respectively. For the contralateral ear, the PTA without and with the HA were measured at 76 ± 5.3 dB and 45 ± 3.7 dB respectively . With thn = 168 for controls vs. 7.4 ± 0.17, 6.7 ± 0.18, and 7.3 ± 0.16, for patients respectively, n = 152, p < 0.0001, Kruskal–Wallis test followed by Dunn’s correction). For the overall performance, patients scored higher with HA than with CI alone (p < 0.01 Friedman test followed by Dunn’s correction). Nevertheless, CI + HA performed better than the implant alone  with an average gain of 20 ± 6.1%.Cochlear implantation appeared to provide good results for ease of communication . Sixteen patients (84%) declared perceiving melodies well and 17 (89%) declared a good perception of rhythms. Five patients (26%) had previously followed musical courses, and six (32%) had previously played a musical instrument. Two of them continued after CI.The average score on the importance of music in every-day life was moderate . Nevertheless, thirteen (68%) trained themselves by listening to already known music, and 11 (58%) regularly attended musical events. Almost all patients reported perceiving pleasant sounds .Participants mainly listened to pop music after implantation . There was no change in musical style before and after implantation (data not shown). Most enjoyed listening to both solo and orchestral instruments  reported being able to recognize a wrong note and six (32%) were able to find a rhythmic error or compare performances. Only two (11%) felt that they could sing in tune and would sing in public. Remaining results of the questionnaire pertaining to musical activities before and after CI do not show a significant change .Auditory performance, as evaluated by SRT in CI + HA condition, was correlated to the APHAB EC subdomain score . MusicalWe did not observe a relationship between frequency of musical education or music listening and musical test performances (data not shown) suggesting that hearing performance and enjoyment may not be directly related.In addition, speech audiometry and performances on musical perception test were not correlated (data not shown). This suggested that musical perception test explores a different domain and may be complementary to speech audiometry in assessing performance in daily situations.We developed a musical test battery which explored musical perception capabilities at several levels ranging from sound characteristics to evoked musical emotions. We showed that this battery was applicable to normal hearing and CI patients without any ceiling or floor effect. The tests discriminated normal subjects from hearing-impaired participants. They could also show the effect of hearing rehabilitation mode. Bimodal stimulation improved musical perception in several categories such as sound brightness, roughness and clarity, but CI did not add to HA performances in texture, polyphony or musical emotion and even appeared to interfere negatively in pitch perception. Musical auditory performances appeared to be related to the quality of life as evaluated by APHAB but not with speech performances suggesting that exploration of musical perception potentially complement the conventional speech audiometry to better describe the every-day life handicap.The performance of a hearing rehabilitation system is basically judged by audibility, speech discrimination and sound quality . While tAuditory categorization requires the detection of details, and at the same time, generalization across variants in the same group . This coIncluding the pitch perception in our test battery allowed us to verify a basic, yet consistent, auditory parameter in controls and implantees. Counter intuitively, patients had a poorer pitch perception with HA + CI than with HA or CI separately. This observation suggested a negative interference between HA and CI for the task of discrimination between ascending and descending notes. It could be explained by the altered pitch place function and degraded temporal cues in the implanted ear . The lacThe influence of cultural background cannot be eliminated in tests based on music. The performance was homogeneous in the controls suggesting that the effect of musical education was limited in this group. However, patients with musical education had higher pitch perception scores than those with no musical background. This observation is consistent with the literature showing the influence of culture on performances in musical and auditory activities . RegardlPatients performed poorly for the categorization of elicited emotions. While the test distinguished normal-hearing subjects from the patients, it did not reveal an improvement of emotion scores by adding the HA to CI. This may appear contradictory to what other investigators have shown in children with bimodal rehabilitation in comparison to CI alone for the categorization of sad vs. happy music based on tempo and mode . This coDespite the well-known deterioration of sound perception by the CI , our bimThe heterogeneity of CI coding strategies and sound processing algorithms as well as HA fitting could have masked some effects in this population. Nevertheless, score variability was moderate in each item and consistent within the hearing condition . Further tests, especially in patients with single-sided deafness and CI, will potentially reduce this heterogeneity and provide precious data on ipsilateral vs. contralateral performances and, also the binaural interactions. The effect of specific CI or HA fittings can also be evaluated by this test battery.In conclusion, BbMAT music test battery yielded data on perceived sound quality which was consistent with hearing-related quality of life and previous studies. Contralateral HA seemed to complete the auditory cues provided by the CI and brought the musical performance of the implanted patients closer to normal. BbMAT could be used to evaluate hearing in a new analytical way and as a complement to conventional audiometry.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by CCP EST III. The patients/participants provided their written informed consent to participate in this study.SD, EB, PL, and ABG designed the study. PL and NM developed the tests. SD included the participants and conducted the tests. SD, EB, CG, and ABG analyzed the data and prepared the manuscript. All authors contributed to the article and approved the submitted version.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.


The double burden of malnutrition is an emerging public health concern nowadays which a correlation with obesity. This study aimed to examine the relationship between resting metabolic rate (RMR) and dietary intake of zinc, vitamin C, and riboflavin in overweight and obese women.The RMR/FFM showed a significant association with riboflavin  and zinc  in the crude model. Moreover, differences in vitamin C and RMR/FFM was marginal significant . After adjusting for confounders the riboflavin association change to marginal significance . After controlling for potential confounders, the associations change between zinc and RMR/FFM  and between RMR/FFM and vitamin C . Our study showed a significant association between dietary intake of zinc, riboflavin, and vitamin C and change in RMR/FFM in overweight and obese women. Obesity rates are growing globally . More thDiet quality can be evaluated to better understand overall eating patterns . Poor diTo the best of our knowledge, this is the first study to investigate the relationship between deficiency of nutrient intakes such as zinc, vitamin C, and riboflavin and RMR in the adult women population. Accordingly, this study was performed to examine the NAR with RMR/FFM among a group of Iranian adult women.2. The exclusion criteria were as follows: regular use of medicine, history of hypertension, cardiovascular diseases, and other chronic diseases, alcohol consumption, smoking, pregnancy, lactation period, and menopause. Furthermore, those who had been following an arbitrary special dietary regimen, and also those with any significant body weight fluctuations over the past 1 year and energy intakes lower than 800 kcal/day or higher than 4200 kcal/day were excluded.This cross-sectional research was performed on 293 adult women aged between 18 and 48 years who were selected by a multistage cluster random sampling method that had been referred to health centers in Tehran recruited. Participants were enrolled in the study according to inclusion and exclusion criteria. Inclusion criteria were: general health, overweight and obese women with BMI in the range of 25–40 kg/m2 consumed and CO2 produced. The RMR was assessed in the morning, after a comfortable night’s sleep, and following a 10–12 h fast. Participants were asked to avoid caffeine or alcohol consumption and severe exercise for a day before RMR measurements. After reclining in a steady-state and a supine position in a quiet room, the RMR was measured for 30 min. The respiratory exchange ratio and oxygen uptake (VO2) were analyzed within the middle 20 min of the resting period. Predictive RMR was determined using the Harris–Benedict equation, which considers the weight, height, and age of participants.RMR was measured by indirect calorimetry . According to the manufacturer’s instructions, gas ventilation and exchange is calibrated before each test. RMR is evaluated by measuring the amount of OBody composition, including weight, BMI, fat mass, and fat-free mass (FFM) were acquired using a multi-frequency bioelectrical impedance analyzer InBody 770 scanner  method .Insulin resistance was estimated by homeostasis model assessment (HOMA). The HOMA was calculated according to the following equation: HOMA = [Fasting Plasma Glucose (mmol/L) × Fasting Plasma Insulin (mIU/L)]/22.5 . InsulinDietary intake data of the past year were obtained using a validated semi-quantitative food-frequency questionnaire (FFQ) , comprisFor calculating the NAR, the ratio of daily individual intakes to the standard recommended amounts for the subject’s sex and age category was used. The standard recommended amounts are based on RDA  . We calcInternational physical activity questionnaire  were obtained by using an interview-based questionnaire from all participants about all the vigorous and moderate elements over the last 7 days, considering the time spent on these activities for height measurements, subjects were in a standing position without shoes, in contact with the wall with their head, shoulders, heels, and hips, and their height was recorded to the nearest 0.1 cm.All statistical analysis was performed using the IBM SPSS software version 22.0 , and P-values less than 0.05 were considered statistically significant. The normal distribution of data was checked by the Kolmogorov–Smirnov test. An independent sample t test was used for assessed differences between groups with the low and standard intake of nutrients. RMR/FFM was analyzed after adjusting for FFM. The differences between RMR/FFM groups and dietary intake of nutrients were assessed by the binary logistic regression were performed to adjust for confounders effects such as age, energy intake, and physical activity (METs/day). Results were presented as odds ratios (ORs) and 95% confidence intervals (CIs) compared with the RMR groups.2 (SD = 3.79), respectively , 161.84 cm (SD = 5.85), 80.22 kg (SD = 11.28), and 30.77 kg/m, 161.84 2 (P = 0.001), V. CO2 (P = 0.007), body fat mass (P = 0.02), FFM (P = 0.006), height (P = 0.005), and weight (P = 0.006) had a significant relationship with zinc. Besides, riboflavin had a significant association with body fat mass (P = 0.05), however, there were showed no relationship between vitamin C and participant characteristics (P > 0.05).Dietary intake of three nutrients including riboflavin, vitamin C, and zinc were categorized based on nutrient adequacy ratios (NAR) and divided into two groups, standard and deficiency Table . The RMRTable The results of this study showed a significant association between riboflavin intake and the RMR/FFM. RMR was distinct in standard or deficiency consumption of riboflavin. There was not any significant association between vitamin C, zinc and RMR/FFM.The findings of the current study indicate that there is no association between the amount of zinc consumed and RMR. However, other studies demonstrated that zinc has different functions in the metabolism of energy and works as a component of several enzymes crucial to the metabolism of carbohydrates, proteins, and lipids and metabolism of hormones that take part in the progress of obesity, especially insulin, and seems to be connected with the mechanisms of insulin resistance usually present among obese people , 24–28. In this study, we also found that women who consumed higher riboflavin were more likely to have higher RMR. Considering the dietary restrictions on food intake or common dietary mistakes perceived among obese people, changes in the micronutrient intake leading to their deficiency are possible. Suitable riboflavin content is necessary to perform the effector function of macrophages with inhibition proliferation, intensification of apoptosis incidence, and also the reduction in phagocytosis efficiency . FurtherIn conclusion, we could find a significant association between dietary intake of riboflavin, and change in RMR/FFM in overweight and obese women, however after controlling for ranges of potential confounding factors the statically meaningful for zinc and vitamin C disappear.The major limitation of this study was the participants in the same-sex sample that it is not possible to generalize the results to men population. Because of the study type, cross-sectional study, we could not determine the causality. Another limitation for assessing dietary intakes from FFQ is misclassification. Albeit we controlled for the effect of the potential confounder by the statistical methods, because of unknown confounder cannot be excluded residual confounding will affect.


Mycoplasma hyopneumoniae is the primary agent of enzootic pneumonia in pigs. Although cell mediated immunity (CMI) may play a role in protection against M. hyopneumoniae, its transfer from sows to their offspring is poorly characterized. Therefore, maternally-derived CMI was studied in piglets from vaccinated and non-vaccinated sows. The potential influence of cross-fostering before colostrum ingestion on the transfer of CMI from dam to piglets was also investigated. Six M. hyopneumoniae vaccinated sows from an endemically infected herd and 47 of their piglets, of which 24 piglets were cross-fostered, were included, as well as three non-vaccinated control sows from an M. hyopneumoniae-free herd and 24 of their piglets. Vaccinated sows received a commercial bacterin intramuscularly at 6 and 3 weeks prior to farrowing. The TNF-α, IFN-γ and IL-17A production by different T-cell subsets in blood of sows, colostrum and blood of piglets was assessed using a recall assay. In blood of sows cytokine producing T-cells were increased upon M. hyopneumoniae vaccination. Similarly, M. hyopneumoniae-specific T-cells were detected in blood of 2-day-old piglets born from these vaccinated sows. In contrast, no M. hyopneumoniae-specific cytokine producing T-cells were found in blood of piglets from control sows. No difference was found in M. hyopneumoniae-specific CMI between cross-fostered and non-cross-fostered piglets. In conclusion, different M. hyopneumoniae-specific T-cell subsets are transferred from the sow to the offspring. Further studies are required to investigate the role of these transferred cells on immune responses in piglets and their potential protective effect against M. hyopneumoniae infections.The online version contains supplementary material available at 10.1186/s13567-021-00968-0. Mycoplasma hyopneumoniae (M. hyopneumoniae) is the primary agent of enzootic pneumonia in pigs, causing significant economic losses in swine production worldwide [M. hyopneumoniae may occur already during the first weeks of life, and dam-to-piglet transmission has been shown to be a major transmission route [M. hyopneumoniae colonization in piglets [+, CD4+, CD8+CD4+ and CD8−CD4− [orldwide , 2. Coloon route , 4. Mate piglets , 6. As p piglets . ColostrCD8−CD4− . AntibodCD8−CD4− . AntibodCD8−CD4− –13. BesiCD8−CD4− .M. hyopneumoniae at weaning compared to piglets from non-vaccinated sows and gilts [Vaccination of sows during gestation increases vaccine-specific antibodies in serum and colostrum, which are then transferred to the suckling piglets , 15, 16.M. hyopneumoniae as serum antibody levels are not correlated with the degree of protection [M. hyopneumoniae colonization in piglets has been shown, it is not commonly practiced [Nevertheless, cell mediated immunity (CMI) might play a more important role in the protection against otection –21. Althracticed .M. hyopneumoniae vaccination of sows resulted in the presence of vaccine-specific lymphocytes in colostrum, which were able to proliferate after in vitro M. hyopneumoniae stimulation. These cells were transferred to their offspring because after colostrum intake, the lymphocytes, isolated from the blood of the piglets, proliferated as well after in vitro stimulation. When piglets from vaccinated dams were injected intradermally with purified killed M. hyopneumoniae (300 µg/mL in 0.1 mL) antigen, a delayed-type hypersensitivity (DTH) reaction was observed, indicating the presence of M. hyopneumoniae specific Th1 cells [M. hyopneumoniae vaccinated sows [M. hyopneumoniae can activate T-cells [M. hyopneumoniae vaccination and infection, it might be important to characterize the different M. hyopneumoniae-specific T-cell subsets and their ability to produce cytokines in blood of sows, colostrum and the transfer to neonatal piglets [In a previous study , M. hyoph1 cells . This DTted sows . It is w T-cells , 21, 24, T-cells . Activat T-cells , 27. To  piglets , 28, 29.M. hyopneumoniae vaccine may activate T-cells in the sows and second to explore if these M. hyopneumoniae-specific T-cells are transferred to their offspring. Therefore, M. hyopneumoniae-specific humoral and cell-mediated immunity in blood of sows, colostrum and blood of 2-day-old piglets were investigated. The presence of IFN-γ, TNF-α, and IL-17A producing T-cell subsets and their proliferative ability after in vitro stimulation with M. hyopneumoniae antigen were analyzed. The potential influence of cross-fostering before colostrum ingestion on the transfer of CMI from dam to piglets was also investigated.The objectives of this study were first to investigate if vaccination of sows with an inactivated M. hyopneumoniae (pathogen isolated from slaughterhouse lungs) and farm B was free of M. hyopneumoniae. The free status was based on historic information such as absence of clinical signs, lung lesions and serum antibodies upon routine serological testing. The farm also tested negative for M. hyopneumoniae using PCR on tracheobronchial swabs  prior to onset of the study. The experimental design used on the two farms is shown in Figure The study was performed after approval by the Ethical Committee for Animal Experiments of the Research Institute for Agriculture, Fisheries and Food   and after approval by the Ethical Committee of the Faculty of Veterinary Medicine and the Faculty of Bioscience Engineering, Ghent University . Two commercial farrow-to-finish farms were included in the study. Farm A was endemically infected with M. hyopneumoniae vaccine, constituted of inactivated whole cells of the J strain , at 6 and 3 weeks before farrowing to boost M. hyopneumoniae-specific immune responses. Farrowing was induced at 115 days of gestation by intramuscular injection of 2 mL prostaglandin  followed by intramuscular injection of 1 mL oxytocin 24 h later . Immediately after birth and prior to colostrum ingestion, piglets were placed in plastic tubs under a heat lamp for maximum six hours. From each sow, the first seven to eight piglets (n = 47) with a birth weight of at least 1.0 kg were ear notched to allow individual identification. Four piglets (n = 24) from each sow were moved to another dam within 6 h after birth and before colostrum ingestion, while the other three to four piglets (n = 23) remained with their mother.On farm A, six sows (mixed breed and of different parities) were intramuscularly vaccinated with a commercial n = 24) with a birth weight of at least 1.0 kg were included in the study. No M. hyopneumoniae vaccination was performed on the farm and piglets were not cross-fostered.On farm B, three Naima sows and eight piglets per sow  and EDTA tubes (non-clotted blood), from all sows before the first vaccination and within 6 h after farrowing. In farm B, blood was only collected from the sows within 6 h after farrowing. In addition to the blood samples, the sows on both farms were sampled using a laryngeal swab . Colostrum (45 mL) from all sows in the study was collected shortly after birth and before the piglets were allowed to suckle. Different teats  were sampled and the colostrum samples were pooled to obtain one sample per sow.At 2 days of age, blood was taken from all piglets by puncture of the jugular vein in sterile serum and EDTA tubes.M. hyopneumoniae, DNA was extracted from the laryngeal swabs using a commercial kit  and a nested PCR (nPCR) was performed [To test for the presence of erformed .M. hyopneumoniae antibodies with a commercial blocking ELISA  following the manufacturer’s instructions. Samples were considered positive if the optical density (OD) of the sample was lower than 50% of the average OD of the buffer control. Samples were considered negative if the OD of the sample was equal to or higher than 50% of the average OD of the buffer control. To determine M. hyopneumoniae-specific immunoglobulin (Ig) G and IgA levels in serum and colostrum, an indirect in-house ELISA was used as described by others [M. hyopneumoniae negative pigs from experimental trials) plus three times the standard deviation (SD).The serum was analyzed for the presence of y others . Serum w6 cells/well in 0.5 mL of AIM-V medium  and stimulated in vitro overnight (20 h) with 3.125 × 107 CCU of M. hyopneumoniae J strain bacterin in 0.5 mL of AIM-V medium. The M. hyopneumoniae J strain bacterin was made based on the protocol for the production of M. hyopneumoniae F7.2C bacterin [Peripheral blood mononuclear cells (PBMCs) were isolated from fresh, unclotted blood using a Lymphoprep™ density gradient . Colostral mononuclear cells (CMCs) were purified using a Ficoll-Paque® density gradient . The stimulation and staining of the PBMCs and CMCs was based on the protocol described by others . Brieflybacterin . Concana6 cells/well in 0.5 mL complete cell culture medium  and stimulated in vitro for 87 h with 3.125 × 107 CCU of M. hyopneumoniae J strain bacterin. Concanavalin A (10 µg/mL) was used as a positive control and complete cell culture medium as a negative control. Cells were harvested and a surface staining protocol was performed. First, cells were incubated with anti-CD4 and anti-CD8α monoclonal antibodies and subsequently with the corresponding secondary antibodies anti-mouse IgG2b FITC  and anti-mouse IgG2a AlexaFluor 647  together with anti-CD3 DyLight755 and propidium iodide. Data were acquired with a CytoFLEX flow cytometer and the results were further analyzed with CytExpert software. The gating hierarchy is shown in Additional file PBMCs were labeled using a CellTrace™ Cell Proliferation Kit  following the manufacturer’s instructions. Afterwards, cells were plated in 24-well plates at 1 × 10P-value was lower than 0.05.Statistical analyses were performed using IBM SPSS® Statistics Version 26 . Kolmogorov–Smirnov and Shapiro–Wilk tests were used as tests for normality distribution of the residuals. The paired-samples T-test or the Wilcoxon signed-rank test were used for analyzing statistical differences in CMI parameters in blood of sows before and after vaccination. The independent-samples T-test or Mann–Whitney U test were used for comparing the CMI data (1) from sows and 2-day-old piglets on farm A and B and (2) from 2-day-old non-cross-fostered and cross-fostered piglets. To investigate correlations in CMI between sows and 2-day-old piglets, a Spearman-rank test was performed. Differences were considered statistically significant if the M. hyopneumoniae-specific antibodies in the sows upon M. hyopneumoniae vaccination and their transfer to piglets via colostrum, antibody levels were assessed in colostrum and serum of sows and piglets. At the time of farrowing, all sows and 2-day-old piglets, were positive for M. hyopneumoniae specific antibodies on farm A, whereas all animals were negative on farm B  did not show an IgA response after vaccination. On farm B one sow had M. hyopneumoniae-specific serum IgA levels above the threshold  had low IgG levels in colostrum and their piglets had serum IgG levels below the threshold. Two sows (sow 1 and 3) had low IgA levels in colostrum and their piglets had serum IgA levels below the threshold. On farm B piglets from one sow had IgA levels in serum above the threshold, this sow had serum IgA levels above and colostrum IgA levels below the threshold. An overview of the antibody concentrations in serum of 2-day-old piglets is given in Figures To further evaluate the vaccine boosted antibody responses,  Figures A and B.  Figures C and D. M. hyopneumoniae DNA.All laryngeal swabs from the sows taken 6 weeks before farrowing (farm A) and taken at farrowing (farm A and B) tested negative for the presence of M. hyopneumoniae stimulation was investigated.The frequency of the different T-cell subsets after in vitro M. hyopneumoniae vaccination induced a significant (P = 0.03) decrease in the frequency (average % ± SD) of peripheral blood CD8+ T-cells in sows   Figure B.+ T-cells, followed by CD8−CD4− T-cells, CD8+ T-cells, and CD8+CD4+ T-cells. The only significant difference between piglets on both farms was observed for the CD8+CD4+ T-cells (P < 0.01) with a frequency of 0.9% ± 0.7 and 0.07% ± 0.05, on farm A and B, respectively , TNF-α+ (P = 0.047) and IFN-γ+ (P = 0.04) CD8+CD4+ T-cells, and in TNF-α+ (P = 0.03), TNF-α+IFN-γ+ (P = 0.03) and IL-17A+ (P = 0.03) CD8−CD4− T-cells compared to before vaccination  CD8+ T-cells, TNF-α+ (P = 0.04) and IL-17A+ (P = 0.02) CD4+ T-cells, TNF-α+ (P = 0.04) and IFN-γ+ (P = 0.01) CD8+CD4+ T-cells, and TNF-α+IFN-γ+ (P = 0.02) CD8−CD4− T-cells in their blood compared to sows on farm A at the time of farrowing . Before vaccination, IFN-γ producing T-cells were mainly CD8+, while after vaccination there was a significant decrease in INF-γ+CD8+ T-cells (P = 0.03) and a significant increase in INF-γ+CD8+CD4+ T-cells (P = 0.02) , IFN-γ+ (P < 0.01) and TNF-α+IFN-γ+ (P < 0.01) CD8+ T-cells, INF-γ+ (P = 0.02) CD4+ T-cells, IFN-γ+ (P < 0.01) and TNF-α+IFN-γ+ (P < 0.01) CD8+CD4+ T-cells, and more TNF-α+ (P < 0.01) and IFN-γ+ (P < 0.01) CD8−CD4− T-cells in their blood as compared to piglets from non-vaccinated, M. hyopneumoniae negative sows. In blood of piglets from vaccinated sows, significantly more IFN-γ+CD8+ (P < 0.01) and IFN-γ+CD8+CD4+ (P < 0.01) T-cells were present, while in blood of piglets from M. hyopneumoniae negative sows, significantly more IFN-γ+CD4+ (P < 0.01) T-cells were present  cells were present than in blood of piglets from M. hyopneumoniae negative sows .To assess whether vaccine-induced T-cell responses are transferred from sow to piglets, the presence of TNF-α, IFN-γ and IL-17A producing T-cells was investigated in the blood of 2-day-old piglets after in vitro stimulation with t Figure E. Also, s Figure D. These M. hyopneumoniae-specific IgG and IgA antibodies in serum of piglets at 2-days of age as compared to non-cross-fostered piglets  and positive correlations were found for TNF-α+ and TNF-α+IFN-γ+ CD8+ T-cells between non-cross-fostered and cross-fostered piglets and their birth sow and between cross-fostered piglets and their adoption sow  threshold value for positive samples, and two sows had IgG levels in colostrum above the threshold, which can be due to cross-reactivity between antibodies against M. hyopneumoniae, M. hyosynoviae and/or M. flocculare [To confirm that the transfer of variable , 16, 36.ther sow , 37–39. cination . The obsocculare . The serM. hyopneumoniae vaccinated sows are less often colonized with M. hyopneumoniae at weaning, although serum antibody levels are not correlated with the degree of protection [M. hyopneumoniae infections [M. hyopneumoniae is primarily an extracellular pathogen, CD4+ T-cells, mainly the Th1 cells, are critical to protect against disease, probably due to IFN-γ activation of macrophages [+ T-cells, in pigs and a few other animal species such as chickens, mice and dogs, results in maturation to CD8+CD4+ T-cells, a T-cell subset with an antigen-specific memory function [M. hyopneumoniae vaccination, there was a significant decrease in CD8+ T-cells in blood of sows. Vaccination increased the number of CD8+CD4+ T-cells, although the difference was not significant. This increase could be due to maturation of CD4+ T-cells. Furthermore, no significant difference was seen in the percentage of T-cell subpopulations in blood of sows at the time of farrowing on farm A versus farm B. These findings are in line with other studies, in which no significant differences were found in the percentage of T-cells between vaccinated and non-vaccinated groups [+ T-cells were the dominant population in colostrum of sows on farm A, while on farm B the CD4+ T-cells were the least present. Previous studies demonstrated that CD8+ T-cells predominate over CD4+ T-cells in colostrum [M. hyopneumoniae antigen. The percentage of T-cell subsets in blood of 2-day-old piglets corresponds with the findings of previous research, investigating the T-cell subsets in blood of 1-day-old piglets [+ T-cells dominate over CD8+ T-cells and CD8+CD4+ T-cells are almost absent in newborn piglets [+CD4+ T-cells was significantly higher in the blood of 2-day-old piglets born from M. hyopneumoniae vaccinated sows compared to piglets from farm B. This could be explained by the fact that the vaccinated sows transferred M. hyopneumoniae-specific CD8+CD4+ memory T-cells via colostrum to the piglets, while the sows on farm B did not have M. hyopneumoniae-specific memory cells to transfer. However, comparing T-cell subsets with other studies remains difficult as PBMCs and CMCs in this study were first in vitro stimulated with M. hyopneumoniae bacterin before measuring the percentage of T-cell subpopulations. Although cells are stimulated in vitro, the measured percentage of the T-cell subsets is the total amount of cells present after M. hyopneumoniae stimulation and not only the M. hyopneumoniae-specific T-cells.Previous studies have shown that piglets from otection . Severalfections –21. As Mrophages . Stimulafunction –44. Six d groups , 19. Unlolostrum , 45, but piglets . CD4+ T- piglets , 47. TheM. hyopneumoniae on the presence of cytokine producing T-cells in the blood of sows was investigated. Vaccination of piglets against M. hyopneumoniae increased the number of IFN-γ secreting lymphocytes in the blood [+CD4+ T-cells after vaccination. M. hyopneumoniae vaccination of sows resulted in a shift from IFN-γ production by CD8+ T-cells to IFN-γ production by CD8+CD4+ T-cells.To the authors’ knowledge, no other studies have been conducted in which the effect of sow vaccination against he blood , 21, 48.he blood . Most stM. hyopneumoniae-specific lymphocytes and natural killer cells from sow to offspring. The present study further characterized the cytokine production of these M. hyopneumoniae-specific T-cells. In blood of 2-day-old piglets from M. hyopneumoniae vaccinated sows, significantly higher percentages of IFN-γ producing T-cells were present compared to 2-day-old piglets from non-vaccinated sows. In blood of piglets from vaccinated sows, IFN-γ is mainly produced by CD8+ T-cells. Furthermore, piglets from M. hyopneumoniae vaccinated sows had higher percentages of TNF-α producing CD8+ and CD8−CD4− T-cells and of TNF-α and IFN-γ producing CD8+ and CD8+CD4+ T-cells. Lymphocytes with a memory function, such as CD8+CD4+ T-cells, which produce cytokines that work synergistically, e.g. TNF-α and IFN-γ, are expected to be important in the protection against pathogens [−CD8− lymphocytes, which included B-cells, produce significantly more IFN-γ in blood of piglets from vaccinated sows. Interestingly, IFN-γ producing B-cells were recently described in the context of PRRSV vaccination [Bandrick et al. , 39 demoathogens . Productathogens . Also, Ccination . FurtherM. hyopneumoniae-specific CMI from sows to their offspring. In addition, we showed that 2-day-old piglets from vaccinated sows have more M. hyopneumoniae specific cytokine producing T-cells in their blood than piglets from non-vaccinated sows on a M. hyopneumoniae negative farm. This indicates that vaccination of sows against M. hyopneumoniae in late gestation might have a positive effect on the pathogen specific CMI in their 2-day-old offspring.The results obtained in our study confirm the transfer of M. hyopneumoniae-specific CMI in blood of neonatal piglets plays a role in protection against M. hyopneumoniae infections and if the passively acquired immunity interferes with the development of vaccine-induced immunity. Piglets with different statuses of M. hyopneumoniae-specific MDI were challenged [M. hyopneumoniae MDI, both cells and antibodies, had less and slower M. hyopneumoniae shedding but more lung lesions than piglets with no M. hyopneumoniae MDI. A study demonstrated that piglets from M. hyopneumoniae vaccinated sows did not show increased IgG levels after vaccination [M. hyopneumoniae MDI had no effect on the development of M. hyopneumoniae-specific vaccine induced responses [M. hyopneumoniae challenged nor vaccinated.It remains to be determined if the presence of allenged . They obcination . This inesponses , 29. HowM. hyopneumoniae positive farm, piglets were cross-fostered before colostrum ingestion and they were moved to a sow of a different breed. Cross-fostering had no impact on the transfer of M. hyopneumoniae-specific IgG and IgA antibodies, as previously shown [M. hyopneumoniae-specific T-cells in the blood of 2-day-old piglets, in contrast to others [M. hyopneumoniae vaccinated dam to another vaccinated dam before colostrum ingestion on the one hand, and non-cross-fostered piglets on the other hand. In both, cross-fostered and non-cross-fostered piglets, CD3+ T-cells had the capacity to proliferate upon in vitro M. hyopneumoniae stimulation. Other studies suggested that colostral cells are expected to pass the intestinal epithelium only when the piglet suckled colostrum from its own mother sow [M. hyopneumoniae vaccinated birth gilt to another M. hyopneumoniae vaccinated gilt before colostrum ingestion had a smaller DTH reaction than piglets cross-fostered 12 h or 20 h after birth [+ T-cells, CD8+ T-cells, macrophages and natural killer cells following recognition of an antigen [M. hyopneumoniae specific CMI in 2-day-old piglets.On the ly shown . Surpriso others . Furtherther sow , 12. Preer birth . A DTH r antigen . In cont+ T-cells in blood of M. hyopneumoniae vaccinated sows at the time of farrowing and the blood of their 2-day-old piglets, irrespective of cross-fostering. However, no other relevant correlations for cytokine producing T-cells between blood of sows and blood of piglets could be found. Unfortunately, data from cytokine production by colostral cells are lacking in this study due to the low cell yields from the colostral samples.The distribution of the T-cell subsets in blood of sows, colostrum and in blood of piglets after colostrum ingestion did not show similarities , which iM. hyopneumoniae during late gestation induces M. hyopneumoniae-specific antibodies and poly-functional T-cells in sows, which are transferred via colostrum to neonatal piglets. M. hyopneumoniae-specific cytokine producing T-cells are found in blood of piglets from M. hyopneumoniae vaccinated sows. Further studies are warranted to investigate the role of these transferred maternally-derived poly-functional T-cells for the immune system in young piglets and for protection of piglets against M. hyopneumoniae infection.In conclusion, the present study showed that vaccination of sows against Additional file 1. Gating strategy to assess cytokine production by T-cells with CytExpert software.Additional file 2. Gating strategy applied on the T-cell proliferation assay with CytExpert software.Additional file 3. Optical density values forM. hyopneumoniae-specific antibodies in serum of sows and 2-day-old piglets. Farm A: endemically infected with M. hyopneumoniae; Farm B: free of M. hyopneumoniae. Optical density (OD) investigated with a commercial blocking ELISA . On farm A, sows were vaccinated against M. hyopneumoniae at 6 and 3 weeks before farrowing and blood samples were taken before the first vaccination (pre vacc.) and at the time of farrowing (post vacc.), on farm B blood was sampled of the sows at the time of farrowing. On farm A 47 piglets were sampled (24 cross-fostered and 23 non-cross fostered) and on farm B 24 piglets were sampled. Samples were considered positive if the OD of the sample was lower than 50% of the average OD of the buffer control.Additional file 4.Mycoplasma hyopneumoniae-specific proliferation of CD3+ T-cells in blood of sows. Farm A: endemically infected with M. hyopneumoniae; Farm B: free of M. hyopneumoniae. On farm A, sows (n = 6) were vaccinated against M. hyopneumoniae at 6 and 3 weeks before farrowing, blood samples were taken before the first vaccination (pre vacc.) and at the time of farrowing (post vacc.), on farm B blood was sampled of the sows (n = 3) at the time of farrowing.Additional file 5. Correlations for cytokine producing T-cell subsets between sows and 2-day-old piglets. Significant (P < 0.01) positive correlations for TNF-α and TNF-αIFN-γ producing CD8+ T-cells in blood of sows at the time of farrowing and blood of 2-day-old piglets on an endemically infected M. hyopneumoniae farm. Correlation between  non-cross-fostered piglets and their birth sow;  cross-fostered piglets and their adoption sow;  cross-fostered piglets and their birth sow. r = correlation coefficient.


Data were collected from September 2016 to April 2020 using a web-based questionnaire and speech-in-noise test. The results from this test were used to categorize normal hearing and hearing impairment. Outcomes were compared using (multiple) logistic regression models.P=.02). Use of social media on all devices and use of other apps did not differ. Adults with hearing impairment were more likely to agree with using social media to stay in touch with family members  and friends . Furthermore, they were more likely to agree with using social media to perform their work . There were no differences in the experienced benefits from social media.Adults with impaired hearing (n=384) did not differ from normal hearing adults (n=341) in their use of a smartphone or tablet. They were less likely to make use of social media apps on a smartphone, tablet, or smartwatch (age-adjusted odds ratio [OR] 0.67, 95% CI 0.48-0.92; The potential for eHealth is confirmed because adults with hearing impairment are not less likely to use smart devices than their normal hearing peers. Adults with hearing impairment are less likely to use social media apps on a smart device but not less likely to use social media on all types of internet-connected devices. This warrants further research on the types of social media platforms that adults with hearing impairment use and on the type of device on which they prefer to use social media. Given that participants with hearing impairment are more likely than their normal hearing peers to use social media to perform their work, use of social media may be seen as an opportunity to enhance vocational rehabilitation services for persons with hearing impairment. Disabling hearing loss affects 466 million people worldwide . Its preMost adults in high-income countries have access to the internet, although its use is less ubiquitous in older adults ,6. This So far, only 3 studies have looked at internet access and use among adults with hearing impairment in high-income countries. Of these studies, 2 ,19 showeweb scraping) posted on social network sites such as Facebook, Twitter, and YouTube, as well as from web-based forums and from personal blogs [Several studies have analyzed social media use by distinct groups of adults with hearing impairment by extracting publicly available content and user data :RQ1: Do adults with normal hearing and those with impaired hearing differ in the use of smart devices?RQ2: Do adults with normal hearing and those with impaired hearing differ in the use of different types of apps?RQ3: Do adults with normal hearing and those with impaired hearing differ in the use of social media?RQ4: Do adults with normal hearing and those with impaired hearing differ in their reasons for using social media?RQ5: Do adults with normal hearing and those with impaired hearing differ in the experienced benefits from using social media?Data were available from a long-running Dutch national cohort of adults with normal hearing and those with impaired hearing, the National Longitudinal Study on Hearing (NL-SH). Demographics and use of technology, apps, and social media were collected through a web-based questionnaire. The hearing status of participants was determined by a web-based speech-in-noise test.Speech-in-Noise Test section). After presenting the test results, they are asked if they are interested in taking part in hearing-related research. If they are interested, they are taken to the introduction page of the NL-SH on the study website [Initiated in 2006, the NL-SH is an ongoing, prospective cohort study in which both adults with normal hearing and those with impaired hearing participate. This cohort was set up to gain knowledge on the long-term trajectory of hearing loss and its association with psychosocial health, work outcomes, and health care use in adults of working age. The NL-SH uses convenience sampling. The major portals for recruitment are the web-based Dutch National Hearing Test (NHT)  and the  website , where tInclusion measurements (T0) started in 2006 and still continue. The 5-year follow-up (T1) started in 2011, and the 10-year follow-up (T2) started in 2016. For this study, only the T2 measurements were used. The invitation for the T2 measurement round was sent approximately 10 years after the T0 hearing test was performed. In all, 2 email reminders and a postal reminder were sent within a period of 3 months after the first invitation to fill out the questionnaire. In general, the T2 hearing test is performed directly after participants fill out the web-based questionnaire, but a delay of up to 3 months is possible. People who did not perform this test received a total of 3 email reminders during these 3 months. To be included in this study, both the T2 questionnaire and hearing test had to be fully completed. Data collected up to April 1, 2020, were included in the analyses.The NL-SH study protocol has been approved by the Medical Ethics Committee of the Amsterdam Medical Center, location VUmc, in Amsterdam, the Netherlands .The questionnaire consisted of questions on demographics; hearing; use of technology, apps, and social media; and reasons for using social media and benefits of this use. The questions on use of technology and apps were taken from a web-based marketing study . The validity of these questions is unknown. Standardized questionnaires about use of social media, reasons for using social media, and the experienced benefits from using social media are not available. The questions on these topics were devised by the research team and pilot-tested in a group of adults with hearing impairment. Questions and answer options used in this studyWhich of these devices do you use at least once a week?SmartphoneSmartwatchTabletWhich types of apps do you use at least once a week on your current smartphone, tablet, or smartwatch?WeatherNewsFinances NavigationRemote control FitnessCommunication Medical or healthSocial media Music and podcastsDo you use social media?YesNoTo what extent do you agree with the following statements ? I use social media to...Stay in touch with family membersStay in touch with acquaintancesStay in touch with colleagues or peersShare experiences, videos, or photosView experiences, videos, or photosExpand my work-related networkPerform my workGain new knowledgeFile complaints and problems with the government or businessesWith what frequency do you use social media?Multiple times a dayDailyWeeklyMonthlyA couple of times a yearWhat have you gained from your social media use so far?New acquaintancesNew friendshipsCloser or more intense family tiesCloser or more intense friendshipsExpanded work-related networkNew knowledge about healthI have gained little or nothing from social mediaDemographics concerned sex, current age, highest attained education, and first language Dutch or other. Education was divided into low (elementary school or attended high school but no degree), medium (high school graduate or having an associate’s degree), and high . In all, 2 hearing-related questions asked about having normal hearing or some type of hearing loss and, for those with self-reported hearing loss, whether they use a hearing aid.Use of technology consisted of a list of devices with the question “Which of these devices do you use at least once a week?” The list included devices such as a traditional mobile phone, smartphone, traditional wristwatch, smartwatch , fitness watch , laptop or notebook computer, tablet, television, radio, and more. The list did not mention a PC. Participants could tick the box for all devices that applied. For this study, the use of only mobile devices on which an app can be installed , further referred to as a smart device, was analyzed.other was not included in the analyses.Next, participants who indicated that they used a smart device were asked what types of apps they used at least once a week. The options to tick were as follows: weather, news, finances , navigation, remote control , fitness, communication , medical or health, social media , music or podcasts, and other. The category fully disagree (coded as 1), 5=do not agree, do not disagree (coded as 6), and 10=fully agree (coded as 11), resulting in scores of 1-11, to be handled as a continuous outcome.Participants were then asked if they use social media, for example, Facebook, LinkedIn, Skype, WhatsApp, Twitter, and Instagram. If they said “yes” or if they had a missing answer on this question, they were asked about frequency of use (1 answer possible): multiple times a day, daily, weekly, monthly, or a couple of times a year. In the analyses, monthly and a couple of times a year were collapsed into 1 category. Those who used social media were asked how much they agreed with several statements about reasons for using social media. The reasons provided were as follows: to stay in touch with family; to stay in touch with friends; to stay in touch with acquaintances; to stay in touch with colleagues or peers; to share experiences, videos, or photos; to view experiences, videos, or photos; to expand work-related network; to perform work; to gain new knowledge; and to file complaints. These questions could be answered on a scale from 0 to 10 , with 0=other was not used in the analyses.Finally, social media users were asked what they had gained from social media use so far. They could choose any of the following answers: new acquaintances, new friendships, closer or more intense family ties, closer or more intense friendships, expanded work-related network, new knowledge about health, gained little or nothing, and other. The category At the end of the questionnaire, a personal link was provided to the web-based speech-in-noise test.The ability to recognize speech in noise is salient for measuring the disabling effects of hearing impairment because one of the first and major complaints of adults with hearing impairment is difficulty in understanding what is said when there is background noise . To measValidation of the original NHT version showed a high correlation (ρ=0.866) with SRTns derived from the standard test in the Netherlands that uses sentences in stationary speech-shaped noise. The measurement error (SE of measurement) is estimated to be <1 dB . CompareNormally distributed continuous data are described with means and SDs, whereas nonnormally distributed continuous data are described with medians and IQRs. For nominal and ordinal data, frequencies are reported.P<.10) on both the outcome and the independent variable and (2) the regression coefficient of the influencing factor changed by ≥10% after adding the potential confounder to the model.Adults with impaired hearing and normal hearing adults were compared using multiple logistic regression analysis. Age, sex, and education level were considered potential confounders. They were included in the model if (1) the potential confounder had influence .Answers to the items that were scored on an 11-point Likert scale (fully disagree-fully agree) were not normally distributed and had to be categorized. To prevent uneven numbers in the categories, they were categorized into 3 groups based on approximate 1/3 divisions with increasing levels of agreement. Multiple ordinal logistic regression analysis was used to analyze whether the distribution of these answers and answers about the frequency of social media use  differed between adults with normal hearing and those with hearing impairment. Assumptions of logistic analysis were tested in all analyses. For the ordinal results where the assumption of proportional odds was not met, multinomial logistic regression analysis was used. The results were considered statistically significant if A total of 885 study participants responded to the T2 measurement round between September 15, 2016, and April 1, 2020. Of the 885 participants, 837 (94.6%) fully filled out the questionnaire. Of these 837 participants, 725 (86.6%) also performed the speech-in-noise test. Of the 112 participants who did not perform the speech-in-noise test, 68 (60.7%) reported in the questionnaire that they had hearing loss.Of the 725 participants with complete data, 619 (85.3%) participated from September 2016 to December 2017. Most of the participants were women . The participants’ mean age was 57.7 (SD 11.4) years, and 60% (435/725) had a high level of education .Of the total group, 53% (384/725) had a hearing test score ≥–5.5 dB SNR and were subsequently classified as having a hearing impairment. P=.35; Most of the participants made weekly use of a smartphone: 87.4% (298/341) of the normal hearing group and 81.8% (314/384) of the group with impaired hearing . LogistiP=.82; The rates of weekly use of a tablet were 57.5% (196/341) in the normal hearing group and 58.3% (224/384) in the group with hearing impairment. Logistic regression analysis showed that these percentages did not differ between the groups  reported using one or more smart devices on which an app could be installed . Their weekly use of these apps is shown in P=.65; Of 722 participants, 625 (86.6%) reported using social media. Use of social media did not differ between adults with normal hearing and those with hearing impairment , showing that there was no statistically significant difference in the frequency of social media use between the groups.We also looked at the frequency with which social media was used. Most of the participants  used social media daily or multiple times a day. Of note, of the 627 participants, 2 (0.3%) had a missing score on use of social media, but they answered the question about frequency. The age-adjusted cumulative OR for frequency of use of social media for adults with hearing impairment compared with normal hearing adults was 0.91  and, after correcting for age, to stay in touch with friends . Multinomial regression analysis, in which ORs are estimated separately for the levels of agreement, showed that participants with hearing impairment were also more likely to have the highest level of agreement  with using social media to perform their work . However, the comparison for the middle level of agreement (score 2-5) did not show a statistically significant relationship , meaning that normal hearing participants and those with impaired hearing were equally likely to score 2-5 on this statement compared with scoring 1.The analyses of differences between participants with normal hearing and those with impaired hearing showed 3 statistically significant results . OrdinalLogistic regression analysis showed no differences between adults with hearing impairment and those with normal hearing for the experienced benefits from social media use .Adults with hearing impairment and normal hearing adults did not differ in either weekly use of a smartphone or weekly use of a tablet. Adults with hearing impairment were less likely to make weekly use of social media apps on a smartphone, tablet, or smartwatch, but they were not less likely to use social media on all types of devices (including a desktop computer or laptop). Compared with normal hearing adults, adults with hearing impairment were more likely to agree with the statements that they use social media to stay in touch with family members and to stay in touch with their friends. Furthermore, participants with hearing impairment were more likely to be in the group that very much agrees with the statement that they use social media to perform their work. The experienced benefits from social media did not differ between adults with hearing impairment and those with normal hearing.Among all NL-SH participants, 84.4% (612/725) made weekly use of a smartphone. This percentage is comparable with the 85% of households in the Netherlands that owned a smartphone in 2017 , althougA tablet is used on a weekly basis by 57.9% (420/725) of all NL-SH participants. In 2017, 66% of Dutch households owned a tablet, which is somewhat higher than in our sample . We founOf the 91% (660/725) of the NL-SH participants who use a smart device, 83.5% (551/660) make weekly use of a communication app such as an email app or WhatsApp. Statistics Netherlands found that 80% of the Dutch general population aged ≥12 years used direct messaging (mostly WhatsApp) in 2017 . This prWe found the rate of overall weekly use of medical and health apps, other than fitness tracking apps, to be 12.4% (82/660). Overall use of these apps among the Dutch population is not known, but in February 2019 the most used nonfitness apps were diet-tracking apps (10.8%), first-aid apps (9.2%), and sleep-tracking apps (8.1%) . These pIt therefore seems that, apart from the use of social media apps, no notable differences exist in the type of apps that adults with hearing impairment use compared with normal hearing adults, but other research should confirm these results.Of the NL-SH participants, 86.6% (625/722) used social media on any type of device. Again, this is comparable with the general Dutch population: 85% used social media in 2017 . Most ofDespite the lower weekly use of social media apps by adults with hearing impairment, overall social media use did not differ between adults with normal hearing and those with hearing impairment. A reason for this could be that, in the question on the use of apps, we made a distinction between communication apps (email and direct messaging apps such as WhatsApp) and social media apps  of the whole group agreed that using social media had given them closer or more intense family ties and that 25.6% (161/628) had gained closer or more intense friendships ties in with many participants using social media to stay in touch with people close to them. Research in adolescents shows that social media can have a positive effect on their social connectedness and sense of belonging . PositivWe found no differences between adults with hearing impairment and those with normal hearing for the experienced benefits from social media use. This suggests that despite our previous finding that participants with hearing impairment are more likely to use social media to stay in touch with family members and friends and to perform their work, they derive benefits from this similar to those derived by normal hearing adults.The broad use of smart devices in our sample shows the potential for digitalized hearing health care through specific apps. However, it should be noted that 9% (65/725) of the NL-SH participants did not use a smart device and that this was more prominent in older adults. Of all study participants aged >65 years, 15.7% (182/216) did not use a smart device (results not shown). As most of the people with hearing impairment are aged >65 years, this means that a substantial number of people with hearing impairment access the internet by other means. To ensure equal access, digital hearing health care should not be restricted to apps; it should also be available on desktop computers and laptops. This ties in with the possibility that adults with hearing impairment have a preference to use these latter devices to access social media.The use of medical and health apps appears low in our sample because only 12.4% (82/660) reported using these apps and their use is apparently higher in the general public. This does not imply that adults with hearing impairment have little interest in apps for hearing health care; rather, it means that more research is needed into their needs and wants. A variety of solutions may be necessary, as was shown in previous research on eHealth alongside the customer journey of older people with hearing loss .We speculated that communication through the internet could be specifically attractive to adults with hearing impairment. Indeed, adults with hearing impairment were more likely to use social media to stay in touch with family members and friends than normal hearing adults. Nonetheless, they were not more likely to report closer or more intense family ties or friendships from using social media. This shows that internet-mediated communication does not have more salience for adults with hearing impairment than other modes of communication. More research is needed on the type of social media that adults with hearing impairment use to stay in touch with close family members and friends and whether the higher use mitigates mental health outcomes as we have put forward.Finally, participants with hearing impairment were more likely to use social media to perform their work. Work can be challenging for people with hearing loss because of the difficulties in spoken communication. This can result in increased levels of fatigue, stress, loss of productivity, and job loss ,50. It wThe strengths of this study include the large sample, its diversity in age, the comparison between adults with normal hearing and those with hearing impairment, the correction for confounders, and the functional measurement of hearing ability. As all measurements were performed through a questionnaire and a hearing test that ran in a web browser, the study was likely to attract adults who are fairly comfortable with using the internet through a web browser. Nevertheless, the total sample seems representative of the general Dutch population in their use of technology and social media.Our study includes several limitations. We used existing questionnaires that are used for marketing purposes. We were not able to find any documents showing validity of these questionnaires. Nevertheless, given that they are used in marketing research, we assume that they were developed according to accepted standards and hence valid, although a scientific report on their validity has not been published. We assume that the questions on use of technology and different types of apps were valid. The questions we devised on several aspects of social media use were not tested for validity either. This needs further investigation. In addition, all data were self-reported and could therefore suffer from recall bias, particularly the questions that included frequency of use, as well as from social desirability bias. The actual use of apps and social media on smart devices can be measured by individually tracking their use with software that collects these data and sends them to a research database , but thiThe potential for digitalized hearing health care is confirmed. Adults with impaired hearing are not less likely to use smart devices than their normal hearing peers. More research is needed into the needs and wants of adults with hearing impairment for the type of hearing health care solutions they seek.Adults with hearing impairment agreed more with using social media to stay in touch with family members and friends than normal hearing adults, but this did not result in closer or more intense family ties or friendships. Research is needed on the type of social media that adults with hearing loss use to stay in touch with close family members and friends and to determine whether the higher use of social media mitigates mental health outcomes as we have put forward. Given that participants with hearing impairment are more likely than their normal hearing peers to use social media to perform their work, it would be of interest to study whether and how vocational rehabilitation services for workers with hearing impairment could be implemented on social media platforms as an alternative or supplementary to standard hearing health care. Adults with hearing impairment are less likely to make weekly use of social media apps on a smartphone, tablet, or smartwatch but not less likely to use social media on all types of internet-connected devices. This warrants further research on the types of social media platforms that adults with hearing impairment use and on the type of device on which they prefer to use social media.


Vestibular schwannoma(s) (VS) are benign tumors of the cerebellopontine angle comprising the Schwann cells that line the vestibular branch of cranial nerve VIII. Treatment goals focus on the preservation and improvement of facial nerve and hearing function as well as tumor control. The retrosigmoid (RS) approach is associated with lower hearing preservation rates compared to the middle cranial fossa (MCF) approach. A 60-year-old male was diagnosed with right-sided cystic VS and subsequently underwent surgical resection via a RS approach. Although his preoperative hearing function was quite low, with a right-sided speech reception threshold of 35 dB and a right-sided word recognition score of 48%, he experienced a drastic improvement in his hearing postoperatively with stable residual tumor. Although the RS approach for VS resection is not considered to be as effective at preserving hearing function compared to the MCF approach, we present a case where it resulted in significantly improved hearing function. Additionally, in cases where preoperative hearing function is severely diminished, hearing preservation is not typically an outcome that is considered. However, this case suggests that improvement of hearing in these patients may be attainable, particularly with the RS approach. Vestibular schwannoma(s) (VS) account for roughly 6%-8% of intracranial tumors and are the most common tumors of the cerebellopontine angle (CPA) ,2. OftenSurgical strategies include the translabyrinthine (TL), middle cranial fossa (MCF), and retrosigmoid (RS) approaches. Although advantages of the TL approach include full exposure of the internal auditory canal (IAC), exposure of CN VII from the stylomastoid foramen to the brainstem, and direct access to the CPA, the major disadvantage of this approach is that hearing is sacrificed . HoweverWhile the MCF approach is thought to produce the best rates of hearing preservation, we report the case of a patient whose hearing function greatly improved after undergoing the RS approach. The patient consented to the possibility of his data being used for research. All protected health information was secured according to the Health Insurance Portability and Accountability Act, and this study was approved by our Institutional Review Board.History, physical examination and course of treatmentA 60-year-old male with no pertinent past medical history was initially seen by his physician for a right ear infection and received audiometry testing. The results of the audiometry exam revealed significant hearing asymmetry, and subsequent MRI revealed a right VS.After further evaluation with a neurosurgeon, the patient agreed to follow a treatment plan involving a right RS craniotomy for the resection of his right VS. A complex stereotactic extended RS craniotomy for a transcondylar posterior fossa approach with a microsurgical resection of the patient’s tumor was performed without significant postoperative events.At the one-week follow-up, the patient presented with no complaints except mild postoperative dysgeusia that was described as a minimized sensation of taste. Four months after surgery, audiometry revealed an improvement in hearing function, and six months after surgery, the patient followed up with his neuro-otologist and reported improvement in his hearing, dizziness, and balance, although he did report experiencing some generalized numbness on the right side of his head. Ten months after surgery, the patient did recount some occasional tension headaches that occur approximately once per week, but he also noted that his hearing and balance on his right side had both improved.Preoperative audiometry Postoperative audiometry demonstrated an increased word recognition score in the left ear and maintenance of the operative-side speech reception thresholds.Audiometry was performed approximately seven months and one week prior to surgery Tables . PostopePreoperative imagingThe patient underwent MRI of his brain and IAC with and without contrast approximately five months prior to surgery that revealed a heterogeneous mass (2.2 x 1.3 x 2.0 cm) in the right CPA-IAC compatible with a cystic VS. A mild mass effect was noted on the right side of the cerebellum and pons without abnormal signal or hydrocephalus.Preoperative imaging was performed approximately one month prior to surgery. A CT angiogram of his brain with contrast demonstrated contact of the right anterior inferior cerebellar artery with the anterior and medial borders of the tumor, and a brain MRI with and without contrast was also performed Figure .Surgical resectionThe patient underwent a complex stereotactic extended RS craniotomy for a transcondylar posterior fossa approach with a microsurgical resection of his CPA mass. The tumor was visualized using the vertebral and anterior inferior cerebellar arteries and was dissected in its posterior, superior, and inferior borders. A small carpet of tumor was extremely adhesive to the brainstem as well as to the region of the facial nerve, and we left a thin layer of carpet of tumor on the brainstem and on the facial nerve as it extended into the IAC. The lesion was noted to be of a yellowish color with soft consistency and significant attachments. The tumor specimen was sent off to pathology, and the frozen specimen came back as schwannoma.Postoperative audiometryApproximately four months after surgery, the patient underwent postoperative audiometry at the same center Tables . PostopePostoperative imagingBrain MRI with and without contrast was also performed that demonstrated postoperative changes related to the resection of the tumor, along with some possible representation of residual tumor along the right surface of the brainstem as well as the right IAC. In addition, mass effect on the right brainstem and cerebellum significantly improved compared to preoperative imaging.Approximately 10 months after surgery, an MRI-IAC with and without contrast was performed that demonstrated stability of the residual tumor Figure .VS are benign intracranial neoplasms arising from the Schwann cells that line the vestibular branch of CN VIII . The surHearing function improvementHearing preservation in VS resection is typically attempted when the word recognition score is greater than 70% .Tumor controlA small amount of residual tumor was intentionally left due to its strong adhesion to the brainstem and facial nerve. Upon imaging 10 months postoperatively, it was determined that this residual tumor was stable. MR imaging with gadolinium contrast media is typically used to surveil residual tumors in order to ensure the timely recognition of regrowth and recurrence -14.Although the RS approach for resection of VS is typically not associated with the highest rates of hearing preservation (47% hearing preservation via RS vs 63% hearing preservation via MCF), this case demonstrates improved postoperative hearing function in a patient whose tumor was resected via the RS approach. In addition, his residual tumor was stable at 10-month follow-up with no adverse outcomes associated with the surgery. Therefore, postoperative hearing improvement may still be attainable in VS patients with significant hearing loss, particularly with the RS approach.


Hearing loss is one of the most common congenital sensory disorders. It can be associated with several comorbidities, in particular developmental disabilities (DD). In Emilia-Romagna (ER), a region in Northern Italy, Child and Adolescent Mental Health Services (CAMHS) provide the diagnostic framework and treatment for these conditions. The aim of the present study is to evaluate the prevalence of hearing loss, both isolated or in association with comorbidities, in the juvenile population. The study draws its data from the ER Childhood and Adolescent Neuropsychiatry Information System (SINPIAER), an Administrative Healthcare Database collecting the clinical data of all those who have attended CAMHS since 2010. The most frequent type of hearing loss was bilateral sensorineural hearing loss, which was present in 69–72% of the cases, while bilateral conductive hearing loss was the second most common type, ranging from 8 to 10%. Among DD, congenital malformations, mental retardation, visual impairment, and cerebral palsy were the most common. In particular, autism spectrum disorders show increasing incidence and prevalence among CAMHS users in ER region. In-depth knowledge of hearing loss epidemiology and related conditions, such as developmental disabilities, in the juvenile population is crucial for disease prevention, health planning, and resource allocation. Hearing loss is one of the most common congenital sensory disorders, affecting one out of every 3000 newborns ,2. An eaSince January 2012, Emilia Romagna (ER), a region of nearly 4.5 million people in northern Italy, has extended the newborn hearing screening (NHS) program to all of its counties and has contextually endorsed a hearing disabilities multidisciplinary regional group that includes many professionals such as neonatologists, audiologists-otolaryngologists, infantile and adolescence neuropsychiatrists, and speech therapists [Child and Adolescent Mental Health Services (CAMHS) are spread over the local territory on the basis of geographical area and the number of inhabitants and represent an important resource out of the hospital, providing a diagnostic framework and clinical monitoring. They deal with developmental disabilities (DD) that represent a group of chronic conditions that may result in functional limitations and that often require life-long support ,6, proviTrends in the prevalence of DDs and their co-occurrence need to be measured to plan community and medical resources. In particular, children with significant disabilities and hearing loss face a great set of challenges  since abUpdated and improved estimates of children and adolescents with disabilities are important to better quantify the burden of disease and the resources required to address the needs and rights of these children . This study is a regional survey based on the evaluation of CAMHS data and aims to deduce the prevalence of hearing loss in the juvenile population that is associated with other DDs. The analysis was focused on congenital malformations, visual impairment, mental retardation, cerebral palsy, and autism spectrum disorders (ADS). In particular, the overall prevalence and trends over time have been considered.The Italian National Health System provides universal coverage and is organized at three levels: national, regional, and local. Administrative data are collected by local health units and are processed at the regional level.The analysis involves data of an IT management program called Sinpiaer, which used by all the regional CAMHS, and was fully introduced in 2011, with the aim of monitoring the implementation and analysis of intervention programs.Sinpiaer can also be accessed by those aged < 18 years old who under the care of CAMHS before their transfer to adult healthcare/social services. The program generates an annual data flow, reporting personal data, clinical features, and the date and number of health care treatments received by CAMHS users. Clinical conditions are classified according to the Manual of International Statistical Classification of Diseases and Related Health Problems, ICD 10th revision, as for all clinical conditions . H90 Conductive and sensorineural hearing loss:H90.0 Conductive hearing loss, bilateral;H90.1 Conductive hearing loss, unilateral with unrestricted hearing on the contralateral side;H90.2 Conductive hearing loss, unspecified;H90.3 Sensorineural hearing loss, bilateral;H90.4 Sensorineural hearing loss, unilateral with unrestricted hearing on the contralateral side;H90.5 Sensorineural hearing loss, unspecified;H90.6 Mixed conductive and sensorineural hearing loss, bilateral;H90.7 Mixed conductive and sensorineural hearing loss, unilateral with unrestricted hearing on the contralateral side;H90.8 Mixed conductive and sensorineural hearing loss, unspecified.H91 Other hearing loss:H91.8 Other specified hearing loss;H91.9 Hearing loss, unspecified.The present study was performed using the IC10 codes for hearing loss (H.90–H.91):Code H91.3, Deaf mutism, not elsewhere classified, was excluded from the analysis, as no cases were present in the Simpiaer database).Code attribution to clinical conditions was made by neuropsychiatrists from the services that attended a specific training course on the ICD 10 system. The same professionals inserted the DC into the IT program. Concerning hearing loss, DC was attributed based on audiologists/ otorhinolaryngologists reports.-Prevalence and incidence of H90–H91 users among the general population and among CAMHS users;-Gender and citizenship of H90–H91;-Distribution by age range: 0–2 years, 3–5 years, 6–10 years, 11–13 years,14–17 years, and 18 years. Age range groups are related to school-aged children: maternal school, primary school, secondary school;-Number and percentage of users with isolated diagnostic codes (DC) H90-H91;-Number of DC H90-H91 with the following other associated codes:Q00–Q99 Congenital malformations, deformations and chromosomal abnormalities;Q10–Q18 Congenital malformations of eye, ear, face, and neck;Q35–Q37 Cleft lip and cleft palate;Q67 Congenitalmusculoskeletal deformities of head, face, spine, and chest;Q75 Other congenital malformations of skull and face bones;Q80–Q89 Other congenital malformations;Q90–Q99 Chromosomal abnormalities not elsewhere classified;F70–F79 Mental retardation;F84 Pervasive developmental disorders (autism spectrum disorders listed here);G80–G83 Cerebral palsy and other paralytic syndromes;H3–H59 Visual impairment;P00–P96 Certain conditions originating in the perinatal period.Data collection was performed including data from 1 January 2011 to 31 December 2020, and the extrapolated data were:The Q00–Q99 Group, including congenital malformations, deformations, and chromosomal abnormalities was analysed by age, and its prevalence in the general juvenile population was calculated. This is an observational retrospective chart review study; the study did not affect patient care in any way since the study only incorporates the recordings of a database and its evaluation. It was conducted according to the guidelines of the declaration of Helsinki. The prevalence and incidence of hearing loss in the juvenile population under the care of regional CAMHS are represented in The cohort of H90–H91 subjects is represented by 58% males and 48% females; 23% are foreign citizens. The age range distribution is indicated in Those aged 0–2 years are mainly identified through newborn hearing screening (NHS), and this group has a stable incidence, representing 12–14% of the population in charge and 50–60% of new cases under the care of CAMHS each year , Table 2Subjects affected by hearing loss, subdivided according to ICD 10th classification into further subtypes H90–H91, are indicated in Children admitted to CAMHS with just a hearing loss code (H90–H91) progressively decreased from 58% in 2011 to 40% in 2020 . InverseConcerning DDs, congenital malformations, mental retardation, visual impairment, and cerebral palsy were the most frequent; in particular, autism spectrum disorders (F84 code) show growing incidence and prevalence among CAMHS users in the ER region; P codes slightly decreased over the years  Genetic malformations and genetic syndromes (Q codes), with a percentage comprised between 13.9–17.1%, represent the most frequent condition. The percentage of children with code Q has progressively increased from 16% to 24% in last five years . Prevalence has increased constantly . Going into detail, Q codes increased in children older than 6 years of age, while they were stable in very young children . When planning and allocating resources for hearing disability intervention programs, epidemiological data are crucial. The present study demonstrates significant data on regional hearing loss prevalence and related conditions in the young population accessing CAMHS, and, to our knowledge, this is one of the first investigations of a regional database with this purpose in Italy. Hearing loss is a complex condition that can occur at any age and is associated with a wide array of etiologies ,14. In tThe prevalence of hearing loss in the juvenile population, which is stratified by age, is important, as it enables a better identification of those cases at late onset, not identifiable at the NHS, and more detailed epidemiological data can direct efforts to prevent its progression . It has In the literature, calculating prevalence reflects the use of different criteria to include and describe cases with hearing impairment, according to type, entity, and age of children. In this regard, the estimated prevalence of hearing loss per 1000 children was 6.4 in a 2009–2016 National Health Interview Survey concerning children aged 3–17 years  based onThere is a need for uniformity in collecting data to determine the real prevalence and incidence of hearing loss cases. The number of generic H90 codes has decreased, confirming an improvement in the appropriate use of the ICD 10 classification system. The majority of cases was due to permanent hearing impairment, which is caused by both genetic and environmental factors, and it is estimated that a genetic factor is responsible for about 50% of all congenital sensorineural hearing loss cases ,21,22. MA growing number of unilateral hearing loss cases, underestimated in the past years, was found. This demonstrates the prompt response of the public health services to the identification of different hearing loss types, as the diagnosis and management of pediatric hearing loss have changed significantly in recent years. The main reasons are the implementation and diffusion of NHS and the development of a new generation hearing aids and cochlear implants. DDs due to an impairment of physical, learning, language, or behavior abilities usually require personalized programs. A recent review reveals that the number of children and adolescents with disabilities in the world is at least 291 million globally and that this prevalence increases with age .Trends in the prevalence of DD may change due to risk factors or to preventative public health measures. In particular, improvements in maternal and child health care and an increased community awareness of disorders may contribute to improving the diagnosis of different DD.The WHO’s Global Burden of Disease Study (GBD) estimated that in 2004, at least 93 million children and adolescents (0–15 years) worldwide  lived with a moderate-to-severe disability and that 13 million (0.7%) had a severe disability . These eA study from the USA recently reported that the percentage of children (age 3–17 years) diagnosed with a developmental disability has increased, resulting in a growing population of children with one or more developmental disabilities . In the ER cohort, the percentage of H90–H91 users with other associated DDs progressively increased from 42% to 60% in recent years, which is probably due to different factors: syndrome diagnosis and treatment improvements besides awareness in the family of therapeutic possibilities. On the contrary, the improved neonatal survival rate, particularly among low birth weight and preterm infants  does notThe Q code group, which describes congenital malformations and chromosomal abnormalities, was the condition that was the most frequently associated with hearing loss. More than 400 syndromes associated with hearing loss have been described, and syndromes represent about 30% of all genetic causes, which are often associated with a delayed onset of hearing loss . PrevaleCerebral palsy, a heterogeneous condition in terms of etiology and severity of impairments, is the most common childhood physical disability . This stA stable percentage of children presented both visual and hearing impairment. The H3-H5 codes include a wide variety of clinical conditions; in any case, these children, who are facing two sensorial impairments, need personalized high-intervention programs, using many rehabilitative service resources.The percentage of F84 codes ranged from 1.3 to 2.4% in the studied population, indicating the importance of the audiological evaluation in these subjects in order to rule out the presence of hearing problems in those subjects.The major strengths of this study are its large sample size and its regional dimension, allowing the analysis of children with developmental disabilities associated with hearing loss and regarding the use of the CAMSH by these children. Major limitations are the relatively short observation time and the analysis by DC that does not allow us to evaluate the entity of hearing loss of CAMHS users.Knowing the hearing loss prevalence of the juvenile population is important when planning and allocating resources for the governance of health services. The most frequent type of hearing loss was bilateral sensorineural hearing loss, while a growing number of unilateral hearing loss cases, which have been underestimated in past years, was found.In the ER cohort, the percentage of H90–H91 users with other associated DDs progressively increased from 42% to 60% in recent years, and congenital malformations and chromosomal abnormalities have resulted the conditions that are the most frequently associate with hearing loss. Autism spectrum disorders show increasing incidence and prevalence.Evaluating the prevalence of DD is crucial for planning educational, medical, and community resources, as an increasing trend has been confirmed in this regional survey.The results of this study confirmed the importance of a robust IT management for the governance of health service resources.