Objectives: The aim of this study was to validate a novel iPad-based rapid hearing loss screening tool (SHOEBOX QuickTest) in individuals with cognitive impairment.Design: Cross-sectional validation study.Setting: Bruyère Research Institute, Ottawa, Canada.Subjects and Methods: Twenty-five individuals with mild cognitive impairment (MCI) and mild dementia from the Bruyère Memory Program were included in this study. The study consisted of two components: (1) SHOEBOX QuickTest hearing screener and (2) a conventional hearing test (pure tone audiometry).Measurements: Hearing was assessed at 1,000, 2,000, and 4,000 Hz separately for each ear. The agreement between hearing ability groupings (good vs. reduced) from conventional hearing test and SHOEBOX QuickTest was determined. Specifically, accuracy, sensitivity, specificity, as well as alignment between conventional thresholds and hearing threshold ranges.Results: An overall accuracy of 84% was observed for SHOEBOX QuickTest, and a sensitivity and specificity of 100 and 66.7%, respectively. 72%  of conventional audiometry thresholds were within the pre-established 10 dB SHOEBOX QuickTest.Conclusion: SHOEBOX QuickTest is a valid hearing loss screening tool for individuals with cognitive impairment. Implementing this iPad-based screening tool in memory clinics could not only aid in the timely diagnosis of hearing loss, but also assist physicians in providing a better assessment of cognitive impairment by ruling out hearing loss as a confounding variable. Hearing loss has been identified as the most prevalent sensory disability in the world impacting approximately 432 million adults worldwide , 2. It hIn addition to hearing loss, dementia is a one of the major causes of disability among older adults worldwide . DementiThe gold standard for assessing hearing loss is pure tone audiometry (PTA) administered by trained audiologists . PTA assAlternative hearing loss screening methods that do not require specialized health care professionals or expensive medical equipment have been developed recently. These methods are more accessible as they are administered on personal computers , tabletsTo date, only one study has assessed hearing loss in cognitively impaired individuals using a screening method not administered by audiology professionals. Pletnikova and colleagues assessed the feasibility of using a tablet-based audiometer in individuals with cognitive impairment . AlthougEven with the established association between hearing loss and cognitive decline combined with high rates of undiagnosed hearing loss in older adults, no studies have explored the suitability of a rapid hearing loss screening tool to screen for hearing loss in a population of individuals with cognitive impairment. Therefore, the aim of this study was to validate the usefulness of the iPad-based SHOEBOX QuickTest (SHOEBOX Ltd.) hearing screening application in a group of older individuals with cognitive impairment.Twenty-five (25) individuals followed at the Bruyère Memory Program (Bruyère Continuing Care) were recruited into this study. All participants were diagnosed with mild cognitive impairment (MCI) or mild dementia. All patients meeting inclusion criteria were approached by a research staff member who explained the study and if interested, obtained informed consent. The experimental protocol was approved by Bruyère Ethics Review Board and participants were free to withdraw at any point. Demographic information regarding age, gender, and diagnosis, as well as the number of attempts to complete the SHOEBOX QuickTest are displayed in The iPad-based SHOEBOX QuickTest application was performed with calibrated sound-attenuating headphones. Testing took place in a quiet office at Élisabeth Bruyère Hospital. The complete test included two main components, a set of four questions followed by a series of pure tone presentations. The tone presentation component was performed separately for each ear (right then left ear) and included frequencies of 1,000, 2,000, and 4,000 Hz. Participants tapped the circle in the middle of the iPad screen see  to indicFollowing completion of the SHOEBOX QuickTest, participants underwent a conventional pure tone audiometry hearing assessment by an audiologist at the Ottawa Audiology Services Clinic, Ottawa, Canada  using circumaural headphones in a sound booth. The audiologist was blinded to the SHOEBOX QuickTest results. The SHOEBOX QuickTest was always conducted first, in order to disadvantage it against any potential sequential learning effect. Assessments included PTA as well as otoscopy performed on both ears. Results from testing at frequencies of 1,000, 2,000, and 4,000 Hz were used to obtain an overall assessment of hearing ability. Similar to SHOEBOX QuickTest, air conduction thresholds (dB HL) were measured at each of these frequencies to determine hearing loss. Participants were defined as having hearing loss from conventional pure tone audiometry if thresholds obtained at any frequency  exceeded 30 dB HL in any of their ears.Presence of hearing loss was determined by the SHOEBOX QuickTest and conventional audiometry for each participant separately. Reduced hearing ability was defined as >30 dB and was entered in a 2 x 2 contingency table to determine the accuracy of SHOEBOX QuickTest in screening for hearing loss (sensitivity and specificity). Analysis was performed by a at Bruyère Research Institute using Statistical Program for the Social Sciences (SPSS) version 24 .The pure tone thresholds obtained from conventional audiometry were compared to the corresponding ranges estimated in SHOEBOX QuickTest at each frequency and each ear. To determine the correlation between the two assessments, the proportion of pure tone thresholds obtained from conventional audiometry that fell within the estimated pure tone ranges from SHOEBOX QuickTest were computed with 95% confidence intervals. We also computed thresholds obtained by conventional audiometry that were within +/– 5 dB the range obtained by SHOEBOX QuickTest.A total of 25 patients (mean age = 73.84 years) with MCI or mild dementia were tested using SHOEBOX QuickTest and conventional pure tone audiometry. All patients were able to complete the SHOEBOX QuickTest in three attempts without any assistance. Reasons for greater number of attempts required include not responding quickly enough, and not understanding the task on the first attempt see . CompariThe measured pure tone threshold ranges computed using the SHOEBOX QuickTest were compared to the threshold obtained using conventional audiometry to determine correlation between the two assessments. 72%  of conventional audiometry thresholds were within the 10 dB range of the SHOEBOX QuickTest. If we expanded the range by +/−5 dB given by SHOEBOX QuickTest, 89.33%  of thresholds obtained by conventional audiometry were included.n = 13) as measured by an audiologist (sensitivity 100%). It is important to note that SHOEBOX QuickTest may be overly sensitive, identifying hearing loss in some individuals who do not have hearing loss (n = 4). Furthermore, despite the fact that SHOEBOX QuickTest was not intended to give exact thresholds, our results demonstrate that it is still relatively accurate at estimating hearing ranges. Lastly, three of the four patients with unknown cerumen accumulation were correctly identified using SHOEBOX QuickTest. Taking together, although SHOEBOX QuickTest identified some false positives, it can reliably screen for hearing loss in older adults with cognitive impairment.The primary aim of this study was to validate the usefulness of an iPad-based hearing screener as a screening tool in patients with mild cognitive impairment (MCI) or mild dementia. Overall, the test was accurate with 84% of the tested population having matching results between conventional audiometry and the SHOEBOX QuickTest. SHOEBOX QuickTest was a highly sensitive assessment, correctly identifying every patient who had hearing loss  and were likely less impaired than a previous study which included participants with more advanced dementia . Future There is a plethora of literature detailing the relationship between hearing loss and dementia. A recent article by Griffiths et al. proposed that hearing loss leads to an impoverished sensory environment that decreases stimulation and cognitive processing . The impDespite the association between hearing loss and cognitive decline there is a paucity of literature evaluating the reliability of objective hearing loss screening tools in this population. Our study provides preliminary evidence that rapid, objective hearing screeners such as SHOEBOX QuickTest can reliably be used to screen for hearing loss in individuals with mild cognitive impairment. These types of self-administered objective screeners do not require expertise in hearing testing and provide immediate, actional able results  reducing some potential barriers to implementation. Further research is needed to explore the implementation of hearing screening within memory clinic programs.SHOEBOX QuickTest is a valid and accurate hearing loss screening tool for individuals with cognitive impairment. Implementing this screening tool in memory clinics can not only aid in a timely diagnosis of hearing loss, but it can also assist physicians in providing a better assessment of cognitive impairment by ruling out hearing loss as a confounding variable.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 Bruyère Research Institute. The patients/participants provided their written informed consent to participate in this study.AF designed the methodological approach, collected the data, and supervised the findings and revised the final manuscript. SG performed the data analysis. SG, AMF, MB, and AF wrote the article. All authors contributed to the article and approved the submitted version.Trillium Health Partners (Trillium) has a vision to develop a pan-Canadian integrated health network  that would facilitate the adoption of Canadian developed technology solutions and break through the historic challenges that health and life sciences companies have faced, enabling them to scale and grow in Canada. Government of Canada funded this project; Ottawa Audiology Services Clinic, Jean Dallaire for conducting the audiology tests. SHOEBOX Inc. CHEO (funds held by MB) covered open access journal costs.MB is the Chief Medical Officer at SHOEBOX Ltd. AMF is the Manager, Research and Data Analytics at SHOEBOX Ltd. The remaining 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Data for monitoring individual hearing aid usage has historically been limited to retrospective questionnaires or data logged intrinsically in the hearing aid cumulatively over time . This limits the investigation of longitudinal interactions between hearing aid use and environmental or behavioral factors. Recently it has become possible to analyze remotely logged hearing aid data from in-market and smartphone compatible hearing aids. This can provide access to novel insights about individual hearing aid usage patterns and their association to environmental factors. Here, we use remotely logged longitudinal data from 64 hearing aid users to establish basic norms regarding smartphone connectivity  and to assess whether such data can provide representative information about ecological usage patterns. The remotely logged data consists of minute-by-minute timestamped logs of cumulative hearing aid on-time and characteristics of the momentary acoustic environment. Using K-means clustering, we demonstrate that hourly hearing aid usage patterns  across participants are separated by four clusters that account for almost 50% of the day-to-day variation. The clusters indicate that hearing aids are worn either sparsely throughout the day; early morning to afternoon; from noon to late evening; or across the day from morning to late evening. Using linear mixed-effects regression modeling, we document significant associations between daily signal-to-noise, sound intensity, and sound diversity with hearing aid usage. Participants encounter louder, noisier, and more diverse sound environments the longer the hearing aids are worn. Finally, we find that remote logging via smartphones underestimates the daily hearing aid usage with a pooled median of 1.25 h, suggesting an overall connectivity of 85%. The 1.25 h difference is constant across days varying in total hearing aid on-time, and across participants varying in average daily hearing aid-on-time, and it does not depend on the identified patterns of daily hearing aid usage. In sum, remote data logging with hearing aids has high representativeness and face-validity, and can offer ecologically true information about individual usage patterns and the interaction between usage and everyday contexts. The real world benefit obtained from hearing aids varies considerably across individuals . This isIn the past it has been difficult to assess real world hearing aid use and outcomes because assessments have had to rely on retrospective reports from users combined with limited information collected via intrinsic hearing aid data logging or self-reports. The perceived total use-time is often over-estimated –13 or inin-situ vs. retrospective reports of hearing aid outcome  is another approach that has been used to examine real world hearing aid use and benefit. With EMA, participants describe real world experiences in real time in their own natural environments . Recentl outcome , 23. In  outcome , 24, whi outcome , 25. In  outcome  found th outcome  showed t outcome . As noteAn approach that is unobtrusive and minimizes user burden is to use ongoing remote data logging in which data collected by the hearing aids are automatically and continuously transferred from the aids to a smartphone via a Bluetooth connection. Because smartphones usually have ample space for data storage, fine-grained temporal data can be collected for numerous acoustic parameters. Remote data logging has the potential to provide new insights into ways in which hearing aids are being used in real life , 28, andRemote logging is in its infancy and as such there are many unknowns about its reliability and validity. For example, for stable flow of data, most remote logging requires a constant Bluetooth connection between the smartphone and the hearing aids. However, Bluetooth connections can be unstable and not all hearing aid users always keep their smartphone close by, which can then lead to data loss. A thorough investigation of the validity and representativeness of remote data logging is therefore needed to validate its use in audiological research and clinical work.In this study, we investigate the representativeness of remote data logging to understand whether it provides a quantitative account of hearing aid usage and its association with everyday contextual factors, so that in the future, individual deviations from group-level patterns can be identified and used to support patients and hearing care professionals. We compare information obtained through remote data logging with that obtained through intrinsic data logging to assess the extent to which remotely-logged data reflect daily hearing aid on-time and sound exposure. Our analysis leverages an observational and longitudinal dataset from in-market hearing aid users. The dataset has been reported upon and validated elsewhere  and simiParticipants were users of Oticon hearing aids  who had signed up to use the HearingFitness™ feature via the Oticon ON™ remote control app and used it at least once with their hearing aids between May the 15th and September the 30th 2019. The Oticon ON™ remote control app can be used by users of Oticon Opn™ and newer hearing aids and it provides an interface to keep track of battery status, changing listening program, adjusting volume etc. When signing up to use the HearingFitness™ feature via the app, participants gave informed consent for data to be collected, stored, and used for research purposes on aggregated levels. No other action is required by the participants when using the feature. Note that no personal identifiers nor qualitative characteristics  are being collected. However, since the participants represent a random sample of typical hearing aid users, we speculate that 6 in 10 are male, are aged around 74 years based on hearing aid user surveys .https://www.nvk.dk/forsker/naar-du-anmelder/hvilke-projekter-skal-jeg-anmelde).No ethical approval is necessary for this study according to Danish National Scientific Ethical Committee  and signal-to-noise levels (SNRs) estimated from within the hearing aid processing . In addiTremote), and the intrinsically accumulated hearing aid on-time (henceforward referred to as Tintrinsic). From the remote logs, each timestamp represents 60 s of hearing aid on-time and smartphone connectivity. Thus, Tremote is estimated by counting the number of timestamps within a selected time-window that are longer than 1 min. For example, counting 40 unique timestamps in 1 h equates to 40 min of hearing-aid use in that hour. For data to be saved in a remote log, smartphone connectivity to the hearing aid is required. On the other hand, the intrinsically accumulated hearing aid on-time represents absolute hearing aid on-time regardless of smartphone connectivity. More specifically, from a series of N consecutive data logs with accumulated on-time times t1, …, tN spanning time-window T, the total on-time is estimated as Tremote and Tintrinsic) within a time-window provides insight into the amount of data lost due to a lack of smartphone connection. Connectivity is thereby defined as the proportion of time a hearing aid is connected to a smartphone for the duration of the inspected on-time.Daily hearing aid usage can be estimated from two sources: the data log timestamps obtained through remote datalogging  while iteratively selecting cluster centroids that minimize the intra-cluster variation . The optimal number of clusters was selected based on the elbow method (Xd is around the centroids. The Silhouette Coefficient (SC) is calculated for each vector Xd as:We used K-means unsupervised clustering to identify archetype usage patterns, where a usage pattern is defined by the minutes of hearing aid usage per hour during a day from 6:00 to 00:00. Thus, the input data consisted of vectors w method , which sw method  assessina is the mean Euclidian distance between a vector and all other vectors in the same cluster, and b is the mean Euclidian distance between a vector and all other vectors in the next nearest cluster. In general, the SC is bounded between −1 for incorrect clustering and +1 for highly dense clustering. Coefficients around zero indicate overlapping clusters  and the coefficient is positive and higher when clusters are dense and well-separated.where The K-means optimization was implemented in R using “cluster” package .eq), daily median SNR, and the daily standard deviation of the SPL (SPLSD). These predictors represent the intensity, the quality, and the loudness diversity of the daily sound exposure. For simplicity, we did not include the daily standard deviation of the SNR because SNR is a relative measure  and, thus, daily variations in SNR cannot be easily interpreted.The associations between daily hearing aid usage and parameters of the acoustic environment (SPL and SNR) were tested using a linear-mixed model (LMM). LMMs are ideal for regressing longitudinal and hierarchical multi-level data allowing for random offsets and slopes from grouping variables . The modThe random effect's structure accounted for the day of the week, hearing aid laterality, and individual offsets in daily usage  and individual sensitivity toward acoustic characteristics . Accounting for laterality effectively ensure that coefficients from the LMMs are estimated based on the average ambient sound sensed between the left and right hearing aid, while accounting for individual sensitivity toward acoustic characteristics with random slopes ensure that individual differences in e.g., loudness growths functions, do not affect the results.Besides inspecting coefficient magnitude and confidence intervals, significance of predictors was assessed by likelihood ratio testing against an intercept-only model. Prior to modeling, extreme outliers in the acoustic characteristics  were removed to ensure normality of the residuals. This removed 147 observations (hearing aid usage days) in total.To assess the degree of multicollinearity within the model, the generalized variance inflation factor (GVIF) was computed using the ‘car' package in R . The GVEffects size estimates were computed by separating the explained variance by fixed effects alone or by the full model using the pseudo-R-squared for Generalized Mixed-Effect models implemented in the “MuMIn” package  in R. LSD = 0.24) and separated by cluster 1 to 4 it was 0.21 (SD = 0.18), 0.18 (SD = 0.18), 0.58 (SD = 0.18), and 0.39 (SD = 0.16). Thus, the Silhouette Coefficients across pooled usage days were predominantly positive indicating successful clustering. The fine-grained temporal structure of the data collected by remote logging opens the possibility of examining hourly usage patterns to investigate how hearing aid use varies with e.g., time of day. Here, a K-means clustering algorithm is applied to the pooled hourly usage patterns among all participants and days. Note that we only include usage data from the hearing aid that had the highest daily total. The “elbow” approach, i.e., visual inspection of between-cluster variance vs. cluster number, suggested the existence of four clusters . These cTogether with usage data, each remote log contains estimates of the ambient acoustic environment. Such data enables investigations of how environmental factors influence hearing aid usage—that is, an examination of true ecological hearing aid use.eq, daily median SNR, and the daily SPLSD were used as predictors to daily total hearing aid usage with usage estimated from remote logging. eqs and SPLSDs are approximately normally distributed with a grand median of 68.1 dB (SD = 6.9 dB) and 10.56 dB (SD = 2.6 dB), respectively. The daily median SNRs are right skewed with a grand median of 3.6 dB (SD = 1.4 dB), a minimum of 1.6 dB and maximum of 8.6 dB. In fact, only 6.4% of the raw logged SNRs were zero or negative.The daily SPL Ln = 1,907 days) explained 35% of the variance in day-to-day total hearing aid usage and of those 15%-point was related to the acoustic predictors alone. In addition, the acoustic predictors significantly improve the model's account of daily total hearing aid usage compared to an intercept-only model [Likelihood ratio test: p < 0.001] and there are significant main effects associated with each. The fitted coefficients for SPL Leq and SPLSD are positive , while SNR had a negative association with daily total usage . Day of the week (implemented as a random effect) was significant [Likelihood ratio test: p < 0.001] and the largest difference in the intercept of total daily hearing aid usage was Monday and Tuesday (+0.65 and +0.45 h) and Friday (−1.21 h). The VIFs were all <1.44. These results suggest that daily total usage is higher on days with more intense and more diverse sound environments, while days with easier listening environments (more positive SNRs) exhibited lower total usage. The lack of covariance between the acoustic predictors indicated by the low VIF suggests that these effects were independent of each other.The full LMM model (Tintrinsic) with the data log timestamps (Tremote). Note that Tintrinsic is not subjected to data loss, thus, it reflects true hearing aid on-time from the first to the last remote log each day. In While the analysis presented in the preceding sections highlights the potential of using remote logging to understand hearing aid user's ecology, the face-validity and representativeness of such data is still unknown since its generation requires a constant stable Bluetooth connection between hearing aid(s) and a smartphone. Here, we assess the extent to which the minute-based remote data logs correspond to true hearing aid on-time by directly comparing the daily total and the participant-average hearing aid usage measured by the intrinsic accumulation (Tremote − Tintrinsic) between daily usage estimates is 1.25 h (SD = 2.53 h). Pooled across all participants, individual days of data, and hearing aid laterality  the median difference (SD = 1.26 h). The fact that the pooled median difference in usage estimates is ~0.3 h lower than the grand median difference in usage estimates suggests that some participants consistently exhibit poorer connectivity than others. This might also explain the rather large difference in the two histograms of daily usage  by: Tintr is the daily usage from intrinsic logging  and Tremote is the daily usage estimated from remote logs. Next, we computed the average ΔTrel stratified by participant and hearing aid on-time (from intrinsic accumulation) in discrete bins. If connectivity is a fixed ratio of hearing aid on-time, we would expect a constant ΔTrel across all bins. On the other hand, if connectivity is a constant, we would expect a declining ΔTrel with increasing hearing aid on-time.Finally, when inspecting the distributions of estimated daily usage in Trel for each bin. Across all bins, the median ΔTrel is 0.15, which equals an overall connectivity [calculated as 100•(1−ΔTrel)] of 85% of the time a hearing aid is on. However, there is a significant change in ΔTrel with each step of on-time  = 86.88, p < 0.001], suggesting that connectivity first decrease slightly and is lowest between 3 and 7 h of daily usage and then continuously increase. In addition, visual inspection suggests that when on-times are longer than 5 h the inter-individual variability decrease, indicating more stable connectivity patterns across participants. Thus, connectivity is a constant when on-time is >5 h and therefore affect days with higher daily usage less than days with lower daily usage. We also assessed if the connectivity depended on the daily usage patterns identified by clustering (SD = 23.9%), 85.7% (SD = 20.8%), 85.1% (SD = 21.9%), and 83.8% (SD = 23.0%), respectively.ustering . For cluIn this study, we analyzed a longitudinal real-world dataset to demonstrate how remote data logging with hearing aids can produce behavioral and ecological insights into everyday and hourly hearing aid usage. At the same time, we evaluated the validity and representativeness of such data logging by estimating connectivity . The data consists of minute-based remote logs collected via Bluetooth transfer of data from hearing aids to smartphones of hearing aid on-time and measures of the ambient acoustic environment sensed by hearing aid microphones.The K-means algorithm applied to the pooled usage data estimated from remote data logs  identifieq), greater sound diversity (SPLSD), and more difficult listening conditions (lower SNR). These effects can perhaps be attributed to the fact that the longer a hearing aid is worn, the higher is the probability of experiencing varied acoustic environments that include high sound pressure levels and poor signal to noise ratios. However, this might also reflect the fact that individuals choose to wear their hearing aids when their communication needs are greatest, which tends to be in situations in which sound levels are higher and the acoustic environment is more complex, such as at home in the kitchen, in a restaurant, or in meetings , which means that derived insights accurately reflect individual behavior.Remote data logging using smartphone-enabled hearing aids can provide rich data regarding hearing aid usage and the ambient acoustic environment in which they are used. The data have high face-validity and smartphone connectivity is generally high (>85%). Days with poor connectivity can be identified and filtered out using statistical methods prior to assessing hearing aid usage patterns and their association to environmental factors.There are ethical restrictions on publicly sharing the dataset. The consent given by users did not explicitly detail sharing of the data in any format; this limitation is in keeping with EU General Data Protection Regulation and is imposed by the Research Ethics Committees of the Capital Region of Denmark. Data can be obtained by contacting the corresponding author and signing a non-disclosure agreement.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.JC drafted the manuscript and performed that data analysis. GS wrote significant contributions to the manuscript. LH and NP critically reviewed the manuscript. JC, LH, and NP conceptualized the study. All authors contributed to the article and approved the submitted version.The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.JC, LH, and NP are employed by Oticon A/S. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Beauveria isolates collected during a long-term survey in boreal forests of northern European Russia was studied. Based on morphological and sequence analysis of TEF and Bloc loci, three Beauveria spp. were identified: B. pseudobassiana, B. bassiana, and B. caledonica, with abundance of 81, 11, and 8%, respectively. Through multilocus sequencing, four haplotypes of B. bassiana and two haplotypes of B. caledonica were detected. Twelve haplotypes of B. pseudobassiana with non-random distribution were identified. Two haplotypes of B. pseudobassiana were the most abundant and widespread occurring across the whole study area, whereas others tended to be more specific to either the north or south of the study area, indicating the presence of different subpopulations. For further analysis of these putative subpopulations, southern and northern areas were separated along the boundary of the Köppen–Geiger climate zones (dfb and dfc), and the genetic structure was examined by analysis of molecular variance and spatial autocorrelation. Molecular evidence of intraspecific recombination of B. pseudobassiana and B. bassiana across northern European Russia area was indicated.The distribution and genetic diversity of 91 of  Beauveria includes globally ubiquitous soilborne arthropod-pathogenic pleomorphic fungi belonging to Cordycipitaceae  with high ecological and economical importance [Beauveria bassiana  Vuill. and Beauveria brongniartii (Sacc.) Petch are the most common fungi in mycoinsecticide formulations used to suppress various agricultural and forest insect pests [Beauveria spp. produce many secondary metabolites, which offer a promise for biotechnology [The genus portance ,2,3. Theportance . Beauverct pests . Beauverchnology ,7.Botrytis bassiana Bals.-Criv. Vuillemin established the new genus Beauveria and made B. bassiana the type species. During the twentieth century, it became clear that many species, which were previously assigned to Clavaria, Botrytis, Sporotrichum, Isaria, Tritirachium, and others, should be transferred to Beauveria [В. bassiana, B. brongniartii, and Beauveria alba (Limber) Saccas  C.C. Tsang et al.). Subsequently, Rehner et al. [B. bassiana s.l. and B. brongniartii s.l. into several cryptic species based on the three nuclear genes  and the nuclear intergenic region (Bloc) phylogeny. Consequently, the understanding of the taxonomic structure of Beauveria has been significantly broadened. Many species have since been described with the aid of molecular methods [Beauveria, previously only composed of species known from asexual morphs, being expanded to include taxa previously described by sexual morphs as Cordyceps [The history of research on this fungal group started in the early nineteenth century with the work of Agostino Bassi . He was eauveria . On the eauveria  then redr et al.  divided  methods ,15,16,17ordyceps .Beauveria were focused on B. bassiana s.l. These studies have revealed high genetic diversity within local geographical populations using a range of molecular methods, including RFLP, AFLP, DGGE, and microsatellite markers [Beauveria. Recent studies have been more consistent with the sequencing of nuclear intergenic locus Bloc being effectively mandatory for the determination of Beauveria phylogeny [Beauveria spp. have been reported from particular geographical regions, but a few species  have worldwide distributions. Several studies have demonstrated a strong association of B. bassiana with agricultural and B. pseudobassiana with forest ecosystems [The majority of studies concerning the community diversity, ecology, and population structure of  markers ,21,22,23hylogeny ,25. Mostosystems ,25.Beauveria spp. includes 17 orders of Arthropoda [Beauveria [The natural insect host range of thropoda ,26,27. Aeauveria ,30,31,32eauveria ,34.Beauveria, there have been considerably fewer studies in Russia (and the former USSR). Evlakhova [B. bassiana s.l. from the Baltic regions to Sakhalin and from the Kola Peninsula to Transcaucasia. Many previous studies were conducted using obsolete species names and, before the recognition of cryptic species in B. bassiana s.l. and B. brongniartii s.l., based on molecular markers. Therefore, there is a need to reevaluate the presence of species and intraspecific forms of Beauveria according to modern taxonomic understanding using contemporary research methods. Although there has been limited recent work on Beauveria phylogeny, more progress has been made on screening virulent strains for biocontrol purposes and their adoption as bioinsecticides [In comparison to the long history of global research on inter- and intraspecific diversity in vlakhova  reportedcticides ,36,37.Beauveria were undertaken independently in some but not all geographical regions; therefore, the available information is clearly incomplete. Consequently, the goal of this study was to contribute to the information on the species’ and interspecies’ genetic diversity within Beauveria in northern European Russia (NER) because no previous study with material from this region has been conducted with specific molecular markers. We hypothesized that B. pseudobassiana and B. bassiana have a non-random geographical distribution and genetic structure across this focus region.In Russia, systematic investigations of genetic diversity in This study combined data from three field surveys conducted in August 2017, 2018, and 2019 in boreal forest ecosystems of NER. During these surveys, insect cadavers with signs of mycosis were collected from under the bark of living trees, logs and stumps, and from litter around trees. Ninety-one fungal isolates were collected from infected host insects from 31 locations. In 2017, collections were made in the Republic of Karelia and the Leningrad region. The target areas shifted to the Vologda, Pskov, and Novgorod regions in 2018 and the Republic of Karelia and Arkhangelsk and Vologda regions in 2019. In addition, two accessions from the Pskov region, originally collected in 2013, were included in the analysis. The distance between the most distant locations was over 1000 km. A detailed list of the collections and Genbank accession numbers of sequences are given in Beauveria spp. and entomopathogens was performed based on the examination of macro- and micromorphological features.Fungal isolation was done by transferring conidia and mycelium fragments from insect cadavers on Sabouraud dextrose agar  with a sterile inoculating needle. When no conidia were observed, the stimulation of fungal development was done by the moist-chamber technique. Initial identification of Genomic DNA was prepared from homogenized mycelium in 1.5 mL Eppendorf tubes using CTAB/chloroform DNA extraction procedure . DNA pro2O. Parameters of DNA amplification were as in Rehner and Buckley [All PCR reactions were performed in a final volume of 25 μL containing 2.5 μL 10× PCR buffer, 0.5 μL dNTP mix (10 mM), 0.5 μL of each primer (10 μM), 0.15 μL of Taq DNA polymerase , 1 μL of genomic DNA, and 19.85 μL diH Buckley  and Rehn Buckley .The PCR product quality was assessed by electrophoresis on an agarose gel (1%) stained with ethidium bromide in 1× TBE buffer. The bands chosen for sequencing were excised and then purified with silica particles . The SanNucleotide sequences obtained were assembled and manually edited using Vector NTI Advance 11.5.1 software . Sequences were aligned using algorithm MUSCLE  in bioinBeauveria spp. The relative species abundance was considered as the percentage of isolates from each fungal species to the total number of fungal isolates. The species’ relative occurrence was estimated as the percentage of the locations in which a certain species was detected to the total number of locations.The number of haplotypes and haplotype diversity (Hd) were calculated using DnaSP v. 5.10 ,54. SpecBeauveria spp. isolates had a varying heterogeneous genetic structure in the southern and northern parts of the study area. Therefore, the boundary between the two Köppen-Geiger climate zones [http://koeppen-geiger.vu-wien.ac.at/present.htm (accessed on 4 March 2021)). The south area was in the Köppen-Geiger zone dfb with a warm-summer-humid continental climate, and the north area was in zone dfc with a subarctic climate. Arlequin 3.5 was used to test the hypothesis that variability in the genetic structure of B. pseudobassiana was related to climate zones (dfb and dfc) based on the hierarchical analysis of molecular variance (AMOVA) [te zones  was used (AMOVA) .SplitsTree 4.10 was used to find evidence of recombination based on phylogenetic incompatibilities of polymorphic sites along with concatenated sequences with PHI test ,58. The The standardized index of association (IAs) indicating the degree of linkage disequilibrium among different loci and significance of the null hypothesis was calculated under Monte Carlo simulation  with LIAN 3.7 . Indicesp < 0.05.We used the global multilocus spatial autocorrelation analysis implemented in GenAlEx 6.5  to descrThe geographical mapping of the sampling locations and species/haplotypes distribution were done with the R packages “maps” , “ggplotBeauveria was limited to three species: B. pseudobassiana, B. bassiana, and Beauveria caledonica Bissett and Widden. Beauveria pseudobassiana was the most frequently collected and abundant species (occurrence 77% and abundance 81%). Beauveria bassiana and B. caledonica were less dominant, with abundance of 11 and 8%, respectively.Overall, specimens (insect host cadavers) from 31 locations of northern European Russia were collected, and 91 fungal isolates were purified and sequenced . SpeciesBeauveria bassiana was collected in eight locations (occurrence 26%), usually separate from other species. However, in two locations (locations 12 and 26), B. bassiana was obtained from Coleoptera (Scolytinae) concurrently with B. pseudobassiana . Therefore, it could not be included in all statistical analyses.bassiana . BeauverBeauveria spp. across the study area was recorded (B. bassiana isolates (80%) were collected from the southern part of the study area (Köppen-Geiger zone dfb). In contrast, most B. pseudobassiana isolates (77%) were collected in the north (Köppen-Geiger zone dfc). Six B. caledonica isolates were collected from locations 9 and 8 in zone dfb, and only one (location 23) was from zone dfc.The uneven distribution of recorded B–D. MostB. pseudobassiana isolates were collected from Coleoptera; among them, a significant portion was isolated from hosts in the subfamily Scolytinae (73%). Less frequently, B. pseudobassiana was isolated from Lepidoptera (3%), Hemiptera (1%), Hymenoptera (1%), Diptera (1%), and undefined Insecta (5%). Beauveria bassiana was isolated from Coleoptera (50%), Hemiptera (10%), Hymenoptera (10%), Diptera (10%), and undefined Insecta (30%). Beauveria caledonica was only isolated from bark beetles (Scolytinae).About 88% of Beauveria spp., entomopathogenic fungi from other taxonomic groups were identified in the same locations: Akanthomyces cf. attenuatus (Zare and W. Gams) Spatafora, Kepler, and B. Shrestha , Cordyceps bifusispora O.E. Erikss (location 5), Cordyceps militaris (L.) Fr. , Cordyceps farinosa (Holmsk.) Kepler, B. Shrestha, and Spatafora , Metarhizium sp. (location 8), Ophiocordyceps entomorrhiza (Dicks.) G.H. Sung, J.M. Sung, Hywel-Jones, and Spatafora (location 29) and Tolypocladium sp.  all identified species including entomopathogenic fungi from other genera  theria spp. , and (3)plotypes . RarefacB. pseudobassiana was sufficiently greater than for the other two species. Total Hd for B. pseudobassiana isolates across all locations reached 0.638 (TEF), 0.738 (Bloc), and 0.863  and four Bloc alleles  and two Bloc alleles (cB1 and cB2). Each of the two B. caledonica haplotypes (cT1B1 and cT1B2) were found in separate climate zones.B. pseudobassiana isolates, and the genetic structure of this species was obtained in more detail. Beauveria pseudobassiana had four distinguishable alleles by TEF, which were marked as pT1, pT2, pT3, and pT4, according to their abundance . The most predominant allele was pB1.1, occurring in 47% of isolates. Less frequent were pB1.2 and pB3, with an occurrence within isolates of 12 and 14%, respectively. All other six Bloc alleles had an occurrence of less than 8% each and were detected in up to six isolates. Alleles pB1.1, pB1.2, and pB3 were more or less evenly distributed, whereas alleles pB2.1, pB2.2, pB4, pB5, and pB6 were found only in isolates from the northern zone. Allele pB1.3 was found in a single isolate from the Pskov region.The intergenic region Bloc of Haplotypes with a combination of pT1B1.1 and pT2B1.1 were the most frequent  and widespread. Haplotype pT1B1.2 had a uniform distribution and was detected in the Republic of Karelia and the Novgorod and Vologda regions but was quite rare. Since alleles pB2.1, pB2.2, pB4, pB5, and pB6 were found only in the northern zone, all occurred combinations with TEF alleles  were detected also strictly in the northern zone.B. pseudobassiana. For example, eight haplotypes were found in location 14 and four haplotypes in locations 17 and 20, respectively.It is worth noting that several haplotypes were collected from one location, revealing the highly variable heterogeneous haplotype structure of B. pseudobassiana in two climate zones (dfb and dfc), with each population corresponding to one location (p = 0.007), while it was lower and not significant between groups .location . This pap = 0.029) and exceeded the fixation index within populations  showing a strong population genetic structure at the group scale. As expected, the grouping of populations only by administrative boundaries did not provide evidence of a genetic structure at this level .To avoid the impact of heterogeneity within locations, we increased the size of the populations and linked them to the administrative division . In this case, the fixation index between the groups was significant  between the haplotypes across the area of NER studied (p = 0.010) and still reflected the recombination process . Further testing of B. bassiana in zone dfb did not confirm recombination. Testing of B. bassiana (dfc) and B. caledonica  did not provide evidence of recombination due to the insufficient informative characters  Siemaszko in the old Russian-language literature devoted to entomopathogens of boreal forests [B. caledonica and the absence of B. brongniartii in the presented dataset, considering their similar morphological characteristics [B. brongniartii (=B. tenella) determinations in the earlier Russian literature may actually refer to B. caledonica, which was recently detected in Russia and considered to be quite rare [The 91 fungal  forests . The exiite rare .Beauveria spp. in the study area made it necessary to more closely examine the data to seek an explanation for this phenomenon. Analysis of biodiversity according to artificial administrative boundaries has widely been used but was not suitable in terms of ecology, especially if we can define any gradient of environmental factor. For these purposes, we divided the survey area north–south by climate zone (dfb and dfc) according to the Köppen-Geiger climate classification. The division was between the warm-summer-humid continental climate and subarctic climate. However, it is possible that a division of the southern and middle boreal forests would be more informative, even though this boundary is relatively close to the boundary between dfb and dfc.Intraspecific heterogeneity of B. bassiana and B. pseudobassiana was revealed. Earlier studies indicated a strong association of B. bassiana with agricultural and B. pseudobassiana with forest ecosystems [B. pseudobassiana, and the proportion of B. bassiana increased towards the southern (dfb) more agricultural areas  than in B. bassiana (4 haplotypes per 10 isolates). In contrast, phylogenetic studies of Beauveria spp. isolated from soils in Slovakia based on sequencing analysis of ITS and Bloc loci found a limited genetic structure in B. pseudobassiana since one haplotype was found in 47 isolates. In contrast, only a slightly larger number of isolates (56) of B. bassiana had 15 haplotypes [Beauveria spp. in natural and agricultural ecosystems in China based on 641 isolates, 14 haplotypes of B. pseudobassiana and 13 haplotypes of B. bassiana were identified [Sequencing of TEF and Bloc indicated significantly more haplotype richness in plotypes . While sentified . We founB. bassiana in relatively small areas has been reported frequently [B. bassiana isolates collected in pine forests in southeast China. Seven SSR markers used to study 81 B. bassiana isolates from Lygus hesperus of San Joaquin Valley  found three to nine distinct alleles [B. bassiana s.l. into several phylogenetic species.High haplotype diversity of equently ,21,22,23equently  characteB. brongniartii [Beauveria, including B. pseudobassiana, that also have a confirmed sexual reproduction cycle [B. bassiana and B. pseudobassiana isolates revealed that sexual or parasexual recombination across NER is possible. Based on our experience and multi-year surveys, there was no evidence of a teleomorph of these species that could be confirmed from the specimens collected. Cordyceps teleomorphs within the Beauveria clade have been mainly reported from East Asia or Amazonia [A teleomorph–anamorph connection was previously reported for gniartii . Currenton cycle ,16,18,72Beauveria species diversity, with only three species  confirmed by molecular methods. Despite earlier reports of B. brongniartii in northern European Russia, it was not recollected in this more comprehensive study, so these are considered doubtful. Consistent with earlier findings, B. pseudobassiana was more abundant in forest ecosystems, and B. bassiana increased in occurrence towards the more agricultural areas sampled. Significant haplotype diversity in B. pseudobassiana revealed widespread haplotypes and haplotypes that tended to occur in the more northerly areas. Despite the absence of teleomorph specimens in this study, there was molecular clear evidence of intraspecific recombination in B. pseudobassiana and, to a lesser extent, in B. bassiana.The boreal forests of northern European Russia are characterized by low


With the increasing prevalence of syphilis in different parts of the world, it is important to be cognizant of serious forms of syphilis. Otosyphilis is a rare form of syphilis with an extremely high rate of complications. Early diagnosis is essential to prevent a complete loss of hearing and decrease mortality. We present a unique case of otosyphilis who presented with left hearing loss, tinnitus, and vertigo, with audiometric findings confirming the hearing loss. An MRI brain showed asymmetric enhancement of the left cochlea and vestibular apparatus. She initially received oral steroids and trans-tympanic steroid injections with transient improvement of symptoms. She was diagnosed with syphilis through contact tracing after her ex-boyfriend tested positive. She received three weekly doses of intramuscular penicillin. Interestingly, her symptoms, rapid plasma regain (RPR) titer, and audiometry findings markedly improved. Once a diagnosis of otosyphilis was established, she received 14 days of intravenous penicillin. Treponema pallidum, remains to be one of the major sexually transmitted infections in the USA [Syphilis, caused by  the USA , 2. Desp the USA . Otosyph the USA . If not  the USA .A thirty-three-year-old female patient presented with a decreased hearing of L-ear, tinnitus, and vertigo of three weeks' duration. She started to experience decreased hearing and tinnitus suddenly while she was playing the piano. She developed vertigo later the same day while she was exercising. She denied preceding trauma and having ear pain or ear discharge. There was no change in the severity of her symptoms. Her vital signs were stable. When she was seen at the ear, nose, and throat (ENT) clinic, she had no mastoid tenderness. Both ears had ear canals and tympanic membranes were intact with normal landmarks. An audiogram showed a normal right ear but a mild sensorineural hearing loss of 2000–8000 Hz in the left ear. Viral labyrinthitis and an early episode of endolymphatic hydrops were considered and started on a two-week course of oral steroid and a low salt diet and encouraged to hydrate. Her symptoms improved while she was on steroids, but only to recur when steroids were stopped.Her course was complicated by the development of a generalized nonpruritic maculopapular rash as soon as she completed treatment with oral steroids. The rash spared the palms and soles. She had associated sore throat. She was evaluated by a dermatologist and received doxycycline  for 4 weeks for possible folliculitis and rosacea. At the end of treatment with doxycycline, the skin rash resolved, but she continued to have decreased left ear hearing, tinnitus, and vertigo. Ear examination was unchanged and the left ear audiogram showed worsening . MRI obtAbout three months after presentation, she got a call from her former boyfriend who had been tested positive for syphilis and she was told to get tested. Subsequently, she was found to have a positive fluorescent treponemal antibody absorption (FTA-ABS) test, and a rapid plasma regain (RPR) titer of 1 : 64. The fourth-generation HIV ELISA was negative. She received three weekly doses of 2.4 million units of intramuscular penicillin G. Her L-ear symptoms markedly improved after the first penicillin dose and resolved after the third dose. A repeat audiogram showed a marked improvement . The lefμL with normal glucose and protein. CSF venerable disease research laboratory test (VDRL) was negative. Although her clinical symptoms resolved and RPR titer decreased, the audiogram result of the left ear was not as normal as the right ear. Therefore, she was started on a 14-day course of intravenous penicillin (24 million units per day).About 6 months after her presentation, she was seen at an infectious disease clinic. Tinnitus and vertigo have resolved. The left ear hearing was back to normal. A follow-up RPR titer was 1 : 8. Cerebrospinal fluid (CSF) analysis showed 2 white blood cells per This case is unique because (i) the diagnosis of otosyphilis was made after a patient was identified through contact tracing, (ii) partial or no response to steroids or doxycycline, and (iii) marked clinical, audiometric, and serologic response following three doses of weekly intramuscular penicillin G. The prevalence of syphilis is increasing, mainly associated with HIV , 6. ThisOtosyphilis is one of the complications of syphilis that may lead to deafness and other complications if untreated . OtosyphBecause it is rare, treatment guidelines rely on results from case series and case reports . It is rIn conclusion, otosyphilis should be considered in sexually active patients with unilateral sensorineural hearing loss, and appropriate treatment is essential to prevent irreversible hearing loss.


POU3F4 gene mutation. The IP-III anomaly is mainly characterized by incomplete separation of the modiolus of the cochlea from the internal auditory canal. We describe a 71-year-old woman with profound sensorineural hearing loss diagnosed with an IP-III of the cochlea that underwent cochlear implantation. Via targeted sequencing with a non-syndromic gene panel, we identified a heterozygous c.934G > C p. (Ala31Pro) pathogenic variant in the POU3F4 gene that has not been reported previously. IP-III of the cochlea is challenging for cochlear implant surgery for two main reasons: liquor cerebrospinalis gusher and electrode misplacement. Surgically, it may be better to opt for a shorter array because it is less likely for misplacement with the electrode in a false route. Secondly, the surgeon has to consider the insertion angles of cochlear access very strictly to avoid misplacement along the inner ear canal. Genetic results in well describes genotype-phenotype correlations are a strong clinical tool and as in this case guided surgical planning and robotic execution.Incomplete partition type III (IP-III) is a relatively rare inner ear malformation that has been associated with a  POU3F4 gene [Congenital hearing loss is one of the most common inherited human pathologies that occur in 1–2 out of 1000 newborns . X-Linke3F4 gene .POU3F4 are reported to cause cytoplasmic localization and then proteasomal degradation due to structural abnormalities, leading to non-syndromic hearing loss [POU3F4 gene encodes a transcription factor that consists of two parts, the POU-specific domain, and homeodomain, belonging to the POU-domain family [Douville et al. reported that Pou3f4 is expressed during embryonic development in the brain, neural tube, and otic vesicle in rats . Frameshing loss . The POUn family ,10. It in family . Pou3f4 n family . In addin family .POU3F4 pathogenic variants have shown that hearing loss results from a functional deficiency of the POU3F4 protein [POU3F4 genomic region that do not include the POU3F4 coding sequence [POU3F4 pathology is rare compared to other genetic hearing losses. The hearing loss in patients with different POU3F4 pathogenic variant types vary greatly. Thus, conduction type, mixed or sensorineural hearing loss (SNHL) can be observed in patients with POU3F4 pathogenic variants [Studies of the  protein  and varisequence . Despitevariants ,28,29,30POU3F4 in studies [This hearing impairment, also known as DFNX2, was described by Nance in 1971 as X-linked deafness in men and characterized by profound mixed hearing loss, vestibular abnormalities, and congenital fixation at the stapes with perilymphatic gusher . Later,  studies ,40,42,51 studies .CI is the most effective neural prosthesis in humans to rehabilitate profound SNHL. DFNX2 patients were classified in the IP-III group, which led to some difficulties in CI application in the cochlea that may occur during or after surgery. Although audiological outcomes CI in IP-III anomalies have been noted to be slightly inferior to a normal cochlea ,53,54, CRACIS pursues a minimally invasive direct access towards a designated target instead of a larger surgical exposure. Surgical exposure requires the identification of landmarks to work safely , whereasA 71-year-old woman with profound SNHL diagnosed with an IP-III was referred for diagnostic work-up and candidacy selection for cochlear implantation in her right ear.Baseline hearing tests were performed before and after surgery as part of the standard cochlear implantation workup. They included standard pure-tone audiometry and speech audiometry in quiet, with and without hearing aids included, and performing according to ISO 8253–1 (2010) standards to obtain pure air tone and bone conduction thresholds. The hearing thresholds were determined using pulsed pure tones in the frequency range of 125 Hz to 8 kHz.Molecular analysis was performed in the index patient using standard techniques on DNA extracted from fresh blood. First, a gene panel consisting of 84 genes known to play a role in non-syndromic hearing loss was enriched with Haloplex and sequenced on a NextSeq500 sequencer . Sequence data were analyzed with SeqNext Analysis Software . 30 × coverage for >95% of the coding sequence from each gene, then 30 × coverage for >98% of the total coding sequences of all genes for the total gene panel. After validation of potential pathogenic variants by Sanger sequencing, the variants were classified according to The American College of Medical Genetics and Genomics guidelines .ClinicalTrials.gov NCT04102215) was performed with the approval of the Antwerp University Hospital ethics committee (B300201837507). The HEARO® robotic system  is an otological surgical robotic platform with a focus on cochlear implantation surgery  allowed the surgeon to plan a 3D reconstruction of all relevant anatomical structures and designated the target on the cochlea, and planned the most suitable trajectory to the cochlear round window. This trajectory accommodated the safety distance to the critical structure while minimizing the in and out-plane angles [The patient agreed to RACIS with written informed consent and the study  XCAT XL  confirmed the correct and full insertion with 417 degrees of cochlear coverage at the tip .POU3F4 gene (NM_000307.4). By subsequent familial screening, her two affected sons were shown to be hemizygous for this variant. Her daughter was a heterozygous carrier. This variant has not been reported before and is located in the POU homeoboxdomain. An alanine to valine substitution at the same amino acid position has been reported previously as the cause of hearing loss [A positive familial history of hearing loss was present. The proband of the family was a 71-year-old woman (I:2) who had profound SNHL with late-onset and it progressed with age. Her two sons  and her daughter’s son (III:1) presented with prelingual hearing loss . Next-geing loss . Apart fIntraoperative telemetry revealed low impedances on all electrode contacts (1.75–6.03 kΩ). The first activation of the implant speech processor took place 4 weeks after surgery. With this procedure, sound field thresholds were improved with the implant system applied to the right ear. One month after activation, pure tone averages close to 43 dB HL were achieved with the CI processor and are shown in POU3F4 mutation, it was reported that SNHL increased with age [SNHL due to x-linked deafness (DFNX2) by pathogenic variants in the POU3F4 gene were initially concealed by a consistent air-bone gap ,41. In twith age . Hearingwith age ,68. It iwith age . ConsequOur patient, in this case, was a 71-year-old female patient and had a late profound sensorineural hearing loss that progressed over time. Profound hearing loss can be rehabilitated with CI, although the surgery is challenging due to their inner ear anomaly. There are significant risks in surgery, such as gusher during cochleostomy and electrode misplacement into the IAC ,58. For Robotic technology is thought to allow minimally invasive cochlear access, a controlled electrode placement process, and is also unaffected by human operator limitations . Since tHere we illustrate the usefulness of RACIS in an IP-III anomaly. In CI surgery performed on patients with IP-III anomaly, gusher was reported in all cases in many studies ,62,77,78We have demonstrated for the first time that RACIS can be applied safely in DFNX2 patients with the HEARO procedure, which provides us with these features. We argue that robotic surgery can never replace a surgeon, but it may reach a level such as an autopilot function to control the trajectory of an aircraft. Surgeons should reach out to this technology to standardize surgical outcomes to serve their patients.IP-III anomaly, one of the rarest inner ear anomalies, is also the rarest among incomplete partition groups. Conventional CI is a safe procedure for those with severe-profound mixed hearing loss due to inner ear malformation associated with the POU3F4 mutation and CI can be recommended among the treatment options depending on the level of hearing loss, although there are some surgical difficulties. The present study reports on the first case of IP-III where robotically-assisted cochlear implantation surgery was performed. A technique that provided targeted minimally invasive inner ear access.


The global burden of disability continues to increase. Understanding the hierarchical structure of activities of daily living (ADL) and the trajectories of disability of elderly individuals is pivotal to developing early interventions.To determine the hierarchical structure of the ability of Chinese elderly individuals to perform ADL and further describe the trajectories of disability prior to death.κ−partial and κ−total) were used in the LIRT defining the thresholds for hierarchical structure in ADL . Disability values estimated from the LIRT were fitted to a mixed-effects model to examine the manner in which the trajectories of disability varied with different subject characteristics.Longitudinal item response theory model (LIRT) was constructed for 28,345 elderly participants in the Chinese Longitudinal Healthy Longevity Survey, in which ADL were measured using the Katz scale from 1998 to 2018, until the participants’ death. Two difficulty parameters , toileting) at the level of partial limitation, with an overlap of partial and totally limited , and finally a total loss of capability for toileting, feeding, transferring, and continence . Disability trajectories varied with sex , place of residence , and marital status . Females, individuals living in urban areas, and those who lived without a spouse had a poorer disability status.The findings confirmed the earliest loss in the capability to perform ADL (bathing(The loss in the ability to perform ADL has a hierarchical structure. Subject characteristics affect trajectories of disability in the elderly Chinese population.The online version contains supplementary material available at 10.1186/s12877-021-02460-y. The proportion of the global population that will be older than 60 years of age will nearly double by 2050 as life expectancy increases and birth rates decline . HoweverScientists generally interpret disability as the loss or a limitation of a person’s ability to perform activities of daily living (ADL), an important indicator of individual health. Researchers use the Katz Index, CARS scale, and Lawton scale to assess disability , 6. HoweIt has been found that ADL are hierarchical in nature , 12. A nThe present study aimed to use LIRT and a mixed-effects model to study the hierarchical structure of ability to perform ADL and the trajectories of disability of individuals over 60 years old in China. The outcomes will constitute a reference for the development of effective interventions for elderly people living with disability.The Chinese Longitudinal Healthy Longevity Survey (CLHLS) began in 1998 with data collection continuing in 2000, 2002, 2005, 2008–2009, 2011–2012, 2014, 2017–2018, representing eight waves in total. Investigations were conducted randomly in approximately half of the cities/counties in 23 of 31 Chinese provinces, the total population of which represented approximately 85% of the total population of China. Due to the mixed longitudinal design of CLHLS, only one-third of subjects from each wave had been studied in the previous wave, with new recruits representing the remaining participants. From 1998 to 2014, 71,130 participants were interviewed, including 16,582 centenarians, 23,207 nonagenarians, 20,135 individuals aged 65–79, and 11,206 adults aged 35–64. A total of 12,411 new subjects were included in the cohort in 2018. A more detailed analysis has been made of these [To fully reflect the natural developmental processes of disability status prior to death, a dynamic model was constructed that spanned all eight waves in which participants older than 60 years of age were selected, with the exact age at death, including those who had at least one Katz measurement available for inclusion in the analysis. We excluded all individuals with incomplete data describing subject characteristics. The data processing process was depicted in Fig. The present study used the Katz scale to assess the ability of individuals to perform activities of daily living, which the Katz scale evaluates, including bathing, dressing, transferring, feeding, toileting, and continence, using a three-point scale  for task performance. The Chinese version, which has been extensively tested in pilot interviews, has yielded reliable and valid responses . Particiκ-partial and κ-total) defining the thresholds for change . For example, bathing-partial indicated the threshold from no limitation to partial limitation for bathing. In the disability severity continuum, items with a small κ represent activities that elderly individuals are more likely to lose the ability to perform. In the present study, difficulty parameters reveal the hierarchical structure of the ADL. (II) An item with a higher discrimination parameter (α) is one for which individuals could more closely be positioned at the correct disability level.In light of the ordered categorical responses of the Katz scale, a graded response model (GRM), proposed by Samejima  was seles) response score of a specific item (i) at a given time (t) was recorded as Ys, t, i, while the corresponding disability status of an individual was θs,t . In the present study, the response category of every item was K = 3, with a cumulative probability expressed as Ps, t, i, K = 1.Ki, k represented the difficulty parameter of item i, and αi represented the discrimination parameter of item i. k corresponded to the selected category of the individual. The longitudinal aspect of the model was captured by setting θs, t = γs0,  + γs1,  × t. γs0,  and γs1,  represented the intercept and slope of disability status. The mean value of γs1,  was described by μ, representing the mean decline of ADL over time. γs1,  was modeled as Zs represented each characteristic of a subject, including sex, age, years of education, place of residence, and marital status, β referred to the regression coefficients of Zs, while γs1, . Age and years of education were zero-centered and standardized for model fitting.To achieve the dual goals of identification of difficulty and discrimination parameters of the Katz scale and assessment of the decline in the ability to perform ADL, we chose an LIRT model for data analysis . Each inγs0,  [N  prior distribution. The slope γs1,  selected a hierarchical prior distribution.The model was cast within a Bayesian framework and then implemented using a Markov Chain Monte Carlo (MCMC) method. The posterior 95% credible interval for each parameter was displayed with posterior credible intervals . A weak information prior distribution was adopted in all parameters except γ0, s , which ut) and the disability level (θ) of the elderly individual, obtained using the aforementioned LIRT, represented the dependent variable . A mixed-effects model [To determine trajectories of disability, the time between interview and death was used as the independent variable  was multivariate normally distributed with mean of zero and a 2 × 2 variance-covariance matrix Σ. Using this process, t was considered level one, s as level two, and all subject-specific covariates  were included in the model as adjustment factors.where 3.5.3 environment. OpenBUGS software used thin = 1 and 1000 iterations after a 4000 burn-in.The LIRT methodology was performed using OpenBUGS software while calculations for the mixed-effects model were conducted using MLwiN software. Pre and post-data processing were completed in the RThe exact age at death was recorded for 28,390 individuals for which there was at least one Katz record. After excluding 45 individuals with incomplete covariate data (a missing ratio of 0.15%), 28,345 participants were included in the study. The median elapsed time between the initial and final visit was 3 years (range: 0–19 years). Females accounted for approximately 60% of the study population , 0.003)) and toileting-partial ) were observed in succession. The last item for which the elderly required partial assistance was continence. Bathing was the first task that was restricted at the level of totally limited ). Finally, at the end of the structure, feeding ), transferring ), and continence ) were totally limited.The hierarchical structure of declining ability to perform ADL, provided by the estimated difficulty parameters, is presented in Table γs1, . Sex, years of education, place of residence, marital status, and age displayed significant associations with slope values. The value can only be interpreted in relative terms (not the risk of disability), such that males, older age, fewer years of education, urban residence, and living without a spouse was associated with a faster decline. The posterior mean of the slope parameter μ was 0.857 , indicating that individual disability increased by 0.857 units per year.Table β = 0.041, SE = 0.001), place of residence , and marital status . Females, individuals residing in urban areas, and those living without a spouse had a poorer disability status. Further cross-group analysis in Fig. Trajectories of disability varied with sex  than the other activities (ranging from 0.759 (dressing) to 3.507 (transferring)). Furthermore, its discriminative capability was very high, indicating that the item correctly discriminates between individuals at the two levels of disability.The second ADL to be lost was toiletingThe Bayesian methodology allowed longitudinal slope estimates to remain vague for subjects with little (or no) follow-up time. We fitted our model on all participants and concluded that males, greater age, fewer years of education, living in rural areas or without a spouse were associated with a faster deterioration in the ability to perform ADL. We discovered that older females had a higher level of disability, but their functional capabilities deteriorated at a slower rate. As a result, there are a larger proportion of dependent women within the elderly population in China. Education has always been considered a factor that slows aging and decline in ability –40. The The estimated trajectories of disability highlighted that the extent of disability became progressively serious as death approached. Trajectories of disability at the end of life are quite variable , 46. In The innovative feature of the present study was that it relied on a longitudinal analysis of long-term follow-up data from a substantial sample of the general elderly population. Moreover, the LIRT and mixed-effects models allowed a capture of the multifaceted nature of disability. The LIRT also allowed us to estimate item and disability distribution parameters, as the data were from a longitudinal cohort study. In addition, the correlation between the subject-specific characteristics and the slope of deterioration was embedded in the same model.Three limitations of this study should be noted. It has been suggested that instrumental ADL (IADL) and ADL have a hierarchical relationship, with older adults first declining in IADL functionality , 49. HowIn conclusion, toileting and bathing are promising domains for detecting early signs of disability in the elderly Chinese population. At the same time, toileting and transferring are more discriminative than other ADL items. LIRT methodology and the mixed-effects model, as applied here in an elderly population, are suitable methods to jointly capture the multifaceted nature of disability and its rate of change. As a result, we found that males, those of older age, fewer years of education, living in rural areas, and living without a spouse often decline faster in their ability to perform ADL. However, females, individuals who live in urban areas and those without a spouse had a lower ability to perform ADL. Therefore, we recommend a reasonable allocation of health resources toward mitigating declining ability and encourage the widowed elderly to engage in more social activities. Furthermore, health interventions are required to address deficits in the home bathing environment, especially in developing countries such as China.Additional file 1: Table S1. Disability status of the elderly with cross-group characteristics.


Purpose: Available evidence indicates that kinetochore-localized astrin/SPAG5-binding protein (KNSTRN) is an oncogene in skin carcinoma. This study aimed to evaluate the prognostic value of KNSTRN in lung adenocarcinoma (LUAD) underlying the Cancer Genome Atlas (TCGA) database.Methods: The relationship between clinicopathological features and KNSTRN was analyzed with the Wilcoxon signed-rank test and logistic regression. The clinicopathological characteristics associated with overall survival (OS) were evaluated using Cox regression and the Kaplan-Meier method. Gene ontology (GO) analysis, gene set enrichment analysis (GSEA), and single-sample GSEA (ssGSEA) were performed using TCGA data.Results: The KNSTRN expression level was found to be significantly higher in LUAD tissue than in normal lung tissue. Also, it correlated significantly with advanced clinicopathological characteristics. The Kaplan-Meier survival curve revealed a significant relationship of high expression of KNSTRN with poor OS in patients with LUAD. The multivariate Cox regression hazard model demonstrated the KNSTRN expression level as an independent prognostic factor for patients with LUAD. GO and GSEA analyses indicated the involvement of KNSTRN in cell cycle checkpoints, DNA replication, and G2-M checkpoint M phase. Based on ssGSEA analysis, KNSTRN had a positive relationship with Th2 cells and CD56dim natural killer cells. The KNSTRN expression levels in several types of immune cells were significantly different.Conclusion: The findings suggested that the increased expression level of KNSTRN was significantly associated with the progression of LUAD and could also serve as a novel prognostic biomarker for patients with LUAD. Lung cancer is still the leading cause of cancer-related death in both men and women worldwide KNSTRN) gene, also known as a small kinetochore-associated protein gene KNSTRN in 19% of cutaneous squamous cell carcinoma (SCC) KNSTRN, more than half of them mapped to a 17-amino-acid N-terminal region, with a “hotspot” serine-to-phenylalanine substitution present at codon 24 (p.Ser24Phe). In addition, KNSTRN mutations were found in 23 of 490 (4.7%) melanomas, and the p.Ser24Phe mutation was found in 19% actinic keratosis (AKs) KNSTRN gene, especially the p.Ser24Phe mutation, might functionally lead to disrupted chromatid cohesion in normal cells and correlated with increased aneuploidy in primary tumors and enhanced SCC development in vivoKNSTRN gene was associated with basal proliferative AK lesions and invasive carcinoma KNSTRN, the essential molecular for cell-cycle progression, may be related to the proliferation of cancer cells. Recent studies also found that altered KNSTRN expression resulted in the loss of chromatid cohesion in the noncutaneous tumor cell line HeLa cells. These data suggested a possibility that aberrant KNSTRN expression might exist in other tissues as well as in the skin, and played an important role in tumorigenesis.The kinetochore-localized astrin/SPAG5-binding protein  database. To gain further insight into the potential functions, the biological pathways involved in LUAD pathogenesis-related KNSTRN regulatory network, Gene Ontology (GO) analysis and gene set enrichment analysis (GSEA) were performed. Moreover, the relationship of KNSTRN with tumor-infiltrating immune cells in different tumor microenvironments was analyzed using single-sample gene set enrichment analysis (ssGSEA).Thus, the objective of the present study was to evaluate the prognostic value of https://portal.gdc.cancer.gov). There was a total of 522 cases of lung adenocarcinoma. Eventually, 513 patients were enrolled into analysis due to eligibility of both clinical information as well as RNA-seq data. The transcript expression levels were estimated using the fragments per kilobase per million fragments mapped (FPKM) method in HTSeq. Also, the RNA-Seq gene expression level 3 HTSeq-FPKM data of 513 patients with LUAD and clinical data were converted into transcripts per million (TPM) reads format for further analysis.Clinical information of lung adenocarcinoma patients and high-throughput RNA-sequencing data were downloaded from the TCGA database  KNSTRN and its list of differentially expressed molecules, including biological processes, molecular functions, and cellular components. The parameters were set at P < 0.01, minimum count > 3, and enrichment factor > 1.5. The GSEA KNSTRN expression-related pathways and ranked the genome 1000 times per analysis. The C2.all.v6.2.symbols.gmt composition was used as the reference gene set. The threshold for statistically significant GSEA analysis was set to a corrected P < 0.05 and an FDR < 0.25. The results of the enrichment analysis were characterized using corrected P values and normalized enrichment scores (NESs). The Cluster Profiler package The Metascape . The Wilcoxon rank-sum test was used for unpaired samples, while the Wilcoxon signed-rank test was used for paired samples. The receiver operating characteristic (ROC) curve was used to analyze whether KNSTRN expression in LUAD and normal tissues was analyzed, revealing a difference in the KNSTRN expression levels in LUAD and normal tissues  of KNSTRN was 0.815, and the results suggested that KNSTRN might be a potential diagnostic biomarker  = 1.04 (1.02-1.07), P < 0.001], N stage , clinical stage , tumor status , outcome of the primary therapy , and TP53 mutation  , progression-free survival (PFS), and disease-specific survival (DSS) are shown in Figure KNSTRN was associated with poor OS , M0 stage , stage I , age >65 years , and smokers ; high expression of KNSTRN was related to poor OS . Moreover, high expression of KNSTRN was an independent prognostic factor for OS [HR = 1.730 (1.288-2.234), P < 0.001, Table KNSTRN expression were used to construct a clinical prognostic risk score for LUAD  , the enrichment signaling pathway most significant in terms of KNSTRN gene expression was selected , DNA replication (B), cell cycle (C), mitotic spindle checkpoint (D), G2-M checkpoint 9 (E), and M phase (F).GSEA analysis of the TCGA gene expression data was used to identify functional and biological pathways between low and high expression of ted Fig. . GSEA anKNSTRN expression and 24 different immune cell types was evaluated in LUAD. KNSTRN expression had a close positive relationship with T helper 2 (Th2) cells, Tgd, and NK CD56dim cells, and a close negative relationship with T follicular helper (TFH) cells, mast cells, immature dendritic cells (iDCs), and so forth , survival time, and poor prognosis. Additionally, the subgroup analysis indicated that KNSTRN expression could be used to stratify the prognosis of patients with stage I LUAD. It might also be useful when identifying stage I patients with undesirable prognoses and subsequently guiding their therapeutic regimen. KNSTRN was further validated as an independent prognostic factor for OS in multivariate analysis. In summary, KNSTRN overexpression was associated with cancer progression and poor prognosis in LUAD. It also found to be a diagnostic marker and might be used in the early screening of LUAD.Previous studies showed that KNSTRN was a mitosis-associated protein that contributed to chromosome alignment, accurate chromosome segregation, and maintenance of spindle pole architecture KNSTRN (p.Ser24Phe) KNSTRN, such as overexpression, might be involved in the development of cancer. With respect to the molecular mechanism involved, the STRING website (https://string-db.org/) was employed to predict the potential genes' interaction with KNSTRN. The corresponding protein-protein interaction (PPI) network of KNSTRN was constructed when we selected the interactions pertaining to Homo sapiens, chose physical network and showed minimum interactions with a medium confidence = 0.4 , memory T cells (Tc and Tem), NK cells, DC (iDC and pDC), eosinophils, macrophages, neutrophils, and mast cells. Together these findings suggested that KNSTRN might play an important role in regulating immune functions in LUAD.Another important aspect of this study was that KNSTRN in LUAD also needs further verification.Since KNSTRN was recognized as an oncogene only recently, the present study was performed to investigate its relationship with different progression steps and gradings of LUAD. However, a limitation of this study was that only one dataset was included, and it was not validated in our own clinical samples. Thus, further experimental verifications are necessary to elucidate the biological functions of these predicted molecular mechanisms in LUAD to deepen our understanding of the direct impact of KNSTRN on LUAD. Moreover, the prognostic value of KNSTRN in LUAD tissues compared with normal lung tissues. High expression of KNSTRN in patients with LUAD was significantly associated with advanced clinicopathological characteristics. Survival analyses indicated that high expression of KNSTRN could serve as an independent factor for poor survival in patients with LUAD. Furthermore, the KNSTRN high-expression phenotype was associated with cell cycle checkpoints, DNA replication, cell cycle, mitotic spindle checkpoint, G2-M checkpoint, and M phase, as revealed by GSEA putatively via physical interactions of CENPE, CENPL, PRPF19, and KIF2B. Taken together, the findings suggested that KNSTRN could be a novel prognostic biomarker for patients with LUAD. However, the mechanisms by which KNSTRN promotes tumor progression and metastases in LUAD need further elucidation.In summary, the data showed aberrantly increased expression levels of Supplementary figure S1.Click here for additional data file.


Hearing loss is common and associated with reduced quality of life, particularly among elderly people. However, many patients do not use hearing aids. We evaluated the use of hearing aids among people with hearing loss by health services availability near their residence in a rural area in the state of Brandenburg, Germany.Audiometry was performed in a convenience sample of subjects in ten towns and hearing loss was determined, defined as a threshold of ≥ 30 dB in at least one ear and at least one of the frequencies 0.5, 1.0, 2.0 and 4.0 kHz. For each participant, age and gender were collected and whether or not hearing aids were available.p trend = 0.001).Among 186 persons with an average age of 74 years (interquartile range 71–81), 97% had hearing loss [95% confidence interval (CI) 95–100]. Among 121 patients with hearing loss who reported whether or not they have a hearing aid, 93 had no hearing aid . The proportion of hearing-impaired persons who do not have a hearing aid significantly increased with the absence of a hearing aid specialist or ear nose throat (ENT) physician or both in the town where the tests were performed (Hearing loss is common among elderly people in the study area and many people in rural areas in Germany may not be properly supplied with hearing aids due to lack of hearing aid specialists and/or ENT physicians close to their residence. Interventions to improve this situation are urgently required. Over 5% of the world’s population suffer from hearing impairment defined as hearing loss greater than 40 dB in the better hearing ear for adults and greater than 30 dB for children. It is estimated that by 2050 over 900 million people—or one in ten—will have disabling hearing loss . The mosHearing loss can have profound effects on health, since it is associated with poor cognitive performance , increasPresbyacusis is underdiagnosed and undertreated in Germany. A recent systematic review on hearing loss in Germany  identifiDefinitions of hearing loss are very heterogeneous and use different thresholds (dB) for at least one or the average of several frequencies  in at least one ear or in the better hearing ear . Accordi2  (Table p  = 0.307): 94% in Bad Belzig, 97% in Lehnin/Brück and Treuenbrietzen, 94% in Luckenwalde/Jüterbog, 100% in Premnitz and Genthin, 97% in Rathenow and 100% in Ziesar (Table The proportion of patients with hearing loss was similar across towns (p = 0.001) . The proportion of patients with hearing loss who do not have a hearing aid is increasing from 45 patients (67%) in towns with an ENT physician and a hearing aid technician  to 24 (80%) in towns with only a hearing aid technician (Rathenow) to 24 patients (100%) in towns with neither profession (Ziesar and Lehnin/Brück/Treuenbrietzen), which is a significant trend . An average hearing loss exceeding 60  dB was observed in 87  ears , including 26  ears without a hearing aid.In a cross-sectional convenience sample of mostly elderly people from ten rural towns in the German state of Brandenburg, we observed a high proportion of patients with hearing loss. The majority of patients with hearing loss did not have hearing aids. The proportion of underserved patients decreases with the availability of health professionals in the towns.The proportion of patients with hearing loss was 97%, where hearing loss was defined as a threshold of 30 dB or more in at least one ear and at least one of the frequencies 0.5, 1.0, 2.0 and 4.0 kHz, which is one indicator for qualifying for a hearing aid. In the HörMat study , a hearihttps://www.who.int/pbd/deafness/estimates/en/, accessed Dec 17, 2020). Studies with substantially lower proportions of hearing loss either based their definition on the average over four frequencies rather than at least one frequency [The preceding summary illustrates the heterogeneity of definitions for hearing loss used in different studies, which complicates the interpretation of corresponding proportions. We chose our definition, because it is used by German health insurances for the indication of a hearing aid. The study with the most similar definition of hearing loss , i.e., ≥requency , used surequency , 14, or requency ). TherefThe observed proportion of subjects without hearing aids among all subjects with hearing loss greater or equal than 30 dB (77%) was higher compared with two studies identified in the review by Löhler et al. . Von GabOur data show that untreated hearing loss is common in rural areas and may reach close to 100% in areas with no hearing aid technician and no ENT physician. This is consistent with Chan et al. , who obsThe need for optimal rehabilitation of hearing impairments is not only important for optimal sound transmission to the auditory cortex. In addition, it is known that the auditory impulse on vestibulospinal reactions is an important component in balance regulation . Dawes eOur preliminary study includes only a small number of self-selected participants. It is possible that the observed proportion of hearing loss is an overestimate, since hearing-impaired persons may have been particularly attracted by the offer of a cost-free audiometry test. Moreover, only limited demographic and other patient-specific information was recorded, and was entirely missing for a fraction of the subjects. However, our study has several strengths. Audiometry was performed by ENT physicians on standardized equipment in a vehicle which was specifically noise-insulated for this purpose. The high proportion of hearing-impaired persons allowed us to estimate the percentage of underserved patients with high precision . The knowledge about the availability of hearing aid technicians and/or ENT physicians in the selected areas enabled us to evaluate determinants of underserving in Germany.Although our study took place in a local context, the relevance of the objective goes far beyond the particular region studied. Thinly populated areas are common in all European countries (on average 30% of the area), and population density is known to be inversely correlated with health in industrialized countries . The patHearing loss can have profound effects not only on interpersonal communication, but also on health, independence, wellbeing, quality of life, and daily function. It is a field in which modest interventions have the potential of producing a substantial reduction in the global burden of disease. Large representative studies are needed, particularly in rural areas, to assess the level of hearing loss, the fraction of persons without adequate help and the reasons for this, so that interventions, such as mobile diagnostic units, can be designed and evaluated. These interventions aim to improve the hearing of the population to increase their quality of life and to prevent severe morbidity known to be associated with untreated hearing loss, such as falls, dementia, depression, and other diseases.