In general, TCs show significantly asymmetric wind and rainfall structures, with strong vertical wind shear appearing over South Korea during the landfall period. The rainfall area significantly increases with environmental vertical wind shear while the wind area is not sensitive to it. Composite analyses of the cases of strong and weak vertical wind shear confirm that the increase of rainfall area is related to the asymmetric convection (rising/sinking motion in the downshear-left/upshear-right side) induced by the vertical wind shear. This work highlights the importance of local atmospheric environment in determining the area primarily affected by strong winds or heavy rainfall during TC landfalls.The wind- and rainfall areas of tropical cyclones (TCs) making landfall over South Korea were examined for the period 1998–2013 by using the Modern Era Retrospective Analysis for Research and Applications, version 2 (MERRA-2) and Tropical Rainfall Measuring Mission (TRMM) 3B42 data. Here, the wind- and rainfall areas were defined as the regions where wind speeds and precipitation rates exceed 14 m s Despir (ROCI) , 5. For r (ROCI) . Accordir (ROCI) .To develop an accurate forecast system for the areal extents of TCs, it is necessary to understand how they vary according to environmental conditions. Earlier studies showed that the areal extent of a TC varies independently of the TC intensity , 5, 8–11-1) using the Quick Scatterometer (QuikSCAT) data for the period 1999–2009 to suggest spatially and seasonally varying characteristics of TC sizes in global oceans. Chavas et al. [-1 and vanishing wind) in a global perspective using the QuikSCAT data. However, satellite data also suffer from limitations as they cannot provide wind data over lands and can observe TCs twice a day at the most with limited spatial coverages [Despite recent studies, there is a major hurdle in studying the areal extents of TCs, due to limited amounts of observational data. Observation systems over land such as weather stations or radars can provide accurate high-resolution data in both time and space. However, they can observe a TC only when the TC is close to the stations or radars, thus have difficulties in covering the entire area of a TC. Aircraft observations and dropsonde are useful to investigate 3-dimensional structure of a TC, but they are also limited in sampling frequencies and locations. Satellite observations have made the most significant contributions to understanding on characteristics of the areal extents of TCs. For example, TC sizes in terms of the radius of a threshold wind speed can be obtained from satellite-retrieved near-surface winds , 21, 22.s et al.  also exaoverages , 23.As an alternative to the limited observations, recent studies have suggested the possibility of using reanalysis data to investigate the areal extents of TCs. For example, the spatial and temporal distributions of TC positions in reanalysis data compare well with those in the best track data . SignifiAnother issue regarding the areal extents of TCs is the rainfall area induced by the TCs. The areal extent of a TC has been typically defined in terms of TC wind structures such as the radius of a threshold wind speed and ROCI. However, the spatial distributions of TC winds and their variations are different from those of TC rainfall , 30. ForThis study aims to investigate the areal extents of winds and rainfall induced by TCs making landfall over South Korea and to find possible explanations for their variations. South Korea is frequently affected by TCs, about 3 TCs a year to suffer considerable damages. For example, TCs RUSA in 2002 and MAEMI in 2003 caused economic losses of 41 and 35 billion USD, respectively. In addition, large baroclinic environments prevail over South Korea to significantly affect the characteristics of TCs  in this region , 35, 36.The best track data from the Regional Specialized Meteorological Center’s (RSMC) Tokyo Typhoon Center were used to identify TCs which made landfall over South Korea. This data provide information on individual TC such as the location of TC centers (in both latitude and longitude), the 10-min averaged maximum sustained wind speed, and the minimum sea level pressure (SLP) at 6-h intervals over the western North Pacific Ocean from 1951 to present. From this data, only TCs classified as the tropical storm, severe tropical storm, or typhoon are selected for investigation. In this study, the TC landfall over South Korea is defined as the period during which the distance between the TC center and the nearest coastline of South Korea is less than 500 km. This definition deviates from the strict definition of TC landfall , but is consistent with a number of studies in which similar definitions of TC landfall are used because the impact of a TC can occur even before the TC hits the coastline , 32, 37.The observational data for the wind- and rainfall areas affected by TC landfalls are severely limited, especially for wind structures. Observational network over the land usually have limited coverage of the area affected by a landfalling TC. The satellite scatterometers can estimate the surface winds, but only over the ocean. Thus, it is difficult to examine the 3-dimensional wind structure of TCs using these observational data. Because of these difficulties, this study utilizes the Modern Era Retrospective Analysis for Research and Applications, version 2 (MERRA-2)  reanalysThe rainfall data were obtained from the Tropical Rainfall Measuring Mission (TRMM) 3B42 which is 3-h interval precipitation data retrieved from TRMM and other multi-satellite . The TRM−1. Previous studies used various wind speed thresholds, for example, 17 m s-1 [-1 [-1 [-1) and corresponds to the high-wind of the Beaufort wind scale. The areal extent of rainfall  was similarly defined as, also within 1000km from a TC center, the total size of regions where rainfall exceeds 80 mm day−1 (= 3.33 mm hr−1), the threshold value of heavy-rainfall used in the Korea Meteorological Administration. This is analogous to the definition for the TC rainfall area used in Matyas . The overall results are not much sensitive to the threshold values for defining the wind- and rainfall areas. Thresholds within the range of 12–15 m s-1 and 2–5 mm hr-1 yield essentially the similar results. The wind- and rainfall areas were calculated at every six hours for the periods in which TC landfalls occurred in South Korea. This resulted in 283 samples for the wind- and rainfall areas for analysis.17 m s-1 , 22, 15  s-1 [-1 , 12 m s- [-1 [-1 , 21, 5 k [-1 [-1 , to calcThe use of the wind- and rainfall areas instead of more conventional definition of areal extent in terms of the mean radius of the threshold wind or rainfall, is for considering asymmetry of the wind and rainfall fields of TCs –51. Asymple case , 51, 52.r = 0.632 and 0.627 for maximum wind speed and minimum central SLP, respectively). Here, the TC intensity of the MERRA-2 was calculated as the 10-m maximum wind speed and minimum central SLP within a radius of 300 km from the TC center. The daily maximum wind speeds over South Korea obtained from the 69 weather stations during TC landfall are also significantly correlated (r = 0.67) with those from the MERRA-2, although the absolute values in MERRA-2 are smaller (linear regression slope = 0.49) than the observed (not shown). In case multiple weather stations are located in the same MERRA-2 grid box, the daily maximum wind for weather stations was calculated as the average of all stations within the grid box.Characteristics of TCs in MERRA-2 show a robust relationship with those in the observation during the period of landfalls in South Korea. For example, the TC intensity of the MERRA-2 presents significant correlation with that of the best track data at the 95% confidence level . The mean 10-m wind field depicts well-organized cyclonic circulation with distinct asymmetry in the left and right sides of the TC motion . This war = 0.73; significant at the 95% confidence level) with the wind radii of 34-kt in the best track data. The wind radii of 34-kt and the minimum central SLP obtained from the best track data also showed significant negative correlation coefficient  over South Korea. In addition, Chavas et al. [-1 in their study). Since TCs are generally weaker in the landfall period than in the mature stage, the negative relationship between the areal extent and the minimum central SLP may exist only in the vicinity of South Korea.s et al.  presenter = 0.07); however, the rainfall area significantly increases with vertical wind shear . The mean and standard deviation of the vertical wind shear affecting TCs are 11.03 m s-1 and 5.95 m s-1, respectively. To examine the detailed effects of the vertical wind shear, TCs in strong shear cases  are compared against those in weak shear cases . The SS and WS cases are defined in terms of the magnitude of the vertical wind shear; the wind shear in the SS cases exceeds the all-case mean value plus half of the standard deviation (14.01 m s-1) and the WS cases are of vertical wind shear smaller than the all-case mean value minus half of the standard deviation (8.05 m s-1). Applying the conditions, 82 (102) SS (WS) cases are identified.As seen in The TC wind and rainfall structures vary distinctly between the SS and WS cases. −1) than the WS case (5.2 m s−1) (−1) between the two types of TCs can induce the relative rising and sinking motions at the front and rear side of TC, respectively  . Thus, tectively .-1) as also found in this study. In addition, the ET process can be closely related to the findings in this study. In the mid-latitudes, a number of TCs show significant changes such as frontogenesis, vertical tiling, abrupt intensification of wind and rainfall, during the ET process [The difference of the environmental condition in the mid-latitude East Asia between the SS and WS cases supports that the difference of the vertical wind shear within TCs  are indu process –67. Inde process , 69.−1 and 3.33 mm hr−1, respectively. TCs making landfall in South Korea present strong winds and heavy rainfall in the right and front side of the TC moving direction, respectively. Strong vertical wind shear appears over South Korea during TC landfalls as well. This study focuses on the effects of the vertical wind shear on the wind- and rainfall areas of landfalling TCs. It has been found that the vertical wind shear appearing over South Korea during TC landfalls is significantly related to the increase of TC rainfall area by inducing asymmetric convection characterized by rising and sinking motion at down-shear left and up-shear right side, respectively. On the other hand, the TC wind areas are not affected by the vertical wind shear.The wind- and rainfall areas of TCs making landfall in South Korea during 1998–2013 are investigated using the MERRA-2 reanalysis and TRMM-3B42 precipitation data. The wind- and rainfall areas are defined as the regions where wind speeds and precipitation rates exceed their threshold values, 14 m sThis study suggests that it is necessary to consider the asymmetry of wind- and rainfall areas in preparing to minimize the damages by TC landfalls. In addition, various environmental conditions need to be considered in developing an accurate forecasting system for the areas primarily affected by strong winds or heavy rainfall. According to our results, the environmental vertical wind shear over South Korea is a crucial factor in shaping the TC rainfall area in South Korea. However, the wind- and rainfall areas can be affected not only by the vertical wind shear but also by various environmental conditions which varies substantially according to regions e.g., , 19, 20.


Hearing care services for older adults with hearing aids are underutilized and are not covered by the Medicare program. Little information exists to the value of hearing care services for older adults with hearing aids. Using the Medicare Current Beneficiary Survey 2013, we conducted a cross-sectional analysis of the impact of hearing care services use on Medicare spending among those with hearing aids. Older Medicare beneficiaries with hearing aids that received hearing care services in the previous 12 months were propensity score matched to those who did not receive services. Average annual Medicare spending was $8196 (CI:$6670-$9723) among Medicare beneficiaries who used hearing care services and $10,709 (CI:$8878-12541) among matched controls. Spending differences were driven by higher skilled nursing facility and home health spending among matched controls. Increasing access to hearing care services among Medicare beneficiaries with hearing aids may provide value to the health care system and Medicare program.


Consumers purchase fresh strawberries all year long. Extending the fruiting season for new strawberry cultivars is a common breeding goal. Understanding the inheritance of repeat fruiting is key to improving breeding efficiency. Several independent research groups using multiple genotypes and analytic approaches have all identified a single genomic region in strawberry associated with repeat fruiting. Markers mapped to this region were used to evaluate breeding parents from the United States Department of Agriculture – Agricultural Research Service (USDA-ARS) strawberry breeding program at Beltsville, Maryland.Markers mapped to repeat fruiting identified once-fruiting genotypes but not repeat-fruiting genotypes. Eleven of twenty-three breeding parents with repeat-fruiting marker profiles were actually once fruiting, indicating at least one additional locus acting epistatically to suppress repeat fruiting. Family segregation ratios could not be predicted reliably by the combined use of parental phenotypes and marker profiles, when using a single-gene model. Expected segregation ratios were calculated for all phenotypic and marker-profile combinations possible from the mapped locus combined with a hypothetical dominant or recessive suppressor locus. Segregation ratios specific to an epistatic suppressor acting on the mapped locus were observed in four families. The segregation ratios for two families were best explained by a dominant suppressor acting on the mapped locus, and, for the other two, by a recessive suppressor. Not all of the observed ratios could be explained by one model or the other, and when multiple families with a common parent were compared, there was no predicted genotype for the common parent that would lead to all of the observed segregation ratios.Considering all lines of evidence in this study and others, repeat-fruiting in commercial strawberry is controlled primarily by a dominant allele at a single locus, previously mapped by multiple groups. At least two additional genes, one dominant and one recessive, exist that act epistatically to suppress repeat fruiting. Environmental effects and/or incomplete penetrance likely affect phenotype through the suppressor loci, rather than the primary mapped locus. One of the dominant suppressors acts only in the first year, the year the plant is germinated from seed, and not after the plant has experienced a winter.The online version of this article (10.1186/s12870-019-1984-7) contains supplementary material, which is available to authorized users. Fragaria ×ananassa Duchesne ex Rozier) are an economically important crop in the United States (US). At 2.3 billion US dollars, the US 2014 strawberry crop was third-most valuable after grapes (6.3 billion USD) and apples (3.5 billion USD) among noncitrus fruits [Strawberries  and day neutral (DN), often spelled “dayneutral” in catalogs and on web pages. Short-day genotypes, also called June bearers in northern states, initiate flower buds either under short day-lengths (< 14 h of day length) or at temperatures below 15 °C. These plants flower only once a year and, therefore, have only one harvest period. “Day-neutral” genotypes were reported to be photoperiod insensitive, initiating flowers under any photoperiod condition, as long as temperatures are moderate (below 30/26 °C day/night) . ContinuF. virginiana ssp. glauca (Wats.) Staudt strawberry plant collected in the Wasatch Mountains, south of Salt Lake City, UT, has been used as the source of repeat fruiting to produce new cultivars in many breeding programs [Because knowledge of the inheritance of any trait is useful to improving breeding efficiency, several genetic studies have addressed the inheritance of repeat fruiting. Some consider repeat fruiting to be controlled by a single gene in cultivated strawberry, either recessive  or dominprograms .F. virginiana ssp. glauca plant attributed as the source of repeat fruiting in cultivars around the world [The objective of this study was to determine if molecular markers linked to this collectively identified repeat-fruiting genomic region could correctly predict phenotypes and segregation ratios in breeding families in the USDA-ARS strawberry breeding program pool at Beltsville, MD. This breeding program produced ‘Delmarvel’ , which whe world . TherefoF. ×ananassa reference genome. The approximate string-matching algorithm found sequence similarities in the scaffold FANhyb_rscf00000019.1, which was selected for further analysis. To identify other regions that could be used as a target from which to design more primers for repeat fruiting, other SSR markers  out of the 36 primer pairs designed did not produce any amplification products. Of the 30 primer pairs that amplified a product from the mapping parents, three  were polymorphic only in the ‘Delmarvel’ × ‘Selva’ population, two (FANhyb19.1–13 and FANhyb64.1–1) were polymorphic only in the ‘Tribute’ × ‘Honeoye’ population, and 13 were polymorphic in both populations. These primer pairs amplified 61 products in the ‘Delmarvel’ × ‘Selva’ population, but only 33 of them fit acceptable segregation ratios for mapping and were used to construct the linkage map. Products from primer pairs FANhyb19.1–1, FANhyb19.1–3, FANhyb19.1–4, FANhyb19.1–6 and FANhyb19.1–15 mapped to the region associated with repeat fruiting in HGIV, whereas product sizes from primer pairs FANhyb611.1–1, FANhyb682.1–1, FANhyb45.1–1, FANhyb45.1–2, FANhyb758.1–1, FANhyb758.1–4, FANhyb64.1–1, FANhyb64.1–2, FANhyb64.1–4 mapped to other HG not associated with repeat fruiting : FANhyb19.1–15-121, FANhyb19.1–4-189, Bx215–148, ChFaM148–184, Bx064–238, and Bx089–236. Examining the marker phenotypes of the breeding parents, regardless of flowering pattern, FANhyb19.1–15-121 and FANhyb19.1–4-189 were either both present, or both absent, indicating very close genomic proximity to each other  had no individuals flowering the first year, and both parents had a repeat-fruiting marker profile. Families from a repeat-fruiting parent and a once-fruiting parent were predicted to either contain half first-year-flowering progeny (if the repeat-fruiting parent was heterozygous) or all first-year-flowering progeny (if the repeat-fruiting parent was homozygous dominant). Eighteen families were derived from a cross between a repeat-fruiting parent and a once-fruiting parent, but only seven of these contained half first-year-flowering progeny. No families, regardless of phenotype or marker profile, contained only first-year-flowering progeny. Families from two repeat-fruiting parents were predicted to contain all first-year-flowering progeny (if one or both parents was homozygous dominant), or three times the number of first-year-flowering progeny as not flowering (if both parents were heterozygous). Just as none of the families contained all first-year-flowering progeny, none of the families with three times the number of first-year-flowering progeny were derived from two repeat-fruiting parents. One of the possible predicted segregation ratios based on known parental phenotype was the same as the observed segregation ratios for only eight out of thirty-one breeding families  or a recessive suppressor locus (81 combinations) . The next best fitting ratios  included 13:3, also indicative of a dominant suppressor, and 3:1, which could be explained by either a dominant or recessive suppressor with both parents being once fruiting , and a 7:9 ratio (p > χ2 = 0.0379), and both are consistent with a cross between repeat-fruiting and once-fruiting parents  which, in a cross between a once-fruiting and repeat-fruiting parents, can be explained by a recessive, but not a dominant, suppressor , followed by 7:9 (p > χ2 = 0.4890). Unfortunately, under the model of a recessive suppressor acting on a dominant mapped locus, those ratios are not expected if both parents are once-fruiting. The observed segregation ratio weakly fit a 1:1 ratio (p > χ2 = 0.0499), and can be explained by either a dominant or recessive suppressor  that best predict that a parent with a once-fruiting marker profile  were developed in this study from a single contiguous sequence and mapped 1.9 cM from repeat fruiting in one mapping population and 8.4 cM and 10.1 cM from repeat fruiting in the other population. Mapping differences were not considered to be evidence of anything more complicated than simple experimental error.Although the absence of these three markers was very useful in identifying once-fruiting parents, their presence could not be used to identify repeat-fruiting parents and incorrectly predicted repeat fruiting in about half the parents. When FANhyb19.1–15-121 and FANhyb19.1–4-189 were present or Bx215–148 was present, there was about a 43% chance of the genotype being repeat fruiting. Bx215–128 was only 85% positively predictive in a collection of germplasm . And theMarker profiles combined with known phenotypes of the parents failed to predict observed segregation ratios for the progeny of all but four parental combinations. These two failures of the hypothesis that repeat fruiting was entirely controlled by one locus with a completely dominant allele conferring repeat fruiting lead to the supposition that at least one additional and independent locus affecting repeat fruiting exists in this breeding program pool. Because only one locus was detected through mapping processes generally assuming additivity of genetic effects, the hypothetical additional locus was presumed to have non-additive genetic effects. Epistasis was considered more likely than the non-additive effect of incomplete penetrance, because of the combined evidence acquired through genetic linkage and breeding-parent phenotype and marker profile comparison. Where one line of evidence allowed multiple explanations, the combined evidence did not, and ruled out incomplete penetrance of the mapped locus as a significant reason for discrepancies observed. This evidence also implied that the second locus acted as a suppressor of repeat fruiting through epistasis on the mapped locus.Hypothetical segregation ratios were calculated for all phenotypic and marker-profile combinations possible from the mapped locus combined with a dominant suppressor locus  or a recessive suppressor locus (81 combinations)  [F. vesca [FLOWERING LOCUS T is strongly affected by CONSTANS, a well-known example of epistasis on a molecular level [F. vesca, overexpression of a homolog to SUPPRESSOR OF OVEREXPRESSION OF CONSTANS1 (Fv SOC1) repressed flower initiation under inductive short days, whereas its silencing caused continuous flowering in both short days and noninductive long days, similar to mutants in the floral repressor F. vesca TERMINAL FLOWER1 (Fv TFL1), and that Fv SOC1 activates Fv TFL1 in the shoot apex, leading to the repression of flowering in strawberry [Previously, two markers flanking the repeat-fruiting region were used to search for sequence identity in the diploid reference genome v2.0.a1 sequence and found to span a 1108 Kb region containing 234 predicted genes, including 15 classified as flowering-associated, one of which had sequence homology to  T (FLT) , a key tF. vesca . The actar level . In F. vrawberry . Just coFlowering is also strongly affected by vernalization epistatically, and a vernalization requirement in some strawberry genotypes, but not others, has been reported . It’s poF. vesca [Sixty-six gene homologs that, by sequence similarity, putatively correspond to genes of all known genetic flowering pathways have been identified in diploid F. vesca . These aIt is likely that only one locus was detected because of the methods used to phenotype and the populations used. Data were collected from the ‘Tribute’ × ‘Honeoye’ after the seedling year so the population could be clonally propagated and tested in multiple states . When thMapping populations often are developed from parents with extreme opposing phenotypes. Both the ‘Tribute’ × ‘Honeoye’ and ‘Delmarvel’ × ‘Selva’ populations were used because the parents had opposing phenotypes. The current study showed that segregating families can be obtained from two parents with repeat-fruiting marker profiles and repeat-fruiting phenotypes Table  or from Mapping software generally assumes additive genetic effects, including some of the newer approaches being used , 35. SomAgain, it is likely that only one locus was detected by multiple research groups with multiple populations because of how/when the phenotypic data were collected and the genetic composition of the parents of the populations. Yet, this does not explain the unlikely finding of the same locus by these multiple groups. If the multiple loci hypothesized to control repeat fruiting are independent in both genetic distance and expression, at least one of the groups should have found a unique locus affecting repeat fruiting. The fact that all groups found the same locus indicates that the mapped locus is the only locus capable of influencing segregation independently of the others. The loci that have not yet been mapped are dependent on the mapped locus to be revealed. Whether the parents have once-fruiting or repeat-fruiting phenotypes, the epistatic suppressor loci can be mapped most efficiently when both parents have the repeat-fruiting marker profile for the locus already mapped. Possible examples from the current study would include any of the repeat-fruiting parents B2409RB, B2325, or B2411RB crossed with the once-fruiting parent B1806, which has the repeat-fruiting marker profile, as the resulting families segregated in a ratio close to 1:1 . Custom scripts (available upon request) using Python programming language were used that allowed a mismatch of up to 4 bp . Genome-sequence scaffolds containing regions with high sequence similarity to the primer sequences were selected for designing new SSR markers for the repeat-fruiting region. Repetitive motifs were identified by SSR identification tool . Oligonucleotide primers were designed in the SSR-flanking sequences using Genious 7.2 software tool [To further saturate the repeat fruiting region with markers for this study, additional SSR markers were designed using markers previously mapped to the region , 18. Theananassa , from thare tool . PrimersThe SSR primer pairs developed were tested for polymorphism detection with the mapping parents . The populations derived from them were genotyped with those primers that detected polymorphisms. Details regarding these two mapping populations were described previously , 18. TheP ≤ 0.005 were selected as the most tightly linked.For use in parental screens and genetic mapping, the 5′ ends of the forward primers were modified with the addition of the M13 sequence (5′-TGTAAAACGACGGCCAGT-3′), and separate M13 primers were labeled with the fluorescent dyes 6-FAM, VIC, NED and PET  . The 5′ Seeds were germinated and transplanted to 72-well trays in a greenhouse. Seedlings were planted on the Henry A. Wallace Beltsville Agricultural Research Center Linkage Farm . Observation plots and replicated evaluation plots were on the North Farm . Daylength was recorded at Greenbelt, Maryland. Air temperatures (2016) were recorded at 1.5 m high at the Linkage Farm. A 2-m high weather station located less than 300 m from all fields on the Linkage Farm measured sheltered temperatures with a CS107 temperature sensor inside a 41,303-5A RM Young six-plate solar radiation shield . Measurements were taken and collected every 10 s, and averaged at 15-min intervals. Data were transmitted through a 900 Mhz spread-spectrum protocol using an RF450 radio (Campbell Scientific) to a NL100 network link (Campbell Scientific) for display with Vista Data Vision sensor data management software, .− 1 nitrogen. Small weeds were regularly removed from planting holes by hand. Strawberry seedling stolons or “runners” were pulled from under the plastic mulch, away from neighboring seedlings, and away from the bed center to prevent confounding of phenotypes in neighboring planting holes.An annual plasticulture production system , used toPrevious studies described how repeat-fruiting genotypes could be identified in their seedling year. Seeds were germinated in late winter to early spring, established in the field in the spring, and evaluated for flowering and fruiting from mid-summer to early fall . AlternaSince 2007, annual crossing plans were divided into two types of crosses: those designed to be all once fruiting (“once-fruiting” crosses), planted in July on black plastic beds and fruited the following year; and those designed to segregate for repeat fruiting (“repeat-fruiting” crosses), planted in March in white-plastic beds and fruited the same year  was collected from all breeding selections in the strawberry breeding program for characterization with molecular markers of interest. Each year, from each observation plot, young leaves, still folded, were collected and desiccated for long-term storage. The leaves from an observation plot were collected and placed in a labeled glassine envelope . Up to six envelopes, representing one selection each, were placed in a gallon-size sealable plastic bag with around 177 mL molecular sieve desiccant, Type 4A round beads, form 8 × 12 , with a humidity indicator card. Air was left in the sealed bag to facilitate drying, and the bag was turned repeatedly in the first two days until the indicator card stayed blue. The desiccant was refreshed annually. From the parents of the strawberry breeding project’s 2016 repeat-fruiting seedling families, dry leaf tissue was fragmented using a TissueLyser , and DNA was extracted using the DNeasy® Plant Maxi Kit  in a QIAcube® machine .PCRs were conducted with the breeding parents as described for mapping the new markers. PCRs were completed in 96-well plates with two reactions per selection as replication, and one primer pair per plate. Mapping parents, ‘Tribute’, ‘Honeoye’, ‘Delmarvel’, and ‘Selva’, were included on each plate to confirm product size.Segregation ratios for flowering in the first year (repeat fruiting in subsequent years) were predicted for each breeding family resulting from the breeding parents. Predictions were based on both the known field phenotypes of the parents (over multiple years) and the molecular profile of the parents of each family. Predictions also were based on the results from multiple studies indicating repeat fruiting was conferred by a dominant allele at a single locus , 23–25. The strawberry breeding project’s seedling families expected to segregate for repeat fruiting were planted in a field at the Beltsville Agricultural Research Center (BARC) in Spring 2016. Throughout the summer, from late June through late September, any plant that flowered was marked with a white flag. Selections were made from among these seedlings and evaluated in observation plots the following year. For each family, the number of plants that flowered, the number of plants that did not flower, and the number of diseased or dead plants were recorded. Observed segregation ratios were compared with expected segregation ratios using the Chi-square goodness-of-fit test. The probability of a greater Chi-square value was calculated rather than using an exclusion probability.Additional file 1:Table S1. List of commercial strawberry genome sequence scaffolds selected for primer design and characteristics of the new SSR primer pairs developed. (DOCX 27 kb)Additional file 2:Table S2. Amplification products from SSR markers in ‘Delmarvel’ × ‘Selva’ and ‘Tribute’ × ‘Honeoye’ strawberry (F. ×ananassa) F1 mapping populations (DOCX 24 kb)Additional file 3:Table S3. Breeding-parent marker profiles using all markers of Linkage Group IV, which is associated with repeat-fruiting in commercial strawberry (Fragaria ×ananassa), that were amplified from the repeat-fruiting mapping parent and had a significant association with repeat fruiting when using the Kruskal-Wallis test. Markers are listed in order according to Kruskal-Wallis test value for mapping population generated by 'Tribute' × 'Honeoye'. Primer amplification of a product is designated by a "1", no amplification of the product when others were amplified by the primers is designated by a "0", and no amplification of any products from the primers was considered a failed reaction and designated by "m" for "missing". Marker products associated with once-fruiting are colored grey . (XLSX 17 kb)Additional file 4:Table S4. Calculations of segregation ratios for progeny families from all possible phenotype/genotype parental combinations for a two-locus model to explain repeat fruiting vs once-fruiting of strawberry. Calculations assume the primary, already mapped locus, has a dominant allele (RB) conferring repeat fruiting, and a recessive allele (jb) conferring once-fruiting. Repeat-fruiting parental and progeny phenotypes are highlighted in dull yellow, and once-fruiting phenotypes are highlighted in pale green. On the left of the grey vertical bar are calculations that assume the presence of a second locus with a completely dominant allele (STOP) conferring epistatic suppression of the mapped locus when homozygous (STOP STOP) or heterozygous (STOP stop), and a recessive allele (stop) that does not affect the mapped locus). On the right of the grey vertical bar are calculations that assume the presence of a second locus with a recessive allele (stop) conferring epistatic suppression of (or failure to support) the mapped locus when homozygous (stop stop), and a completely dominant allele (STOP) that does not change the phenotype conferred by the mapped locus. Horizontal grey and purple bars separate different genotypic parental-combination possibilities for similar phenotypic possibilities. Resulting progeny phenotypes are characterized as repeat-fruiting (RB) or once-fruiting (jb) similar to the mapped locus. Expected resulting segregation ratios are highlighted in bright yellow boxes. (XLSX 235 kb)Additional file 5:Table S5. Segregation ratios for progeny families from all possible phenotype/genotype parental combinations for a two-locus model to explain repeat fruiting vs once-fruiting of strawberry. Segregation ratios assume the primary, already mapped locus, has a dominant allele (RB) conferring repeat fruiting, and a recessive allele (jb) conferring once-fruiting. Repeat-fruiting parental phenotypes are highlighted in dull yellow, and once-fruiting phenotypes are highlighted in pale green. On the left of the grey vertical bar are segregations ratios that assume the presence of a second locus with a completely dominant allele (STOP) conferring epistatic suppression of the mapped locus when homozygous (STOP STOP) or heterozygous (STOP stop), and a recessive allele (stop) that does not affect the mapped locus). On the right of the grey vertical bar are segregation ratios that assume the presence of a second locus with a recessive allele (stop) conferring epistatic suppression of (or failure to support) the mapped locus when homozygous (stop stop), and a completely dominant allele (STOP) that does not change the phenotype conferred by the mapped locus. Horizontal grey and purple bars separate different genotypic parental-combination possibilities for similar phenotypic possibilities. Resulting progeny phenotypes are characterized as repeat-fruiting (RB) or once-fruiting (jb) similar to the mapped locus. Similar segregation ratios are highlighted in similar colors, and simplified to the right if appropriate, with non-segregation designated as RB for all repeat-fruiting, and jb for all once-fruiting. (XLSX 41 kb)Additional file 6:Table S6. Segregating strawberry breeding families planted 2008 and evaluated the summers of 2008 and 2009. Parental and progeny phenotypes were classified as once-fruiting (jb) or repeat fruiting (RB) for each summer. Segregation ratios were calculated and tested for Chi-square goodness of fit. Chi-test probabilities over 0.000001 were highlighted in light green. The best fitting ratio or ratios were determined for the year of planting and for the subsequent year. Differences in segregation ratio from one year to the next occurred for several families. (XLSX 58 kb)


Hearing loss is one of the most common modifiable factors associated with cognitive and functional decline in geriatric populations. An accurate, easy-to-apply, and inexpensive hearing screening method is needed to detect hearing loss in community-dwelling elderly people, intervene early and reduce the negative consequences and burden of untreated hearing loss on individuals, families and society. However, available hearing screening tools do not adequately meet the need for large-scale geriatric hearing detection due to several barriers, including time, personnel training and equipment costs. This study aimed to propose an efficient method that could potentially satisfy this need.In total, 1793 participants (≥60 years) were recruited to undertake a standard audiometric air conduction pure tone test at 4 frequencies (0.5–4 kHz). Audiometric data from one community were used to train the decision tree model and generate a pure tone screening rule to classify people with or without moderate or more serious hearing impairment. Audiometric data from another community were used to validate the tree model.In the decision tree analysis, 2 kHz and 0.5 kHz were found to be the most important frequencies for hearing severity classification. The tree model suggested a simple two-step screening procedure in which a 42 dB HL tone at 2 kHz is presented first, followed by a 47 dB HL tone at 0.5 kHz, depending on the individual’s response to the first tone. This approach achieved an accuracy of 91.20% (91.92%), a sensitivity of 95.35% (93.50%) and a specificity of 86.85% (90.56%) in the training dataset (testing dataset).A simple two-step screening procedure using the two tones (2 kHz and 0.5 kHz) selected by the decision tree analysis can be applied to screen moderate-to-profound hearing loss in a community-based geriatric population in Shanghai. The decision tree analysis is useful in determining the optimal hearing screening criteria for local elderly populations. Implanting the pair of tones into a well-calibrated sound generator may create a simple, practical and time-efficient screening tool with high accuracy that is readily available at healthcare centers of all levels, thereby facilitating the initiation of extensive nationwide hearing screening in older adults. Age-related hearing loss adds a significant burden to individuals and society. Compared to their normal hearing peers, individuals with hearing loss are at significantly greater risk of incident dementia –3, fallsThe existing literature supports the hypothesis that treating hearing loss is effective in reducing the aforementioned adverse consequences. Nonetheless, moving towards early treatment requires the early identification of individuals with hearing loss. Hearing impairment is highly prevalent in older adults, affecting 33% of persons over the age of 50 years, 45% of persons over the age of 60 years  and 63.1The gold standard for estimating hearing impairment is clinical pure tone audiometry administered by trained audiologists ; howeverA number of time-efficient hearing screening strategies have been proposed over the past few years. Portable screeners, such as Audioscope , screen Despite the intensive effort to promote hearing screening in community-based geriatric populations, none of the currently available screening instruments have been systematically implemented, and their correlation to clinical audiometric tests varies. To date, no studies have shown that these screening tools resulted in an increased geriatric hearing screening rate or hearing aid use. There was also a global lack of improvement in hearing loss burden as measured by age-standardized disability-adjusted life years (DALYs) over 25 years (1990~2015) , implyinNo parsimonious and feasible screening instrument to date has been developed to fill the above need. The present study was the first attempt to simplify the clinical standard pure tone audiometric assessment by using a machine learning technology on a large pure tone evaluation dataset collected from communities. The goal was to explore an efficient data-driven approach is applicable in the community-based physical check setting for screening moderate-to-profound hearing loss. Specifically, we aimed to implement decision tree algorithms to determine objectively the acoustical screening criteria for hearing classification.Decision tree is a nonparametric supervised machine learning method used for classification and regression. It creates a practical model that classifies target conditions or predicts the value of a target variable by learning simple decision rules inferred from a set of training data features with a known output. The features most highly related to the outcome are included in the model. Decision tree methodology is ideal for building clinically useful classification models because it uses simple logic for classifying conditions, making it easy for patients and clinicians to interpret data –30.The decision tree model, as a basic machine learning form, is playing an increasingly important role in healthcare applications. Specifically in the hearing science field, this technique has been used to seek the optimal suprathreshold test battery to classify auditory profiles towards effective hearing loss compensations . More frA decision tree analysis is commonly used to help identify a strategy most likely to reach a goal. In the context of the current study, a decision tree can produce a simple explicative model to determine which pure tone frequencies and intensities could maximize the screening test efficiency. A decision tree has proven a valuable tool for extracting meaningful information from measured data and represents a plausible solution for massive data learning tasks . AdditioThe research question guiding the present study was whether there is a parsimonious pure tone set that can predict moderate-to-profound hearing loss based on the clinical standard audiometric pure tone thresholds measured in the community-dwelling geriatric population. The classification boundary of moderate hearing loss (pure tone average PTA > 40 dB HL) was selected because moderate or greater hearing loss in older adults is significantly associated with an increased risk of developing frailty , lower ln = 1261  after excluding 61 participants due to missing audiometric data from either ear. Of the 536 participants recruited from the Nanmatou community (community B), 4 were excluded from the analysis due to missing audiometric data, yielding a final sample size of n = 532 . The demographic information regarding age, sex and hearing severity are displayed in Table Adults aged 60 years or older from two typical communities  in Shanghai were recruited to undertake clinical audiometric pure tone testing. No history of audiological rehabilitation experience  by self-report was required to participate in the study. A total of 1322 participants were recruited from the Jiuting community (community A), yielding a final sample size of Audiometric pure tone testing was administered by two trained audiologists in a quiet consulting room in each of the community healthcare centers located within a 15-min walking distance from the residents’ homes. Prior to the audiometric assessment, the ears were examined for wax or abnormalities. The air conduction thresholds were obtained at 0.5~4 kHz over an intensity range of −10 to 120 dB using an Interacoustics MA52 audiometer with manual testing per protocol. Each individual’s hearing thresholds were annotated as dB HL at each of 4 frequencies . Stimuli were presented through supra-aural headphones (TDH-39), except in rare cases of ear canal collapse or crossover retesting when insert earphones (Ear Tone 3A) were used. As acoustic isolation was not available, the ambient noise levels were monitored during the pure tone testing by an AWA5636 sound level meter. The average ambient noise level ranged between 35 and 38 dBA.Hearing loss severity was defined per the classification of the World Health Organization as a pure tone threshold  between 25 dB HL and 40 dB HL indicating mild hearing impairment and a hearing threshold of more than 40 dB HL indicating moderate or more severe hearing impairment. Data were collected over a 4-month period in community A and a 2.5-month period in community B.The descriptive statistics related to the community sample characteristics were evaluated using PASW 24 . Pearson’s chi-square test was employed for the analysis of proportions comparison. Regression analysis was performed to test the relationship between age and hearing acuity. The level of significance was established at the 0.05 level.n = 1261, i.e., 70.3% of the dataset) served as the training dataset, and data collected from community B  served as the test dataset in the decision tree analysis.The decision tree analysis was performed using the Python 3.7.0 SKlearn 0.19.2 package. We used a decision tree approach with a depth of 2 levels to analyze the audiometric pure tone data. A deeper tree was not considered in this study because the number of features in the model  associated with the hearing severity determination was fairly small, and the goal of the study was to simplify the hearing assessment procedure by using only 2 of the 4 frequencies. The known classification output for model training and testing was two classes of hearing status labeled as “normal-to-mild hearing loss (PTA<=40 dB HL)” and “moderate-to-profound hearing loss (PTA>40 dB HL)”. Data collected from community A  with node t classification ratio N is the number of samples.A brief mathematical illustration of the tree-based machine learning methodology used in the current study is displayed in Fig. terature , and we terature  and the terature . EquatioThe above functions were plotted in Fig. Conventionally in the clinical hearing severity classification, all 4 frequencies are assumed to be equally important and are required upon a hearing assessment when determining severity. To simplify the procedure for screening purposes, we computed the importance rank of the 4 frequencies through the tree structure training process, seeking to discover the 2 most important frequencies of the 4 for classification with high accuracy. The importance weight of each frequency was computed using Eq.  41]:3\d:3\d41]:3N is the total number of samples, Nt is the number of samples for the current node, Ntr is the number of samples for the child node on the right side of the tree branch, Ntl is the number of samples for the child node on the left side of the tree branch, and i is the to-be-optimized impurity function for the corresponding nodes.where In addition to the decision tree analysis, 3 state-of-the-art machine learning analyses applicable to our datasets were performed for classification outcome comparisons. These machine learning models included Support Vector Machine (SVM), Random Forest (RF), and Multilayer Perceptron (MLP). The same training and testing data used in the decision tree were fed to these models. The SVM model was fitted with the Radial Basis Function kernel . The RF As an individual’s hearing status can be labeled either by the better-hearing ear’s PTA according to WHO or based on the worse-hearing ear’s PTA for screening purposes as suggested by hearing screening researchers , 59, thet (1791) = 13.962, p < .001. The sex ratio of participants with hearing loss showed opposite patterns between the two communities; there were significantly more male than female participants with hearing loss in community B, λ2(1)=9.303, p = .002. The hearing severity distribution was significantly different between the two community samples depending on how hearing loss was defined, λ2(4)=186.086, p < .01. Specifically, when hearing loss was defined by the better-hearing ear’s PTAs, there was no significant difference in the proportion of older people with moderate-to-profound hearing loss between community A (51.9%) and community B (54.9%%), λ2(1)=1.205, p = .272. However, if hearing severity was categorized according to the worse-hearing ear’s PTAs, the prevalence of moderate-to-profound hearing loss was significantly higher in community A (70.7%) than in community B (62.0%), λ2(1)=13.070, p < .01.The demographic characteristics of the participants from the two communities are shown in Table λ2(1)=30.738, p < .01.Asymmetrical PTA was defined in the present study as a difference in the four-frequency pure tone average between the worse- and better-hearing ears larger than 20 dB HL. The PTA difference between better- and worse-hearing ears ranged from 0 dB HL to 55 dB HL in the community A sample and from 0 dB HL to 68.75 dB HL in the community B sample. The community A geriatric sample (3.7%) had a significantly smaller proportion of asymmetrical PTA than the community B sample (10.4%), B = .601, F  = 256.418, p < .001, adjusted R2 = .125). Specifically, the hearing acuity dropped 0.6 dB for every one-year increase in age above 60 years old.The regression analysis on the PTA predicted by age illustrated that age was significantly associated with hearing acuity . The classification using 40 dB HL cutoffs in community B produced an accuracy of 91.35% (with a sensitivity of 90.00% and a specificity of 92.55%). The performance of different screening criteria is illustrated in Fig. The current study used a fundamental machine learning technique to explore a parsimonious pair of pure tones that can be applied for hearing screening with a sensitivity, specificity and accuracy over 85% in community-dwelling older adults over 60 years of age. This was the first effort to objectively simplify the standard clinical pure tone hearing test procedure and construct an acoustic hearing screening criteria feasible for large-scale geriatric hearing screening. The screening tones were determined by collecting standard audiometric testing results from 1793 older community residents and by implementing decision tree analysis on their pure tone thresholds.In line with Ciurlia-Guy et al.’s  finding,The optimal screening criteria computed based on the worse-hearing ear were slightly different at 2 kHz due to the proportion of participants with asymmetrical hearing loss. The cutoff value of 37 dB HL produced a sensitivity of 97.53% with an accuracy of 89.93%, which implies a more aggressive screening approach. However, the specificity was compromised by 15.31%, which indicates a high false positive rate that will result in a waste of health resources. The difference in the criteria between the two ears suggests a consideration of what rationale to follow prior to massive screening. If healthcare providers believe that older adults’ hearing severity should be defined by the worse ear’s PTA and that unilateral hearing loss should be treated in this population, then the criteria computed based on the worse-hearing ear thresholds are recommended. If healthcare providers support that the better ear represents an individual’s overall hearing function and an early intervention should be implemented when the better ear has moderate or greater hearing loss, then the criteria calculated based on the better-hearing ear thresholds are recommended.The results of the current study suggested that the decision tree models constitute useful analytical tools to screen moderate-to-profound hearing loss. The decision tree technique formed a simple explicative model and produced easy-to-interpret results Fig. . AlthougThe results can be readily translated into feasible clinical applications. In the simplest form, an inexpensive well-calibrated sound generator can be used to incorporate the computed pure tones and deliver them in the correct order to the target individuals. This method integrates the advantages of previous screening approaches. First, its accuracy is as high as that of the screening audiometers reported in the literature . In both community samples, the accuracy of using the pair of 2 kHz and 0.5 kHz tones exceeded 91%. Second, since the screening criteria were directly calculated based on the standard pure tone thresholds, the correlation of the screening result with the gold standard audiometric results is inherently strong. Third, screening with acoustically calibrated tones is perceived as more objective than using self-report and uncalibrated methods such as the whisper test  by both The prevalence of moderate-to-profound hearing loss shown in this study’s samples  was consistent with the prevalence documented in previous epidemiological studies , 62–64 . The proThe results of the present study illustrated that hearing loss is largely underrecognized in the community-dwelling geriatric population. Given the increasing prevalence and disease burden of undetected hearing loss in older adults and the availability of effective treatment , early identification of individuals with moderate or greater hearing loss is a cost-saving strategy. However, screening methods at the community level are inadequate. There is an unmet need for a feasible data-driven screening protocol for healthcare policy makers to promote early identification and immediate treatment of hearing loss in geriatric patients. The current study demonstrated how a machine learning technique, specifically decision tree analysis, can be used in the hearing healthcare setting to meet the need for a parsimonious acoustical screening protocol for community-dwelling geriatric populations. Community health care centers have the potential to serve as the first point of access to identify moderate or greater hearing loss. The proposed simple two-step pure tone screening approach made it possible for the hearing test to be included in routine checkups. This study suggests a feasible and powerful means to deliver quality services when the gold standard audiometric evaluation of hearing is not available.The main limitation of our study was that our data were collected from two communities in a single city, which may affect the generalizability of the results. Validating the tree model with audiometric data from communities in a few randomly selected cities and rural areas is needed to generalize the proposed screening instrument nationwide.Our study proposed a parsimonious two-step screening procedure using decision tree analysis. A pair of tones (2 kHz and 0.5 kHz) was identified to screen for moderate-to-profound hearing loss in community-based geriatric populations over 60 years of age in Shanghai. Implanting the pair of tones into a well-calibrated sound generator can create a simple, practical and time-efficient screening tool with high accuracy that can be made available at health centers at all levels and can thus facilitate the initiation of nationwide extensive hearing screening in older adults. The decision tree approach is an appropriate method to determine the optimal pure tone hearing screening criteria for local geriatric populations and identify high-risk subpopulations that need early prevention and intervention programs and, therefore, could be used to make the most of public health resources.


Knowledge of ear health and hearing loss is essential for early intervention and treatment, but the state of public knowledge of such in Jeddah, Saudi Arabia, remains unknown.To measure public knowledge of ear health and hearing loss.t-tests were applied to determine the significant difference. p-values of 0.05 or less were considered significant.This cross-sectional study was conducted during August 2018 in Jeddah, Saudi Arabia. An electronic survey questionnaire was distributed to 2372 residents of various districts in Jeddah. The survey was created in 2013 by adopting previously published World Health Organization material, designed to assess knowledge and perception of ear health. All males and females aged 10 years or older living in Jeddah had the chance to participate in this study. A total of 2372 people participated. Percentages mean ± standard deviation, one-way analysis of variance (ANOVAs) and independent The overall mean number of correct responses on the survey’s true/false questionnaire was 10.66 ± 1.92 out of 14. Female participants gave a higher mean number of correct answers than did male participants . Participants with a family history of hearing loss gave a higher mean number of correct answers compared with participants who reported a negative family history .Overall awareness of ear health and hearing loss management is fair. However, the results indicate a need for more integrated educational materials to be made available both to the general population as well as to hearing loss individuals and their families. Hearing loss limits one’s ability to distinguish between sounds correctly, making it challenging to understand basic conversations. Furthermore, hearing loss in early life can significantly impair both development and educational achievement, thus negatively impacting both emotional and social quality of life  and smoking. The second part of the survey was designed to assess the knowledge and perception of ear health and hearing management. This questionnaire was created in 2013 by adopting previously published WHO material  software version 22 , which was used to code and analyse all the data. All identifying information from the participants was removed to ensure privacy and confidentiality, and only the authors had access to the data. Categorical variables are presented as percentages, while continuous variables are presented as mean ± standard deviation. One-way analysis of variance (ANOVAs) and independent This study was approved by the Institutional Review Board (IRB) of King Abdulaziz University Hospital. All identifying information from the participants was removed to ensure privacy and confidentiality, and only the authors had access to the data. Ethical Clearance number is 510-18.Out of 5648, 2372 people agreed to participate in our study, reflecting a response rate of 42%. Of these, 64.7% were women and 35.3% were men. The mean age was 31.31 ± 11.85 years. A total of 45.1% of participants fell within the age range of 19–29 years. Most of the members of our sample were Saudi (90.1%). The percentage of participants who reported that they had been previously diagnosed with hearing loss and had a positive family history of hearing loss was 5.5% and 37.5%, respectively. Additionally, 35.6% of the respondents stated that they had been exposed to potentially harmful noise. Demographic characteristics of the sample are presented in There were 14 questions on the true/false questionnaire, and the mean number of correct responses was 10.66 ± 1.92. The eighth question ‘hearing aids need to fit accurately to provide the maximum benefit’ had the highest rate of correct answers (93%), while the 10th question: ‘Listening to music for more than 3 h a day using earphones may cause permanent hearing loss’ had the lowest rate of correct answers (53.4%). The prevalence of correct answers for all questions is shown in p = 0.005). Importantly, participants with a family history of hearing loss had a considerably higher mean number of correct answers compared to those who reported no family history . Regarding exposure to noise, people who considered themselves as being regularly exposed to loud noise had a lower mean number of correct answers compared to those who did not (10.59 ± 2.01 vs. 10.71 ± 1.87). Details of the mean number of correct responses within our sample are presented in We compared the mean number of correct answers between various age groups and found that the respondents younger than 18 years had the lowest mean number of correct answers (9.93 ± 2.13), while those aged 40 or older had the highest mean number of correct responses (10.85 ± 1.76). Female participants had a higher mean number of correct answers compared to male participants . Furthermore, Saudi participants had a significantly higher mean number of correct answers compared to non-Saudi participants  was for a question about the need for hearing aids to fit correctly to provide maximum benefit, while the lowest correct-answer rate (53.4%) was for a question about whether listening to music for 3 h a day leads to permanent hearing loss, followed by a question about whether vocal cord injury causes deaf–mute persons to be unable to speak (55%). Regarding the questionnaire’s four domains, the percentages of correct answers for each domain varied between 68.26% and 85.5%.In the current study, we found a strong association between age and level of awareness: participants who were aged 40 years or older were the most likely to answer the questions correctly, while those aged 18 years or younger were the least likely to answer questions correctly. To the best of our knowledge, this observation has not been reported previously. It could be theorised that this association is because of older participants having had more exposure to and interactions with deaf individuals.There are only a few studies that have assessed awareness of hearing loss in an integrated manner that includes causes, effects and preventive and management measures . Moreover, Di Berardino et al. reported that exposure to noise was not significantly correlated with a lack of awareness. In contrast, we observed that participants who reported being exposed to noise were more likely to correctly answer questions related to physical agents and overexposure (the effects of kisses and slaps and the recommended duration of noise exposure). The findings in our study can be explained by that having a family history and exposure to noise provides a better background of knowledge and experience, while the lack of knowledge in this group in their study (Di Berardino et al., Although our study shows a fair overall awareness of factors related to hearing loss and ear health, with an average score of 10.66 out of 14, the lack of knowledge in 20% – 50% of the population on some points could possibly have a negative effect on the care and well-being of deaf people, as well as on hearing loss prevention efforts in the general population. For example, a lack of knowledge about the association between deaf-mutism and early hearing loss could delay the diagnosis and treatment. Indeed, a qualitative study on healthcare staff and parents of affected children in India reported that parents were less likely to recognise delayed speech and delayed response to speech in their children if they did not possess specific knowledge regarding the matter, even if they were highly educated in other fields (Merugumala et al., Moreover, a lack of knowledge about the association between hearing loss and performance in school may prevent hearing-impaired children from gaining access to proper care and education. Similarly, a lack of awareness about the association between hearing loss and behaviour in elderly people can precipitate social problems for both affected individuals and their families, hinder the role of elderly people in society and prevent the diagnosis and treatment of hearing loss in this population. Many studies have shown associations between elderly deafness, especially if untreated, and diminished physical ability and activity (Chen, Genther, Betz, & Lin, 7 Studying the influence of education level would also have implications for estimating awareness in small towns and rural areas. Furthermore, the age distribution of the sample was skewed towards younger participants by the method, requiring an electronic form, and because literacy levels are low among the elderly in Jeddah. This could affect the accuracy of our estimations of awareness. Moreover, this study included residents of Jeddah. A future nation-wide survey would better assess awareness of ear health and hearing loss management in the entire Saudi population, including those living in the rural areas. Finally, we did not include healthcare staff or a representative number of deaf individuals. Studies that include healthcare staff and a more representative number of deaf individuals and their families need to be carried out to accurately assess the effect of awareness on the incidence of hearing loss, as well as to assess the psychosocial well-being, access to healthcare and quality of education and work in the deaf population of Saudi Arabia.Our study had several limitations. Firstly, we did not account for the education level of the respondents, although there is some evidence that education affects awareness level (Merugumala et al., The overall awareness of ear health and hearing loss management in Jeddah is adequate, although our results indicate the need for more integrated educational materials for both the general population and hearing-impaired individuals and their families. Furthermore, the development of a broad national screening programme can significantly contribute to early detection and management of hearing loss.


Untreated hearing loss is recognized as a growing global health priority because of its prevalence and harmful effects on health and well-being. Until recently, little progress had been made in expanding hearing care beyond traditional clinic-based models to incorporate public health approaches that increase accessibility to and affordability of hearing care. As demonstrated in numerous countries and for many health conditions, sharing health-care tasks with community health workers (CHWs) offers advantages as a complementary approach to expand health-service delivery and improve public health. This paper explores the possibilities of task shifting to provide hearing care across the life course by reviewing several ongoing projects in a variety of settings – Bangladesh, India, South Africa and the United States of America. The selected programmes train CHWs to provide a range of hearing-care services, from childhood hearing screening to management of age-related hearing loss. We discuss lessons learnt from these examples to inform best practices for task shifting within community-delivered hearing care. Preliminary evidence supports the feasibility, acceptability and effectiveness of hearing care delivered by CHWs in these varied settings. To make further progress, community-delivered hearing care must build on established models of CHWs and ensure adequate training and supervision, delineation of the scope of practice, supportive local and national legislation, incorporation of appropriate technology and analysis of programme costs and cost–effectiveness. In view of the growing evidence, community-delivered hearing care may now be a way forward to improve hearing health equity. The loss of hearing has repercussions on individuals, families and societies. With the world’s ageing population, the condition affects a growing number of individuals, and is one of the leading causes of years lived with disability.,,The global burden of hearing loss lies primarily on adults given the prevalence of age-related hearing loss. However, unaddressed hearing loss in children impairs speech and language development and literacy and educational attainment, which have direct and indirect effects on children’s health and attainment over their lifetime.,,,,,,Little progress has been made in tackling the global burden of hearing loss. Few people with hearing loss use hearing aids, despite the consequences of untreated hearing loss and the existence of evidence-based treatment.,–promotores de salud , community health aides, peer counsellors and public health aides.,,,,Public health programmes have adapted community-delivered models to manage care within resource-constrained settings, including limited availability of professional expertise. A common solution is task shifting where community health workers (CHWs) work in partnership with professional health-care providers and under their supervision.CHW programmes have focused on a range of health conditions across the life course, from delivery of maternal and child healthHere, we share our experiences with several early programmes in Bangladesh, India, South Africa and the United States of America (USA) and lessons learnt to inform best practices in community-delivered hearing care. The programmes were selected to represent different resource-constrained settings and a range of activities, scopes and target populations, from children to older adults . This pa,,–Remote communities are at a higher risk of untreated hearing loss because of the scarcity of specialists and the long distance to reach health-care services. To overcome these barriers, policy-makers in Alaska, USA, formally introduced a community-based model in 1968 in which community health aides deliver frontline care in more than 250 village clinics.The community health aide model, with specialty triage provided through a telemedicine network, has been used for clinical care for more than 15 years, but has only recently been used for a population-based preventive screening programme for hearing. A randomized trial is being conducted in 15 communities throughout north-west Alaska that uses mHealth smartphone-based hearing screenings, and referrals through the telemedicine network to improve the effectiveness of the school-based hearing screening and referral processes in remote communities.The challenges of a telemedicine network supporting ear and hearing care delivered by community health aides include training and equipment maintenance. Regular and frequent training of community health aides is necessary to ensure quality and encourage continued use of mHealth technologies. Telemedicine equipment, such as video otoscopy and audiometers, requires calibration, servicing and routine maintenance, all of which can be difficult in remote environments. Within the community health aide programme, ongoing training is provided, including continuing education and real-time training, and telemedicine equipment is actively managed at all sites.,–,,,,,South African CHWs have historically focused on communicable diseases rather than noncommunicable conditions such as hearing loss. Research on the delivery of hearing screening by CHWs is limited, in part due to the expense of conventional equipment and the advanced training required to operate it. New mHealth technologies, such as tablet- and smartphone-based audiometers and video otoscopy, increase the range and quality of care provided by CHWs.Oyendo Bien (hearing well) is a hearing loss education and support programme, which is designed to be culturally relevant to older Spanish-speaking adults. The goal of this group intervention is to help individuals and families manage age-related hearing loss. The programme began in 2015 and is facilitated by Spanish-speaking CHWs, who work at an Arizona community health centre on the border between the USA and Mexico. CHWs receive training in identification of the signs and symptoms of hearing loss and facilitation of a hearing-health education group.–Oyendo Bien was guided by community-based participatory research principles.Oyendo Bien include: participation of communication partners, who are typically family members or friends; rehabilitation services facilitated by CHWs and audiologists; training in communication strategies for individuals with hearing loss and their communication partners; and an emphasis on peer support. Preliminary results from the Oyendo Bien pilot programme show positive outcomes, including adoption of communication strategies by individuals with hearing loss and their communication partners, improved quality of life and increased use of hearing care by those with hearing loss.Through a collaboration involving community members and experts from audiology, public health and translation,Oyendo Bien was a lack of training curricula for CHWs on hearing loss and rehabilitation options. The content of curricula designed for other health professionals and even the lay public, tended to be highly technical or device-centred, while the focus of Oyendo Bien is on rehabilitation. The training also needed to be relevant to CHWs already working in a health centre. In the end, training was co-developed with CHWs to make use of their strengths as experienced health educators.A challenge in the development of Shruti  programme is the result of a partnership between public and private sectors, specifically CHWs, physicians and device manufacturers, including amplification devices or hearing aids. Shruti is a community-based, door-to-door programme that offers hearing care for low-income people in Bangladesh and India.The Shruti programme, including increased awareness of and access to hearing care, improvements in work performance and social interactions in patients who had their hearing loss treated, and increased employment opportunities for CHWs.The programme began in 2013 and now operates in 65 hospitals and clinics. As of July 2019, more than 650 000 people have been screened. A 2017 report documented several social impacts of the Shruti depends on a team of health workers who are engaged, motivated and remain with the programme. Hiring and retention of these CHWs is a continuing challenge, which is complicated by a growing local health-care industry that offers increasing employment opportunities. Another important challenge is to optimize staff size to balance personnel costs with the delivery of high-quality services. Efforts are ongoing to make Shruti financially self-sustaining by scaling up the size of the programme.As a programme delivered by CHWs, Oyendo Bien, the HEARS programme includes education on hearing loss and communication strategies but, like Shruti, provides a low-cost, over-the-counter amplification device.The HEARS (Hearing Equity through Accessible Research and Solutions) intervention is another community-delivered aural rehabilitation programme designed for older adults. The programme began in 2013 in partnership with local affordable housing organizations for older adults based in Baltimore, USA. Similar to –These peer educators deliver hearing care to low-income older adults with remote supervision provided by an audiologist. The HEARS model maximizes hearing care accessibility in multiple ways, including peer mentoring to help tackle mistrust of health-care professionals,Recruiting peer educators who have the time and motivation to take on additional duties, while also often managing their own health and family obligations, is a challenge. Openness to interacting with and learning to use mobile, touchscreen technologies, such as a smartphone or tablet, can further limit the pool of potential peer educators. Furthermore, peer educators must be able to read at a basic level to complete the training, which relies on interactive and text-based instruction, although the programme does not require a certain literacy level for clients.Initial evidence supports the use of CHWs to deliver hearing care in a range of capacities, including screening and diagnosis of paediatric hearing loss in different settings, and the provision of aural rehabilitation and hearing technology to adults and older adults.Box 1Best practicesTraining: Competency-based, needs-driven. Based on clear procedures and protocols. Topics and teaching techniques driven by CHWs. Include full spectrum of knowledge required; skills, not limited to clinical skills alone. End in certification.Supervision: Structured, regular and provided by trained supervisors. Monitor with defined quality measures. Regularly assess skills. Match intensity of oversight with complexity of task.Continuing education: Structured, regular mentoring opportunities provided by supervisors and peers. Explicit opportunities for career advancement. Performance-based incentives. Employ CHWs whenever possible rather than relying on volunteers.Application to hearing careTraining: Incorporate hearing health, hearing care, relevant technology, as well as other skills, such as public speaking, teaching and empathic training, as appropriate. Ensure procedures and protocols reflect programme; cover history-taking, screening, counselling and advanced counselling, as needed.Supervision: By audiologists and/or ear, nose and throat surgeons, but require proficiency in supervision of CHWs. Frequency and nature of supervision (in-person or remote) reflect CHWs’ scope of practice (e.g. paediatric hearing screening or fitting older adults with amplification devices).Continuing education: Mentoring provided by audiologists and/or ear, nose and throat surgeons. Recognize value of peer mentoring. Create opportunities for increased responsibility.Best practices: Define scope of practice for each member of the care team. Foster environment of collaboration and communication. Emphasize importance of extending services, counteract threat of competition. Tailor degree of task shifting to nature of condition.Application to hearing care: Allow scope of practice to be defined by CHWs, audiologists, ear, nose and throat surgeons, patients and other stakeholders. Encourage culture of support and open dialogue between CHWs, and audiologists/ear, nose and throat surgeons. Vary scope by condition (e.g. paediatric hearing loss versus mild/moderate age-related hearing loss).Best practices: Recognize importance of top-down leadership and role of policy. Involve stakeholders, including CHWs and patients, from the start. Use existing regulations or revise policies as needed. Prioritize sustainable models of care, including those that are reimbursable through insurance. Ensure policies support mechanisms for reimbursement and scope of practice. Appropriately regulate certification process for safety and quality without excess burden or exclusion of parties involved.Application to hearing care: Ensure appropriate regulation and certification of CHWs providing ear and hearing care. For sustainability of hearing health care, work for reimbursement of telemedicine, hearing screening and counselling provided by CHWs through available avenues, such as insurance.Best practices: Make use of technology to strengthen efficiency, monitor quality, improve performance, facilitate care, support research and evaluation, and reduce costs. Select CHWs based on technology demands of the programme. Include training on use, care and maintenance of technologies. Consider usability of technologies by CHWs and patients.Application to hearing care: Incorporate mHealth hearing care technologies  and low-cost, high-quality amplification devices. Select CHWs with understanding of technology as appropriate. Select amplification devices based on quality and usability for patients and CHWs, not supervisors. Include training on how to use smartphones and touchscreens, as needed.Best practices: Track programme costs, including savings. Perform cost-analysis studies whenever possible.Application to hearing care: Record costs of CHWs, examinations and screening technologies, including care and maintenance, and amplification devices, including over-the-counter options.CHW: community health worker; mHealth: mobile health technology,,,,Similar to CHWs who provide care for other noncommunicable diseases, CHWs delivering hearing care must complete competency-based training in ear and hearing care.,,,Oyendo Bien and HEARS, CHWs participate in refresher sessions through in-person group meetings with the audiologist trainers and booster sessions as needed. Supervisors must also consider CHW retention through fair remuneration and opportunities for career advancement, particularly in competitive labour markets.Consistent supervision, mentoring by supervisors and peers, and continuing education are critical, as is the input of CHWs so as to optimize the relevance of the topics covered and the teaching techniques.Overall, task shifting has been met with variable acceptance by health-care professionals with tension stemming from concerns around competition, as well as patient safety and quality.Given that the most common causes of hearing loss change over the lifespan, the role of CHWs varies with the etiology of the hearing loss and associated differences in treatment. For paediatric hearing loss, CHWs in Alaska and South Africa extend the reach of existing professional hearing-care services. In contrast, for adult-onset hearing loss, particularly mild to moderate age-related hearing loss, community-delivered hearing care may shift more tasks to CHWs, who are able to deliver basic group and individual aural rehabilitation, and provide, fit and orient individuals to an amplification device. Regardless of the scope, a close working relationship between team members is needed to prevent situations that could increase the vulnerability of populations who are already at risk of exploitation.,,,Government, local or national, plays a role in the success of community-delivered hearing care through regulations and reimbursement policies.,,,Technological advancements underpin community-delivered hearing care and include digital otoscopy, tympanometry and portable automated hearing testing. These technologies provide point-of-care diagnostics coupled with internet-based data management and low-cost, high-quality hearing technologies.,With an emphasis on technology-assisted solutions, community-delivered hearing care relies on the acceptance and use of technology by CHWs, patients and their families. Selection of CHWs and training must consider the technology demands of the programme. For example, the Alaskan programme requires the community health aides to be able to use a range of devices independently and the HEARS programme requires peer educators to be open to learning how to use a smartphone to fit an amplification device. Sufficient time and resources must be dedicated to training CHWs on device use, care and maintenance. Adoption of technology by users in the long term requires them to believe that these technologies are useful, important and functional.,,Data on the costs and cost–effectiveness of community-delivered hearing care are lacking.Although hearing loss is increasingly recognized as core to health and overall well-being, clinic-based hearing care has not adequately addressed the growing global burden. Drawing on public health approaches used with other prevalent conditions, community-delivered hearing care offers new approaches to task shifting through CHWs. These approaches expand the way in which hearing loss is diagnosed and managed across the life course. As with all global health initiatives, community and stakeholder engagement, together with evolving science and technology, and the support of government, is critical to put promising evidence into practice and improve equity in hearing health.


Mucorales. This infection occurs mainly in immunocompromised patients, especially with hematological malignancy, transplantation, or diabetes mellitus. Rhino-orbito-cerebral and pulmonary mucormycosis are the predominant forms. Interestingly, location is associated with the underlying disease as pulmonary mucormycosis is more frequent in hematological malignancy patients whereas rhino-orbito-cerebral mucormycosis is associated with diabetes. Cutaneous mucormycosis results from direct inoculation, mainly after trauma or surgery. Gastro-intestinal mucormycosis occurs after ingestion of contaminated food or with contaminated device and involves the stomach or colon. Disseminated disease is the most severe form and is associated with profound immunosuppression. Uncommon presentations with endocarditis, osteoarticluar or isolated cerebral infections are also described. Finally, health-care associated mucormycosis is a matter of concern in premature newborns and burn units. Clinical symptoms and CT scan findings are not specific, only the early reversed halo sign is associated with pulmonary mucormycosis. Circulating Mucorales DNA detection is a recent promising diagnostic tool that may lead to improving the diagnosis and prompting therapeutic initiation that should include antifungal treatment, correction of the underlying disease and surgery when feasible.Mucormycosis is an emerging life-threatening fungal infection caused by  Mucorales. Reported incidence of mucormucosis has increased over the years, presumably because of an increase of the population at risk and improved diagnostic tools [Mucormycosis is an emerging invasive fungal infection with a high mortality rate caused by ubiquitous filamentous fungi belonging to the order of ic tools . Mucormyic tools .Mucorales and to the underlying disease of the patients [Six distinct clinical syndromes can occur in susceptible hosts, which have been classified as rhino-orbito-cerebral, pulmonary, cutaneous, gastrointestinal, disseminated and uncommon presentations. The primary site of infection varies according to the different genera included in the order of patients ,4,5,6. Ipatients . In patiPrognosis remains poor with an overall mortality estimated between 32% and 70% in different studies ,5,6,7,8.This is the most common clinical manifestation of mucormycosis. Infection begins with inhalation of spores that allows the fungus to spread to the paranasal sinuses. The infection can then rapidly extend to adjacent tissues: to the palate, the sphenoid sinuses, the orbits and the cavernous sinuses and eventually to the brain. Necrosis of these tissues, revealed by a black eschar, is a worrying sign of local extension .Rhizopus was predominantly associated with rhino-cerebral forms [Mucorales. In experimental studies, ketoacidosis has been found to predispose mice to Rhizopus spp. but not to Lichtheimia spp. infection [R. arrhizus in endothelial cells in mice [In a meta-analysis of 175 ROCM cases published between 1994 and 2005, diabetes mellitus was the predominant underlying condition (64% of the cases), followed by hematological malignancy (15%) and renal diseases (13%) [nfection . This coThe main presenting symptoms were unilateral facial pain (86%), multiple cranial nerve palsies (68%), periorbital edema (59%), fever (50%) and diplopia (41%) in a study of 22 patients with ROCM . Three cRapid differential diagnosis of ROCM and bacterial orbital cellulitis (BOC), much more frequent, is crucial for prevention of extension to orbital and cerebral tissues but can be challenging as early clinical signs are similar in both diseases. In a case-controlled study comparing 14 ROCM patients with 20 BOC patients, the authors found that extraocular muscle limitation was more frequent in ROCM patients, whereas eyelid swelling occurred more often in BOC patients . Althougp = 0.011) [Abnormal paranasal sinus findings were detected on the CT scans of all 14 patients with ROCM (100%), whereas only 12 patients with BOC had sinus abnormalities (60.0%) (p < 0.0001)) [Optimal therapy of ROCM requires a multidisciplinary approach that relies on prompt institution of appropriate antifungal therapy, reversal of underlying predisposing conditions, and surgical debridement of devitalized tissue . The ana0.0001)) .ROCM mortality rate varies according to the extension of the infection and the timeliness of management. In a meta-analysis published in December 2018, the overall mortality rate was 41.5%, which is not significantly better than the previous series published in 1994 by Yohai et al . Early iPulmonary mucormycosis is particularly associated with hematologic malignancies . AccordiSymptoms of PM are nonspecific and include fever, cough, dyspnea and chest pain . Lesionsp < 0.001), whereas some airway-invasive features, such as clusters of centrilobular nodules, peribronchial consolidations, and bronchial wall thickening, were more common in patients with aspergillosis [Symptoms consistent with PM in patients with risk factors should lead to prompt realization of a high-resolution computed tomography (CT). CT findings are not specific but may be suggestive of fungal infection with nodules , mass, cavitation, micronodules and pleural effusion . Notablygillosis . Howevergillosis . Moreovegillosis . Cunninghamella spp. was mostly isolated from PM and was associated with higher mortality than other Mucorales [As in other forms of mucormycosis, therapy relies on the combination of medical  and surgical treatment when necessary . Mortaliucorales .Cutaneous mucormycosis results from direct inoculation of fungal spores into damaged skin, which may lead to disseminated disease. The reverse  is very rare. In a review of 929 reported cases of mucormycosis, cutaneous involvement was the third site of mucormycosis infection in terms of frequency, involving 19% of the patients . Most caApophysomyces elegans, Lichthemia and Mucor species were the main Mucorales isolates. Mucorales were often associated with bacterial infection (41% of the cases), which can delay the diagnosis of mucormycosis [It is interesting to note that post traumatic mucormycosis represented the third cause of mucormycosis in the French “RetroZygo” study (18%) and the second cause (17%) in the European study conducted at the same time. ,6. It mormycosis . Skin or wound biopsies should be systematically performed as the diagnosis can be easily addressed by direct examination and culture.Outcome is better than in other forms of mucormycosis  . Treatmep = 0.002). Diagnosis can be suspected on endoscopic findings showing fungal mass or necrotic lesions that overlie an ulcerated area and that can lead to perforation and peritonitis. Optimal treatment is urgent surgery combined with intravenous amphotericin B. As symptoms of gastrointestinal mucormycosis are non-specific, diagnosis is often delayed or missed and mortality remains high at 57% [Primary gastrointestinal disease is the least frequent form of mucormycosis. It can be acquired by ingestion of contaminated food such as fermented milk and dried bread products but also be healthcare-associated with contaminated devices. The stomach has been described as the most common site of infection, followed by colon, small intestine and esophagus . In a reh at 57% .Disseminated infection is defined as infection involving at least two non-contiguous sites. In a prospective study conducted in 13 European countries between 2005 and 2007, 15% of patients presented with disseminated disease . The mosOther less common forms of mucormycosis include endocarditis, bone and joint infections, peritonitis and pyelonephritis. Notably, mucormycosis is a rare cause of endocarditis in intravenous drug users. Osteoarticular mucormycosis principally occurs after direct inoculation especially after trauma or surgical intervention . PeritonAnother rare manifestation of mucormycosis is isolated cerebral mucormycosis whereas typical central nervous system mucormycosis occurs after spread from paranasal sinus location or in disseminated diseases. In a review of 68 reported cases in the literature, most patients with isolated cerebral mucormycosis had a history of intravenous drug abuse (82%) . LesionsHealth-care associated mucormycosis is a matter of concern, especially in neonatology, hematological, transplantation and intensive care units with burn patients. Rhizopus was the most frequent genus identified (43%) as in other forms of mucormycosis. In a series of 169 cases of HCM identified between 1970 and 2008, major underlying diseases associated with HCM were solid organ transplantation (24%) , diabetes (22%), and severe prematurity (21%) . Forty-oIn intensive care units, burn patients appear to be particularly susceptible to fungal infection because of the loss of the skin barrier and acquired immune deficiency. In these patients, invasive wound mucormycosis is associated with an extremely poor prognosis despite a good tissue diffusion of amphotericin B. In a single-center study conducted between 2013 and 2016 in a specialized referral burn unit, the recorded mortality was 62% for patients with invasive wound mucormycosis .Mucormycosis is an emerging life-threatening fungal infection characterized by host tissue infarction and necrosis that occurs mostly in immunocompromised patients. The distribution of risk factors varies across geographical regions, as hematological malignancy is the main risk factor in Europe and North America, followed by diabetes, trauma and SOT, whereas uncontrolled diabetes is the most common underlying disease found in studies in India or in Mexico ,8,38,39.