Older adults with hearing difficulties face problems of communication which may lead to underuse of health services. This study investigated the association of hearing loss and self-reported hearing difficulty with the use of health services and unmet health care needs in older adults.n = 2144) drawn from a population-based study, Health 2000, were analyzed. Hearing loss was determined with screening audiometry (n = 1680). Structured face-to-face interviews were used to assess self-reported hearing difficulty (n = 1962), use of health services  and perceived unmet health care needs. Multivariable logistic regression analyses were used.Data on persons aged 65 and older  were more likely to have used mental health services than those with non-impaired hearing . Self-reported hearing difficulty was also associated with higher odds for mental health service use (OR = 2.1 95 % CI 1.2–3.5). Hearing was not associated with use of the other health services studied, except presenting for a hearing test. Persons with self-reported hearing difficulty were more likely to perceive unmet health care needs than those without hearing difficulty .Older adults with hearing loss or self-reported hearing difficulty are as likely to use most health services as those without hearing loss. However, self-reported hearing difficulty is associated with experiencing unmet health care needs. Adequate health services should be ensured for older adults with hearing difficulties.The online version of this article (doi:10.1186/s12877-016-0356-5) contains supplementary material, which is available to authorized users. Hearing loss is relatively rare in young adults but its prevalence rises exponentially in older population  due to aThe diagnosis and treatment of hearing loss may require several visits to different health care professionals, such as a general practitioner, otorhinolaryngologist and audiologist. On the other hand, for a marked proportion of those with hearing loss, the condition remains undiagnosed, and even after diagnosis does not receive rehabilitation . CertainOn the other hand, persons with hearing loss may avoid contacts with health care personnel owing to communication problems. It has been shown that older persons suffering from hearing problems are socially less active, i.e. participate in various social activities less often and meet other people less often than persons without hearing problems , 17, mosLittle is known about whether older adults with hearing loss use health services less or more than others. Only one hearing loss study has focused on older adults (who turned 65 during the year of the study) . The autOne explanation for the differences in the results of the previous studies may lie in the use of either objective or subjective methods for measuring hearing. It has been shown that objective and subjective measures of hearing do not correlate very highly and they cover partly different aspects of hearing performance . Pure-toDespite adjusting use of health services for the needs variables (i.e. diseases) persons may vary in perceived access to, and adequacy of, health services. Persons with hearing problems may be dissatisfied with the quality of health services due to communication problems with health care providers and hence, they may experience unmet health care needs. Consequently, in addition to absolute use of health services, perceived unmet need should be studied. To the best of our knowledge, only one study has investigated the association between hearing problems and perceived unmet health care needs. The results showed that, among Canadians from 12 years to old age, persons who reported hearing problems also reported more unmet health care needs than those not reporting hearing problems .In previous studies investigating the associations between hearing and health services, the participants have mainly been either younger adults  or drawnN = 2 144). The sample participation rate for those aged 65 and over was 89 % for the interviews, and 83 % for the health examination.The Health 2000 Study, conducted in 2000–2001, is a cross-sectional survey comprising a comprehensive health interview and a detailed health examination in a population-based large sample of Finnish adults . The samhttp://www.terveys2000.fi/forms.html) were carried out at the participants’ homes or in residential institutions. In the interviews, the interviewer read the questions from the laptop screen and entered the answers directly into the laptop. Health examinations were performed in public health centers or in temporary examination facilities. If the participant was unable to travel to the health center or temporary facility, an abbreviated examination was carried out in the participant’s home [Computer-assisted personal health interviews (questions available at t’s home .0.5–2kHz) was calculated as the mean value over the measured frequencies. Test-retest repeatability was excellent (intraclass correlation coefficient = 0.97) [0.5–2kHz > 40 dB as having hearing loss and those with BEHL0.5–2kHz ≤ 40 dB as having no hearing loss. A hearing threshold of 40 dB is the lower limit for moderate hearing loss [Pure-tone air-conduction hearing thresholds were assessed for both ears without a hearing aid using a screening audiometer  at the frequencies of 0.5, 1 and 2 kHz in a silent room . Headpho = 0.97) . Hearinging loss  and was Self-reported hearing difficulty was assessed with the question “Can you hear without difficulties what is said in a conversation between several people (with or without a hearing aid)?”. The response categories were 1) I can hear without difficulties 2) I can hear, but it causes difficulties and 3) I cannot hear at all. The latter two categories were combined as the number of men in the third category was too low to permit analysis of some of the outcome measures. Data on self-reported hearing difficulty was available for 1962 (92 %) persons.In Finland, public health services, funded by local and central government, are available to all citizens. Some services  are free of charge and for some services , small fees are charged. If a citizen uses private health services a minor proportion of the costs is usually borne by the Social Insurance Institution of Finland. Audiologic rehabilitation, including fitting a hearing aid, is provided free of charge by the public specialized health care service after referral from primary health care.As a part of the home interview, the participants were asked how many times during the last 12 months they had visited a physician  at a health center (primary care), hospital outpatient clinic (secondary care), occupational health care clinic, private clinic, in connection with a home visit, or elsewhere. The numbers of visits reported were summarized. Participants who reported hearing loss were also asked to state the number of physician visits within the last 12 months due to their hearing loss. This number was subtracted from the total number of physician visits to yield the number of visits not related to hearing loss. The total number of visits to a nurse within the last 12 months was obtained from three distinct questions . As physician visits , physician visits due to hearing loss  and nurse visits  were non-normally distributed they were categorized. Physician visits and physician visits due to hearing loss were classified into categories no visits/1–4 visits/5 or more visits) and nurse visits were classified into categories no visits/1–5 visits/6 or more visits. The proportion of the participants reporting a high number of nurse visits was larger than the proportion reporting a high number of physician visits. Applying cut points of five for physician visits and six for nurse visits yielded comparable distributions between these variables. Participants were also asked whether they had received physical therapy  and whether they had used mental health services within the last 12 months. They were further asked whether they had undergone any health examinations  within the last 5 years. Participants were also asked to report any vision test, hearing test, mammography, or prostate-specific antigen (PSA) test taken during the last 5 years. The mammography analysis included women younger than 70, as they form the target group for the mammography screening arranged by municipal public health services. Participation in health promotion groups was defined as having attended a group targeting weight management, smoking cessation, neck/back rehabilitation, other physical exercise, mental wellbeing, support for patients’ relatives, or problems with alcohol or other addictions, parenthood, self-care/management of an illness, or other health promoting activities within the last 5 years. The participants were further asked: “Do you have a chronic illness for which you would like to get continuous treatment by a doctor but do not receive it?” and “Do you have a chronic condition for which you would like to get other type of care but do not receive it?”. Participants answering yes to either question were considered to experience unmet health care needs.Potential confounders were selected according to the criteria suggested by McNamee . AccordiP-values for comparisons were obtained from age-adjusted logistic and linear regression analyses using Stata version 14. Continuous variables were standardized for the analyses. Hearing loss was found to have significant interactions with sex on physician visits, physical therapy, and hearing test. Self-reported hearing difficulty showed a significant interaction with sex on physical therapy. Therefore, the results on these outcomes are reported separately for men and women.The sampling design, i.e. stratification and clustering, was taken into account in all analyses. Observations were weighted to reduce bias due to non-response and to correct for oversampling of those aged >80 years using inverse probability weights constructed using register data on geographical area , age, sex and mother tongue . As age First, we analyzed the proportions of health service users, adjusted for sex (in case of no interaction) and age, using logistic regression analysis and the predictive margins function in Stata. In the case of ordinal regression analysis, the odds ratio describes how likely persons with hearing loss are to have a certain value  of the ordinal outcome variable compared to those without hearing loss. Then, multivariable-adjusted logistic regression models were run using MPlus version 7 . In the Next, the maximum likelihood method was applied in another way to further test that the results were not biased by missing data in the independent variables. This was done by repeating the above mentioned regression analyses and simultaneously requesting means and variances for the independent variables and using Monte Carlo integration without analysis weights in MPlus. In this procedure, the analysis takes into account missing data also in the independent variables. Maximum likelihood method does not fill in missing values but uses observed data to estimate the parameters of the variables with missing data. Based on the available data of the variables in the regression model (complete and incomplete), it identifies parameter estimates that have the highest likelihood of underlying the observed data. The maximum likelihood method, along with multiple imputation, is among the two missing data analysis techniques that are considered as efficient for accounting for missing data when the data are missing at random or missing completely at random . Even ifn = 837) of the participants (n = 1962) reported difficulty hearing a conversation between several people. Among those tested by audiometry (n = 1680), the weighted prevalence of hearing loss (BEHL0.5–2kHz > 40 dB) was 16 % (non-weighted N = 328) (Table p < .001) than those without hearing loss. When adjusted for age, persons with a hearing loss (n = 328) had lower education , income  and BMI , and were more likely to have low vision  than persons without hearing loss (n = 1352). Of the persons with hearing loss, 33 % reported using a hearing aid daily while of those without hearing loss 0.8 % used a hearing aid daily (p < .001). Hearing aid users were present among those categorized as without hearing loss (<40 dB) as the category also included persons with mild hearing loss (25–40 dB).In total, 43 % (ants n = 962 reporp = .020). Persons with hearing loss were less likely to have participated in a health promotion group during the last 5 years than persons without hearing loss . Both men  and women  with hearing loss were more likely to have been for a hearing test during the last 5 years than those without hearing loss. In the multivariable-adjusted logistic regression analyses, hearing loss was associated with increased odds for having used mental health services within the last 12 months . Women with hearing loss were more likely to have been for a hearing test within the last 5 years than women without hearing loss . When maximum likelihood method was used to account for missing data in both independent and dependent variables, the results were parallel to the original results   to have been for a hearing test than those with normal hearing (≤25 dB) whereas the associations between mild hearing loss and use of the other health services studied were statistically nonsignificant . Further, persons with hearing difficulty were more likely to have been for a hearing test  and more likely to perceive unmet need for health care  compared to those reporting no hearing difficulty. In the multivariable-adjusted logistic regression analyses, self-reported hearing difficulty was associated with increased odds for having used mental health services during the last 12 months  and the odds for having been for a hearing test within the last 5 years . Hearing difficulty also increased the likelihood of reporting perceived unmet needs for health care . When maximum likelihood method was used to account for missing data in both independent and dependent variables, the results were parallel to the original results   and women  and not associated with the other health services studied or perceived unmet needs for health care.As hearing loss was not associated with most of the studied health services we explored whether this was due to hearing aid use accounting for a major part of the covariance between hearing loss and use of health services. This was not the case, as hearing aid use was significantly associated only with the likelihood of having been for a hearing test in both men  than those who participated. They also had poorer hearing according to a subjective evaluation by the interviewer, although their self-reported hearing was similar to that of those who participated in the health examination (data not shown). Due to this selection bias, the results may underestimate the strength of the association between measured hearing and use of health services. This study did not include telephone contacts with health care providers or health services provided via the internet. Omitting telephone contacts from the analysis may have led the use of health services to be more underestimated in persons without hearing loss than in those with hearing loss. This is because those with hearing loss are more likely to avoid telephone contacts. However, omission of internet health services is not likely to have presented a significant bias as such services were very uncommon in Finland at the time of the data collection. We measured hearing only at frequencies 0.5, 1 and, 2 kHz. As age-related hearing loss typically first affects high frequencies (4 kHz and higher), it is likely that we classified some persons with hearing loss (determined on the basis of frequencies 0.5–4 kHz) as without hearing loss. However, the definition of hearing loss in this study is likely to have identified persons who experience problems when communicating with health care providers. Although we used several sociodemographic and health-related variables to control for potential confounding factors, we cannot totally rule out the possibility that residual confounding partially explains some of the findings. Further, self-reported health service use as the outcome variable may introduce recall bias. Finally, the cross-sectional design of the present analysis limits the drawing of causal inferences.Self-reported hearing difficulty or moderate pure-tone hearing loss do not appear to be associated with the use of most health services among older adults. However, higher use of mental health services in persons with self-reported hearing difficulty or moderate pure-tone hearing loss, independently of socioeconomic status and confounding comorbidities, suggests that mental health screening may be justified for older adults with hearing problems. Further, self-reported hearing difficulty in men and women and moderate hearing loss in women were associated with higher likelihood of having had a hearing test. Despite similar or higher use of health services, persons reporting hearing difficulty perceived more unmet needs for health care than those without hearing difficulties. One possible explanation for unmet needs for health care may be communication difficulties between patients and health service providers, which could be alleviated by aural rehabilitation and/or by educating health care providers on effective communication strategies. Nevertheless, experience of unmet needs for health care in persons with hearing difficulties may indicate insufficient care of their health problems. This in turn may lead to further health impairment of persons with hearing difficulties. Hence, it seems justified to pay special attention to ensuring that an older patient reporting hearing difficulty receives adequate health services. Further studies are needed to explore whether hearing problems predict future health service use and to explore the factors underlying unmet health care needs in older adults with hearing problems. This study covered only a part of health care among older persons with hearing problems. Future studies concerning use of medication and community services could expand understanding on how older persons with hearing problems take care of their health and manage with their everyday life.


Beauveria bassiana are promising biological agents for control of malaria mosquitoes. Indeed, infection with B. bassiana reduces the lifespan of mosquitoes in the laboratory and in the field. Natural isolates of B. bassiana show up to 10-fold differences in virulence between the most and the least virulent isolate. In this study, we sequenced the genomes of five isolates representing the extremes of low/high virulence and three RNA libraries, and applied a genome comparison approach to uncover genetic mechanisms underpinning virulence.Entomopathogenic fungi such as MAT1–1–1 or the MAT1–2–1 gene. Moreover, a putative new MAT gene (MAT1-2–8) was detected in the MAT1–2 locus. Comparative genome analysis revealed that Bb8028 contains 163 genes exclusive for this isolate. These unique genes have a tendency to cluster in the genome and to be often located near the telomeres. Among the genes unique to Bb8028 are a Non-Ribosomal Peptide Synthetase (NRPS) secondary metabolite gene cluster, a polyketide synthase (PKS) gene, and five genes with homology to bacterial toxins. A survey of candidate virulence genes for B. bassiana is presented.A high-quality, near-complete genome assembly was achieved for the highly virulent isolate Bb8028, which was compared to the assemblies of the four other isolates. Whole genome analysis showed a high level of genetic diversity between the five isolates (2.85–16.8 SNPs/kb), which grouped into two distinct phylogenetic clusters. Mating type gene analysis revealed the presence of either the B. bassiana provide a better understanding of the natural variation in virulence and will offer a major resource for future research on this important biological control agent.Our results indicate several genes and molecular processes that may underpin virulence towards mosquitoes. Thus, the genome sequences of five isolates of The online version of this article (doi:10.1186/s12864-016-3339-1) contains supplementary material, which is available to authorized users. Beauveria bassiana is a cosmopolitan entomopathogenic fungus (EPF) with a broad host range covering most insect orders  and also arthropods (subclass Acari) [B. bassiana is currently used commercially as a biological control agent for different arthropod pests in China such as the pine caterpillar (Thaumetopoea pityocampa), corn borer , peach aphid (Myzus persicae), and pine sawyer (Bursaphelenchus xylophilus) [B. bassiana is also being developed as a biological control tool for vectors of human diseases, such as Anopheles mosquitoes that transmit malaria [Aedes aegypti mosquitoes that are vectors of Dengue, Chikungunya and Zika virus [Triatoma infestans bug, the Chagas disease vector [Ixodes ricinus ticks that transmit Lyme disease [s Acari) , 2. B. bophilus) . B. bass malaria , 5, Aedeka virus , 7, the e vector , and Ixo disease .B. bassiana starts when conidia adhere to the host cuticle via hydrophobic interactions and subsequently germinate. A germ tube is formed that is able to penetrate the cuticle through a combination of mechanical pressure and cuticle degrading enzymes. Once the fungal structures reach the haemocoel, the fungus switches to growth as single-celled blastospores, which are capable of evading the insect immune system, exploit the haemolymph for nutrition, and secrete toxins that eventually kill the host. Once the host is dead, the fungus breaches the cuticle from the inside outwards, allowing the formation of conidia that upon dispersal start new infections [Infection by fections .B. bassiana as well as the genetic mechanisms of virulence is crucial to develop it as an effective and sustainable biological control agent. Substantial progress has been made in the genetic characterization of the mechanisms involved in the infection cycle of B. bassiana inside insects. Many of the recent findings regarding genes involved in virulence were possible due to the development of reliable protocols that allow genetic manipulation [B. bassiana expresses two hydrophobin genes, hyd1 and hyd2, that are believed to be involved in surface hydrophobicity, adhesion, virulence and composition of the rodlet layer. A Δhyd1 knock-out mutant showed decreased virulence and spore hydrophobicity but unchanged surface adhesion, while a Δhyd2 mutant showed reduced hydrophobicity and surface adhesion but unchanged virulence [Bbcyp52x1, was shown to function in enzymatic breakdown of lipids in the waxy layer. A ΔBbcyp52x1 knock-out mutant showed reduced virulence on Galleria mellonella upon topical application of conidia, though not upon intra-hemocoel injection [A good understanding of the life history of pulation  togetherpulation . For insirulence . Similarnjection .B. bassiana , many oisolates  opens thB. bassiana by a comparative genomics study. B. bassiana is well known for having a broad genetic, host, and virulence diversity. As a consequence, genome structure and DNA sequence variation between any two isolates could be related to many factors in the biology of this fungus . Therefore, we sequenced five isolates of contrasting virulence, selected from a panel of 29 B. bassiana isolates of which the natural variation in virulence had been previously characterized [B. bassiana isolate, Bb8028, which provides the community a highly suitable reference genome to be used for comparison with other isolates.The aim of this study was to improve our knowledge in understanding the key factors involved in virulence of cterized . We asseBeauveria bassiana isolates ARSEF 1520 (Bb1520), ARSEF 2597 (Bb2597), ARSEF 4305 (Bb4305), ARSEF 5078 (Bb5078) and ARSEF 8028 (Bb8028) were obtained from the USDA-ARS Collection of Entomopathogenic Fungal Cultures (ARSEF). These isolates were selected based on their previously characterized virulence against malaria mosquitoes. Isolates Bb2597 and Bb8028 were previously shown to display high virulence, Bb1520 has intermediate virulence, while Bb4305 and Bb5078 have low virulence [irulence . IsolateDNA was isolated from freeze-dried mycelium using a CTAB-based method . All isoTo obtain the transcriptome, RNA from Bb8028 was isolated from three different sources: (1) 5-day old mycelia grown on rice medium; (2) proto fruiting bodies (stromata like-structures) obtained from a cross between Bb8028 and Bb5078 co-cultivated for 2 months on rice medium as described ; and (3)de novo assembly was performed using Celera assembler [de novo with Oases [de novo with RepeatScout [For isolates Bb4305 and Bb5078, ssembler  with defssembler  with defssembler  and quivssembler , and errth Oases  and Trinth Oases . Also, tth Oases . Completth Oases . RepeatMth Oases  was usedth Oases , and preeatScout . Local CeatScout , SNAP [3eatScout , and GeneatScout  as ab ineatScout  against eatScout . The BLAeatScout  and GeneeatScout .−5 and 75% coverage. Besides the five newly sequenced genomes presented here, the previously reported genome of B. bassiana ARSEF 2860 (Bb2860) [The pan-genomes and core genomes at the gene level were estimated using OrthoMCL  implemen(Bb2860)  was alsoB. bassiana, including the previously sequenced isolate Bb2860 [C. militaris [The phylogenetic relationships were determined with the software REALPHY  between e Bb2860 , and usiilitaris  as the oilitaris  on the gilitaris  using thTo identify single-nucleotide polymorphisms (SNPs), Freebayes (v0.9.21), a Bayesian method based program, was used  with a mPutative gene clusters that are predicted to be involved in biosynthesis of secondary metabolites were identified using antiSMASH  version 3.0.4 .B. bassiana (including Bb2860) were identified by homology to characterized MAT genes of other filamentous fungi using BLASTp. The mating type alleles MAT1–1–1 and MAT1–2–1 were also determined by PCR with the primer pairs MAT112.F4/ MAT111.R5 and MAT2.F4/ MAT2.R5 [The presence of mating type loci in all isolates of  MAT2.R5 , respectTo detect regions under positive selection, protein-coding DNA alignments based on the orthologous genes were generated with ParaAT. Ratios of non-synonymous (Ka) to synonymous (Ks) nucleotide substitution rates per site were estimated for each alignment using KaKs_Calculator 2.0 . A slidiB. bassiana isolates were sequenced that were previously phenotyped for virulence against malaria mosquitoes. Isolate Bb8028, which is consistently the most virulent isolate in our collection [B. bassiana, Bb2860 [Five llection  was sele, Bb2860 . The finThe three highest quality assemblies  were used to explore structural rearrangements between these three genomes. In total, 695 locally collinear blocks (LCBs) were shared between two or three genomes. We identified 18 cases of clear inversions, where three adjacent LCBs were shared between the three genomes and in one genome the middle block was inverted with respect to the others. Fifteen of these inversions occurred in strain Bb1520 (Bb8028 and Bb2597 remain collinear), while two inversions occurred in Bb8028 and one in Bb2597. The size of inverted regions ranged from ~1 kb to 220 kb. Some LCBs demonstrated significant size differences between the genomes (ranging from 3 to 65 kb), suggesting insertions or deletions. Two inversions in isolate Bb1520 occurred within the coding sequence of a predicted gene (in the Bb8028 reference genome), thereby truncating the coding sequence of that gene in Bb1520. The vast majority of inversions occurred outside coding sequences and were judged to have no impact on gene structure or regulatory regions.B. bassiana for the five isolates sequenced in this study in combination with the previously sequenced isolate Bb2860 [B. bassiana consists of 7,341 orthologous gene clusters  and Bb2597 (89.7%), and lower in Bb4305 (88.4%) and Bb1520 (87.9%). We searched for SNPs in coding sequences of a set of 54 genes that have been functionally analysed by knock-out mutagenesis . By contrast, the number of genes homologous to genes represented in PHI-base follows the expectation based on the whole gene set . An overrepresentation of gene ontology terms was not detected in the 163 genes that are unique to Bb8028.Isolate Bb8028 was previously characterized as the most virulent towards malaria mosquitoes . TherefoMetarhizium species, with the difference that BB8028_0008g00080 has a single adenylation domain and is 1059 amino acids in length, while its Metarhizium homologs possess two adenylation domains and encode proteins almost double in size. In addition, Bb8028 contains a unique polyketide synthase gene (BB8028_0001g06000.1).Secondary metabolites play a role in fitness and virulence of fungal (entomo)pathogens . A Non-RB. bassiana genomes) encode proteins possessing bacterial enterotoxin-like domains. Four of these contain a heat-labile enterotoxin domain (IPR001144) while one protein displays 54% similarity to the Vibrio cholera enterotoxin alpha chain domain (IPR008992). Outside the kingdom Eubacteria, these enterotoxin genes have homology almost exclusively to Beauveria, Cordyceps and Metarhizium species, all of which are entomopathogenic fungi (data not shown). Bb8028 also possesses 11 peptidase genes (from various types) that have no orthologs in any of the other four B. bassiana isolates. Furthermore, two genes encoding the enzyme cyanamide hydratase are uniquely present in Bb8028. Cyanamide hydratase converts cyanamide into urea, and has been studied in relation to fungal survival in the soil since cyanamide is used as a fertilizer and is also synthesized by vetch species [B. bassiana and found to be implicated in fungicide resistance, oxidative stress tolerance, and in virulence [Five genes unique to Bb8028  double the expression (in Fragments Per Kilobase of transcript per Million mapped reads (FPKM)) in the library isolated from infected mosquitoes compared against the library from fruiting bodies or mycelia, and, (2) a value of at least one FPKM. Of the 163 genes, 15 genes fulfilled these criteria. Notably, three of the five genes annotated as a toxin were among these 15 genes  [B. bassiana was previously compared to other entomopathogenic fungi [B. bassiana isolates, with an emphasis on Bb8028. A pan-genome analysis indicated that the core genome of B. bassiana consists of 7,341 orthologous gene clusters, while the pan-genome consists of 13,068 orthologous gene clusters. These numbers suggest that B. bassiana has an open pan-genome, as may be expected for a species that can typically colonize multiple environments [In this study, we provide and compare the genomes of five isolates of oluzzii) . These iic fungi , and in ronments .B. bassiana is not monophyletic, but rather is composed of several clusters that are morphologically identical [B. bassiana that consisted of isolates which did not show any geographic distribution but had common climate characteristics, while a different study [Penicillium expansum revealed a genetic diversity between 1.3 and 7.1 SNPs/kb [Aspergillus niger it was 7.8 SNPs/kb [B. bassiana possesses a high genetic diversity seems to be in agreement with the earlier suggestions that B. bassiana is not monophyletic [The isolates analysed have a high level of diversity with 467,292 SNPs between Bb4305 and Bb8028, and 87,119 SNPs between Bb5078 and Bb8028. Previous studies have suggested that dentical , 60, 61.nt study  describe SNPs/kb , while b SNPs/kb . In bothphyletic , 60, 61 B. bassiana normally reproduces asexually, and for a long time it was believed to be exclusively clonal. Developmental and phylogenetic studies, however, have linked it to the teleomorph Cordyceps bassiana [MAT1-1 and MAT1-2 loci were identified based on homology to the typical fungal mating type genes, encoding the alpha domain protein and the high mobility group box domain, respectively. The presence of either of two distinct alleles of the MAT locus in each B. bassiana isolate indicates that the species is putatively heterothallic. A new MAT gene was detected next to the MAT1–2–1 gene which, based on homology to a newly described gene in Villosiclava virens [MAT1–2–8 following the nomenclature proposed by Dyer et al. [B. bassiana in several combinations to generate fertile fruiting bodies. Based on the mating type, six combinations were possible  of quantitative virulence in the offspring of two isolates that markedly differ in virulence, for instance Bb8028 and Bb5078.bassiana , 65. In a virens , is refer et al. . We atteulations , it is nM. anisopliae gene annotated as tyrocidine synthase (KJK81377). Tyrocidine has antibiotic activity, and the peptide synthesized by the NRPS gene product could thus have antibiotic activity. The set of genes unique to Bb8028 also comprised five genes encoding bacterial-like toxins and 13 transporter genes. The B. bassiana genome contains many more bacterial-like toxins than most other fungi [B. bassiana ARSEF 2860 infecting Plutella xylostella larvae at three different time points after inoculation . In the latter study, an enrichment of genes with functions in antioxidant activity, peroxidase activity, and proteolysis was detected among the genes that are highly expressed in B. bassiana during infection of the host insect. In contrast, toxin genes were not reported to be highly expressed during infection of P. xylostella larvae [P. xylostella larvae infected by B. bassiana at 48 h was 33%, which is much lower than the mortality rate of almost 100% of infected mosquitoes at the time that we sampled RNA for library construction. The infection cycle of B. bassiana is a complex process which includes several developmental transitions that require an intricate genetic regulation [B. bassiana is capable of infecting a wide range of hosts that have different chemical and physical compositions, which most likely requires a tailored response for each host-pathogen interactions.In this analysis, we identified a suite of genes that are unique to Bb8028. Among these are a PKS gene and a gene cluster comprising an NRPS gene with homology to a er fungi . Intereser fungi  analyseda larvae . The morgulation . This biB. bassiana [. As argued by [B. bassiana will improve our methods to use this fungus as an effective and sustainable biological control agent against, amongst others, vectors of human diseases.The availability of a near-complete genome assembly of Bb8028 provided with a manually curated gene set, adds significant value to the previously published draft genome of bassiana . As argurgued by , a high


Resting metabolic rates (RMR) vary across individuals. Understanding the determinants of RMR could provide biological insight into obesity and its metabolic consequences such as type 2 diabetes and cardiovascular diseases.N = 262) predominantly of African and European ancestry with a wide range of ages (10 – 67 years old) and body mass indices .The present study measured RMR using reference standard indirect calorimetry and evaluated genetic variations from an exome array in a sample of children and adults , 1 , 17  and 5 . To evaluate the effect of low frequency variations with RMR, we performed gene-based association tests. Our most significant locus was SH3D21 , which also contained suggestive results from single-variant analyses. A further investigation of all variants within the reported genes for all obesity-related loci from the GWAS catalog found nominal evidence for association of body mass index (BMI- kg/m2)-associated loci with RMR, with the most significant p-value at rs35433754 .Single variant analysis for RMR identified suggestive loci on chromosomes 15  contains supplementary material, which is available to authorized users. Resting metabolic rates (RMR) in humans represent the energy required to sustain body functions under resting conditions, and varies across individuals . General2 ≈ 0.30)  domain containing 21). Both SNPs (rs2358728 and rs2358729) are uncommon, each with an MAF of 0.05. BMI unadjusted results are presented in Additional file The sample consisted of 118 children (ages 10–16) and 159 adults (ages 18–67). A majority  and systolic blood pressure . Cross-phenotype comparison of the two SH3D21 variants revealed nominal associations with glucose level . The overall top variant from the RMR single variant analysis, rs74010762, was not significantly associated with any of the phenotypes evaluated, nor did any variant reach statistical significance accounting for the number of SNPs and phenotypes tested , albeit a conservative threshold given the correlation between phenotypes. Fat free mass, fat mass, and bone mineral density were associated with a small number of variants approaching suggestive significance thresholds. Glucose level was associated with most of the candidate SNPs, with 5 SNPs having a p-value of ≤0.05.In our analysis of primary traits of interest among the other available metabolic and anthropometric phenotypes in a candidate PheWAS (phenome-wide association study) we found a few nominally significant associations Table . The mosSH3D21 , represented by the two variants mentioned above. Other genes of interest included CRHR2 (corticotropin releasing hormone receptor 2) and RANBP3L (RAN binding protein 3-like). Both of these genes were represented by one variant among the top hits from the single variant analysis and each had two total SNPs for the SKAT analysis.Results of gene-based association tests using SKAT for all variants with a MAF less than 5% are presented in Table p-value = 0.0017) was in the gene TNKS, previously implicated in extreme early-onset obesity and adult waist circumference [To best utilize the exome chip, which emphasizes coverage of coding variants, and to account for differences from reported index variants, we evaluated all variants within known obesity-related genes from the GWAS catalog (270 variants from 79 genes) in the context of RMR. Evaluation of these variants did not yield substantially more nominally significant associations than expected by chance  kinase 1) GPGE in tibial nerve tissue as nominally associated with RMR by MetaXcan  in which ACP6  predicted expression was associated with p-value <0.0001.Evaluation of genetically predicted gene expression (GPGE) levels in GTEx tissue references identified This is the first study assessing association of exome chip gene coding variation with RMR measured using a reference standard method in a in a multi-ethnic sample of children and adults. We evaluated 66,088 genetic variants in 262 individuals through single-variant association and gene-based tests of genetic exposures and GPGE, and also considered the effect of known obesity loci. We did not identify a variant or a gene associated with RMR and meeting stringent Bonferroni statistical significance thresholds. However, we identified some suggestive associations, which may have biological plausibility for a role in energy homeostasis and merit further studies.TRPM1  gene showed the most significant association with RMR. This gene has been previously implicated in Mendelian forms of night blindness [SH3D21 gene significantly associated with RMR is not well known aside from containing three SH3 domains suggesting a likely role in protein binding. However, among tissues included in GTEx, SH3D21 is most robustly expressed in thyroid.The lindness –42, and lindness , 44. ExpCRHR2 (corticotropin releasing hormone receptor 2) and RANBP3L (RAN binding protein 3-like). CRHR2 has been associated with endometriosis [RANBP3L with height [SH3D21, one in RANBP3L, one in GDPD4 (glycerophosphodiester phosphodiesterase domain containing 4) and one in NADK2, which is a mitochondrial NAD kinase. These PheWAS results would suggest that RMR is a complex phenotype, and the genetic underpinnings of this trait share some modest effects with other metabolic and anthropometric traits.Other genes of interest included etriosis , localizetriosis , colorecetriosis , stress etriosis , 49, andetriosis . Variantetriosis . This geetriosis . Expressh height , hyperteh height , and serh height . AlthougPLA2G6, NEGR1, and NRXN3 , cerebellum (NRXN3), and cortex (NEGR1)).Evaluation of obesity-related genes for association with RMR suggested a role for variants in  obesity –58. PLA2BARX1 (BARX homeobox 1) and PTPDC1 (protein tyrosine phosphatase domain containing 1), represent a single associated locus for waist-to-hip ratio from the most recent GIANT consortium meta-analysis [ZNF169 (zinc finger protein 169) was implicated at a suggestive p-value with BMI in East Asians [FAR1 (fatty acyl-CoA reductase 1) have been previously associated with bone mineral density in Hispanic children [BCL9 has recently been identified with type 2 diabetes in aboriginal Australians [FAR1 has also been shown to be expressed differently between visceral and subcutaneous adipose tissue in colorectal cancer patients [BARX1, ZNF169 and FAR1 were all significant in brain regions, which is consistent with a popular hypothesis that the central nervous system regulation of energy balance plays a major role in the development of obesity [GPGE results implicated five established genes related to obesity, body composition or glucose metabolism Table . Two of analysis , while Zt Asians . Furtherchildren , and BCLtralians . FAR1 hapatients . Of thes obesity –65.UHMK1 (U2AF homology motif (UHM) kinase 1) gene. Genetic variants in UHMK1 have been associated with schizophrenia [UHMK1 and ACP6  have been implicated in cerebral vision impairment from exome sequencing [ACP6 GPGE was significant in several brain regions , the pituitary and thyroid glands, several tissues in the gastrointestinal system . Among the top results, brain regions were somewhat over-represented (13/39 results = 0.33) compared to the number of tissues evaluated (10/40 tissues = 0.25). Three of the results were in the pituitary gland  which has implications with growth hormone levels, implying a relationship with energy balance in children.The most significant GPGE association of RMR was with the ophrenia –68, and ophrenia  with parophrenia . Interesquencing . ACP6 GPFew other studies have analyzed genetic variants underlying RMR and related phenotypes measured by whole-room calorimetry, particularly in children, on a genome-wide scale. Due to the novel design, we considered a separate evaluations of children, however, the sample size (and therefore power) is reduced dramatically in this case. We have included the results for children alone in the supplementary material . Other genes in this region have also been implicated in differential adipose deposition (LARGE [HMGXB4 [ODF3B) [APOL5) [Previous linkage scans for RMR have implicated regions 16q22.312, 3q26.114, and 11q23-q2413 which do not overlap with the regions identified in this study. The region on chromosome 16 harbors many variants implicated in a wide variety of disorders, including multiple sclerosis , breast n (LARGE  and HMGX [HMGXB4 ) and fat [ODF3B) , and ele [APOL5) , suggestIn summary, this is the first large-scale genetic association study of RMR in African- and European-American children and adults incorporating GPGE data. The results suggest that several obesity and body composition-related loci are also associated with RMR, and highlight the role of PheWAS in evaluating the phenotypic spectrum associated with selected genetic variants. Our findings of previously unknown signals may suggest that RMR is incompletely explained by anthropometrics, glucose metabolism and energy balance genetic variants. Although large-scale association studies combining accurate RMR measurements with comprehensive phenotyping are challenging, their results might provide information for research focused on precision medicine in individuals. In conclusion, our results suggest that RMR may be partially independent of anthropometric phenotypes, and that genetic evaluation of this trait provides evidence supporting a role for RMR in obesity pathophysiology.


Introduction: Aspirin is a routinely prescribed drug, most notably for cardiovascular diseases, such as myocardial ischemia. This cross sectional, comparative study study aims to explore differences in hearing status between the cardiovascular disease patients on aspirin therapy and age matched controls.Methods: The study population consisted of 182 patients with heart disease taking long term aspirin . The control population consisted of 221 age matched controls who were not taking aspirin.Results: It was found that age of patient, not aspirin intake, was more important risk factor contributing to hearing loss. Conclusions: When confounding factors like age of the patient, hypertension and diabetes were taken into account, aspirin in its antiplatelet dose was not found to be the cause of any audiological problems like tinnitus and hearing loss. Infections and malnutrition were the most common cause of death before 1900. Because of improved nutrition and public health measures in the developed countries, the greatest cause of morbidity has been cardiovascular disease (CVD) and cancer. As lifestyle changes have also been observed in developing countries, morbidity and mortality rates due to cardiovascular conditions are also becoming more common in these countries. This is known as the epidemiological transition because this shift is highly correlated with changes in personal and collective wealth (the economic transition), social structure  and demographics (the demographic transition)2. The ototoxic effects of high doses  of salicylates, reversible hearing loss and tinnitus, are well documented3.Aspirin is a routinely prescribed drugs, most notably for cardiovascular diseases such as, myocardial ischemia. Myocardial ischemia or ischemic heart disease (IHD) is a disease where there is a decreased blood supply to the heart muscle due to coronary artery disease (CAD)No studies have been done in the past to assess hearing loss in patients with cardiovascular diseases on aspirin therapy in Nepal. The present study was done to explore the differences in hearing status between patients with cardiovascular disease on aspirin therapy and age matched controls. It also aims to analyze correlation of hearing loss with the age of patients and presence of co-morbid illnesses.st Feb, 2011 to 1st Feb, 2012). This was a cross sectional comparative study.The study was conducted in the department of Otorhinolaryngology and Head & Neck Surgery, BPKIHS, Dharan. The duration of the study was one year . They were informed about the design and purpose of the study and requested to visit the ear, nose and throat outpatient department (ENT OPD) voluntarily to take part in the study. The control population consisted of age matched controls who were not taking aspirin. No major, active interventions were carried out other than those routinely required for diagnosis. Ethical approval was obtained from the institutional ethical review board of B.P. Koirala Institute of Health Sciences (87/2070/071). Written informed consent was obtained from both study and control populations prior to the study. The current study did not involve any invasive procedure and did not cause any physical or mental harm to the patients. No other interventions were carried out. There was no financial burden to the patients during study. The inclusion criteria was patients of age group 15–75 years who were taking aspirin for heart disease. The exclusion criteria was patients with hearing loss after trauma i.e. after explosion, head injury, ear trauma, or perforation of tympanic membrane, and patients with positive family history of hearing loss, or with CNS disease.All study participants visited ENT OPD so that their clinical history could be assessed according to the proforma and so that they could undergo clinical and otological examination. General physical examination and detailed otological examination of ear, nose and throat was carried out according to proforma to exclude middle ear pathology and conductive hearing loss. All the study participants had normal ears during ear examinations. The Heine Mini 3000 otoscope was used in all cases for the examination of the external auditory canal and the tympanic membrane.4. The study population was interviewed regarding hearing loss and tinnitus and any past history of ear disease was excluded. Tinnitus is a recurrent ringing, roaring or buzzing sensation lasting for five minutes or longer5.The study population was asked about regular use of aspirin which was defined as daily intake of 75mgComplete birth and developmental history was taken to exclude congenital and other causes of acquired hearing loss. Detailed drug history was taken, looking especially for ototoxic drugs. Past history of ear trauma and head injury was noted to rule out prior hearing loss. Systemic causes of hearing loss e.g. Diabetes mellitus, hypertension, and chronic kidney disease, should also be noted. The diagnosis of diabetes mellitus, hypertension and chronic kidney disease were made based on the previous medical records of study population and controls.Tuning fork tests  were carried out with 256, 512, 1024 Hz tuning fork. Lower frequency fork e.g. 128 was not used because of difficulty in interpretation. Rinne and Weber tests were done to find the better hearing cochlea. Each participant underwent a hearing test by pure tone audiometry (PTA) in a sound-proof room. The Madsen Electronics Orbiter 922 Version 2 clinical audiometer was chosen for the study, and tests were performed by a trained audiometrician. The audiometric testing was done by a single person to ensure test-retest reliability. The extent of hearing loss was determined in all subjects. An average of two pure tone responses was calculated in cases of doubt. The results were documented as low (250–500 Hz), middle (1000–2000KHz), and high (4000–8000Hz). The value of the worst ear was taken when there was slight difference in the hearing loss value between the two ears. Hearing thresholds of the study group were compared with those of control group. All findings were noted and categorized on the basis of a proforma data collection sheet. A graph was plotted with the PTA findings. The data were entered in Excel and analysis was carried out using SPSS version 16.0. The Chi-squared test was done to compare hearing loss between case and control, across different age groups and at different durations of intake of aspirin. The study population consisted of 182 patients with heart disease taking long term aspirin . The control population consisted of 221 age matched healthy controls who were not taking aspirin. 45.3% of the study population were male and 54.7% were female. Among controls, 48.1% of the cases were male and 51.9% of the cases were female .Both study and control populations were categorized into three groups according to age. The first group ranged between 15–50 years of age, the second 51–59 and the third, 60–75. The mean age was 63.7 years for the study population and 64.2 years for controls. 47.6% of the study population was in the 60–75 year age group; in the control group the number of participants in the 60–75 age group which was higher, with 48.4% .64.3% of the study population were of Indo-Aryan origin and 35.7% were of East Asian origin. Among the controls, 60.1% were of Indo-Aryan origin and 39.9% were of East Asian origin .The occupation of participants was more or less equally distributed, with housewives dominating in both cases and controls. Careful history was taken to rule out noise induced hearing loss in each occupation as seen inOut of 182 study population, only 115 presented with tinnitus. Among 221 controls, 124 presented with tinnitus. The result was statistically insignificant as inOut of 182 study population, only 120 presented with sensorineural hearing loss (SNHL). Among 221 controls, 126 presented with SNHL. The result was not statistically significant  implying that aspirin was not the cause of hearing loss in study population as seen inAs seen inThe data obtained from bivariate analysis was followed by binary logistic regression analysis with backward conditional method using SPSS version 16.0 in order to adjust and explore the significance of explanatory variables. Hearing loss was considered the dependent variable. The independent variables which had p value of 20% or less in the bivariate analysis were then included for binary logistic regression analysis. The variables subjected to the model were age group, duration of aspirin use, hypertension and diabetes mellitus.When logistic regression was applied among the study population it was found that age of the patient was most significantly associated with hearing loss. Patients aged 51–59 were 14.258 times more prone to develop hearing loss and patient aged 60–75 were 61.389 times more prone to develop hearing loss than patients aged less than 50 years of age . It was also found that only age of the study population was significantly associated with tinnitus. Duration of aspirin use, hypertension and diabetes were not found to be associated with tinnitus. People less than 50 years of age were 32.612 less likely to develop tinnitus than people between 60–75 years of age. Similarly patients between 51–59 years of age were 2.799 times less likely to develop tinnitus than people aged between 60–75 years .Raw data collected from the study populationClick here for additional data file.Copyright: © 2018 Pokharel A and Bhandary S2018Data associated with the article are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).Raw data collected from the control populationClick here for additional data file.Copyright: © 2018 Pokharel A and Bhandary S2018Data associated with the article are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).et al’s, which had shown that aspirin given for its anti-platelet effect in cardiovascular patients is responsible for causing hearing loss even in low doses. Hearing loss was seen as one of the complications of regular analgesic use. The risk was seen greatest among men below the age of 60 years. Above the age of 60 years, no relation was seen between hearing loss and aspirin use4.In the present study, the mean age of the patient was 63.7 years. As most patients on regular aspirin were above the age of 60, aspirin was not seen as the principal cause of sensorineural hearing loss in our study. Logistic regression analysis demonstrated that- other factors like duration of aspirin intake, and other comorbidities like hypertension and diabetes were not found to produce any significant effect on the hearing status of the patient. Our results oppose Curhan6. Studies have shown that after the age of 60, hearing thresholds worsen on average by 1 dB per year, but the rate of decline of hearing loss may be even greater in men aged 48–59 years8. The relationship between regular use of aspirin and hearing loss was observed as strongest in men younger than 60 years of age. A possible explanation for this might be that after the age of 60 the cumulative effects of age and other comorbidities will add up in the causation of hearing loss. Bainbridgeet al showed similar impact of age and diabetes on hearing loss9.With increasing age, the prevalence of the hearing loss also increases3. Membrane conductance of the outer hair cell changes because of biochemical and electrophysiological alteration induced by salicylates. Salicylates also cause auditory microvasculature vasoconstriction, most probably caused by their antiprostaglandin activity11.High doses of salicylates can have ototoxic effects which include reversible hearing loss and tinnitus. Animal models have shown that salicylate is responsible for abnormal function of the outer hair cell and decreased blood flow in the cochlea13. Microvascular vasoconstriction leads to strial degeneration. However, strial vascularis degeneration is also one of the characteristic features of age-related hearing loss14. Animal studies have shown that strial degeneration leads to its atrophy and to capillary loss, with basement membrane thickening and deposition of laminin and immunoglobulin in the strial vasculature17.Histopathologic studies of human temporal bones and animals on salicylate administration show degeneration of the strial microvasculature18. Other inflammatory biomarkers like white blood cell count, neutrophil count, IL-6 and CRP are associated with hearing loss in older people19. Over a 10 year period, older people with higher levels of CRP were two times more likely to develop hearing loss than normal20. Aspirin inhibits platelet enzyme cyclo-oxygenase (COX). Increased expression of genes for IL- 1β, IL-6, TNF-α, and COX-2 occurs during prostaglandin biosynthesis, and this effect is inhibited by aspirin21. Aspirin is also responsible for the synthesis of anti-inflammatory compounds called ‘aspirin-triggered 15-epi-lipoxins’. This is responsible for the drug's anti-inflammatory effect even at low doses22. Aspirin also decreases chronic inflammatory biomarkers responsible for the aging process23. A randomized controlled trial where 100 mg of aspirin was given for acute coronary syndrome showed decrease in the level of both CRP and TNF-α24. These studies show that that aspirin in low doses may have a protective effect on hearing instead of a deteriorating effect. Recently, a clinical trial is going on to see whether aspirin in low doses can decrease the progression of age-related hearing loss25. Inflammatory mediators like TNF-α affects microvascular tone, thereby reducing cochlear blood flowThis study has certain limitations. Aspirin in low dose is an over the counter medication and is used by a large proportion of the population. To find out whether aspirin is responsible for causing hearing loss or not, sample size needs to be huge, and the samples should be followed up for a long period of time. Because of time constraints, this was not possible for this study. Hearing evaluation before the patient began aspirin treatment was also not carried out. The lowest age group patient in this study was 34 years and patients below 50 years of age were very few in number so the first age group made was from 15–50 years.Hearing impairment is an important public health issue. Aspirin is one of the most common medications used now-a-days owing to the increased prevalence of cardiovascular diseases. The present study shows that long term use of aspirin doesn’t cause any hearing loss. The relationship between long term use of low dose aspirin and hearing loss is still a debatable subject. Other factors like age of the patient, hypertension and diabetes mellitus must also be looked at if a person on aspirin develops symptoms of hearing loss.The data referenced by this article are under copyright with the following copyright statement: Copyright: © 2018 Pokharel A and Bhandary SData associated with the article are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).Dataset 1: Raw data collected from the study population.10.5256/f1000research.11131.d15696026DOI,Dataset 2: Raw data collected from the control population.10.5256/f1000research.11131.d15696127DOI, I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. IntroductionResearch question: The authors have aimed to look at the effect of prolonged use of low dose aspirin on hearing. The question is relevant as most of the previous studies on the subject have looked at the effect of high dose aspirin.Aim and objectives stated in abstract and introduction differ from the ones stated in the Methods section. These need to be stated clearly and consistently.  MethodsThe authors have done a cross sectional comparative study between patients with cardiac disease on aspirin, and controls without cardiac disease and not on aspirin.Study design:Controls cannot be termed ‘healthy’. They were age-matched subjects without heart disease, and not on aspirin therapy.If age matched controls were selected, why is there a difference in the number of cases and controls? Were there any drop outs from the study?What were the criteria for diagnosing hearing loss? Since patients did not have a baseline audiological test, how were hearing loss and progression of hearing loss defined? Were questionnaires used? Where they standardized?Systemic risk factors for hearing loss e.g. Diabetes mellitus, hypertension, and chronic kidney disease, also had to be ruled out.’ (para 5 in Methods section) These factors were present both in cases and controls (see Datasets). These factors were not ruled out. They were noted as potential confounders in both groups, and addressed in the logistic regression analysis. Chronic kidney disease has been mentioned along with diabetes and hypertension as a confounding factor in the beginning of the manuscript. However, there is no mention of chronic kidney disease in the rest of the manuscript and data sets, and it has not been addressed in the logistic regression model. Please clarify.    ResultsBaseline demographic data should be put in a table to ensure clarity.Please depict the tinnitus and hearing loss in cases and controls, with p-values, as tables.CKD was not included as part of the logistic regression. Why not? Please clarify. The textual interpretation of this could also be better worded.Audiometric data need to be added both in the data set and the results.    DiscussionThe discussion needs to be clearer, more concise, and should proceed in a logical sequence. In the discussion, the authors should cite studies that have shown that aspirin could cause hearing loss, and how the current study differs from them, and possible reasons as to why. Then they should discuss studies and theories to the contrary, that agree with the results of the current study. This should be done in a logical and concise manner. Please avoid unnecessary and confusing details of various theories that have no direct implication on the subject of research.The ‘prevalence’ of hearing loss in both cases and controls is far above the prevalence quoted in existing literature. Is there an explanation for this? et al’s paper at the end of the first citation in the manuscript. (para 1 in discussion)Please give reference number for Curhanet al’s work is not very clear. Are the authors trying to imply that their results conflict with those of this work because the majority of their study population (both cases and controls) was above the age of 60? Please make this clear.The comparison of the present study with Curhan    ConclusionConclusion should correspond with the aim and objectives of the study. The present study found no relationship between long term, low dose aspirin use and hearing loss. Moreover, the study did not find any correlation between hearing loss and systemic diseases; hence the last line in the conclusion is not supported by the results of the study, and therefore, may be deleted.    General commentsCorrection of grammar needs to be done throughout the manuscript.Terminology such as ‘cases’ and ‘controls,’ and ‘incidence’ and ‘prevalence’ has been used loosely and interchangeably. This is not acceptable.      On the whole, the paper addresses a relevant research question, and may be indexed after making the suggested corrections.We have read this submission. We believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above. Introduction: It is well-known that large doses of aspirin may produce reversible tinnitus and hearing loss.  The authors set out to test whether prolonged use of low dose aspirin for heart disease (presumably mostly ischaemic in nature) has a deleterious effect on hearing.  Unfortunately, there are a number of problems with this study.Subjects:The authors are correct in their acknowledgement of vascular risk factors such as hypertension and diabetes for age-related hearing loss.    The design of the study does not allow ischaemic heart disease – itself also a risk factor for age-related hearing loss – to be accounted for, as all the aspirin-taking group were on aspirin for heart disease, whereas none of the control group had this risk factor.  This confounding factor can only be addressed in a blinded, randomised prospective trial of aspirin in healthy individuals, as the authors acknowledge.There is some confusion regarding the risk factors diabetes and hypertension in the manuscript. a) What criteria were used for these diagnoses?  Furthermore, were the subjects screened for these risk factors as part of the study, or was there reliance on medical record review or on patient self-description? b) These risk factors “ ... had to be ruled out” , but these factors were included in the regression analysis .  Were those with hypertension and diabetes indeed excluded from the study? et al. 20131; Agrawal Y,et al.  20082) were not reported.  Were there any group differences in these factors?While there was adjustment for age and sex, other known risk factors for age-related hearing loss such as smoking and educational level  seem rather arbitrary and uneven.  Were these divisions chosen to equalise numbers?  The grouping of 15 year olds with 50 year olds seems inappropriate, and presumably the heart disease for which the 15 year olds were on aspirin was rather different.  I think that the study would have been stronger with the exclusion of this paediatric group .  A histogram of the age distribution of subjects and controls by year of age (not age group) would be illuminating.Methods:better ear, with mild loss being diagnosed at > 25 dB and moderate at > 40 dB.  I presume that a dichotomous classification of hearing impairment was applied given that chi-squared tests were applied to the data, but the definition of hearing loss is not actually stated. Figure 1:  The definition of hearing impairment is unclear.  Why was the WHO classification not used?  This averages the loss in dB at 4 frequencies:  0.5, 1, 2 and 4 kHz in the In a related matter, the results were documented as low, middle, high frequency loss , but this stratification is not subsequently referred to in the Results section. Noise-related deafness was excluded on history .  Was the presence of a prominent notch on PTA at 4 kHz used to complement the history of noise exposure as a cause of exclusionary noise-related deafness?   Conductive loss was excluded on clinical examination and tuning fork tests.  Was there a reason that a bone-ear conduction gap on audiometry was not used to complement this exclusionary point?Results: The results are tabulated with inappropriate precision (often to 4 or 5 significant figures). Discussion: et al. 19903; Shi X. 20114).  There is evidence from humans linking inflammatory states to age-related hearing loss by correlation of markers of mild systemic inflammatory states (raised IL-6 and CRP levels) with hearing loss .  In other words, a reasonable hypothesis would be that low dose aspirin is actually protective against age-related hearing loss.  In this context the study by Curhanet al. cited by the authors deserves further discussion.  It found greater rates of hearing loss with prolonged regular use of aspirin, NSAIDs, and paracetamol (acetaminophen).  There are two problems with that study, however:  firstly, it relied on self-report of symptoms of deafness, with confirmation by a professional again self-reported.  A second and potentially greater problem is confounding by indication, in that the reason for taking these medications in the first place (e.g.  mild inflammatory state) may itself have been responsible for some or all of the hearing impairment. Age-related hearing impairment is presumably the major cause of deafness in this study, as the relative risks of the older age bands suggest.  There is animal evidence for microvascular involvement in age-related hearing loss : 231–237.Noise induced Hearing Loss was excluded from history taking as well as from pure tone audiogram findings.Thank you for your review. There are few queries raised which I want to address. There are typographic errors included a repeated word three lines into the abstract. The author’s state that pure tone audiometric evaluations were performed but do not include graphical data in the manuscript, nor do they indicate frequency specific thresholds in the raw data attached, only PTAs. Air conduction and bone conduction information needs to be included in order to ascertain the impact of standing hearing loss has on the included participants, especially since many occupations of participants included are readily exposed to noise such as farmers, labourers, and drivers. Furthermore, ototoxic events primarily initiate at ultra-high frequencies > 8 kHz, which was not even measured in the present study and can have significant impact on conclusions. The use of tuning fork is not exactly clear if pure tone audiometry was performed. Unless pure tone audiometry was only performed on the “better hearing cochlea”, in which case the authors should have performed these studies binaurally. The studies included do not fully address the impact that salicylate may have on hearing capability. Animal models have shown that salicylate can impact not only DPOAEs but permanently damage spiral ganglion neurons as well. Which could result in recoverable DPOAE’s and thresholds but have a permanent impact on word recognition capabilities. While these observations have been made with significantly higher dosage of salicylate, and may not be present at lower dosages, details should still be included in the manuscript. There are many claims in the text which are written as though supported by research. While I believe the text included in the manuscript, proper references need to be included for readers. This event is widespread throughout the manuscript. et al’s research. While findings were different, they need to include the significant differences between the two studies, one primary difference being the number of participants. This is addressed as the limitation, but should be also be interpreted in regards to difference in study results with Curhanet al. Despite the lower number of participants in the present study, the participants were well controlled age and gender. However, the youngest age group is inappropriately large. Dramatic differences in hearing are expected between the ages of 15-50 and should not be included in the same group. The authors claim their data opposes Curhan The definition of tinnitus in the text is incorrect. The authors reference a previous studies classification used in that research paradigm (performed in 1988), but is not generally accepted definition of tinnitus. This likely has resulted in the inaccurately inflated occurrence of tinnitus in used participants. Typically, tinnitus can be present in ~15-20% of the general public, but the ~63% reported in the control group in the present study is much higher than expected. Overall, the findings of the study could potentially be of interest. However, significant changes need to be made with clarity of writing, appropriate citations, divulging specific raw data to include frequency specific air and bone conduction results, better classification of tinnitus and labeling of such in raw data, along with other methodological changes to specifically address the question at hand.I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Thank you for reviewing my article. I want to add few explanations for your review comments.ve taken detailed history before recruiting the study population and have tried to exclude such patients. 1. I have included noise induced hearing loss as my exclusion criteria. For ototoxic medications, I ha 2. PTA was done for both ears.   3. DPOAE was not done this facility is not available in my institution. 4. In my study the percentage of tinnitus has come higher, because both in my study population and control, I have included patients with comorbidities like DM, HTN which themselves are responsible for causing hearing loss. Thanks for your review.


Computer adaptive testing (CAT) of the activities of daily living (ADL) functions is required (i) to reveal the advantages of using an efficient and accurate estimation method, (ii) to determine the cutpoint for classifying ADL strata in patients with stroke, and (iii) to evaluate the feasibility of online CAT used in clinical settings for smartphones.Maximum a posteriori estimation, expected a posteriori estimation, and maximum likelihood estimation (MAP) were used to compare the Pearson correlation coefficients and different number ratios of paired measures yielded by CAT and NAT. The number of items and the cutpoints for the scale were separately determined.Normally standardized distributions of ADL measurements were simulated using item parameters from published papers. We retrieved item parameters of the combined Barthel Index and Frenchay Activities Index from the literature  and simulated three 1000-person measures from a normal standard CAT distribution: [i] CADL (CADL-CAT), [ii] ADL (ADL-CAT), and [iii] NAT (Non-Adaptive Testing). The cutpoints of ADL person strata were determined using a norm-reference method. not active, fairly active, active, and very active). (iii) An available-for-download online ADL-CAT APP for clinical practice was demonstrated.We found that (i) correlation coefficients for the three CAT-estimated measures were 0.77 (CADL), 0.93 , and 0.93  compared with their NAT counterparts. Different number ratios of person-paired measures between CAT and NAT for the three scales were all less than 5 %, indicating no difference exists between CAT and NAT. However, CAT might be 66 % more efficient than NAT. (ii) The estimated cutpoints of T scores  were 45, 55, and 65  contains supplementary material, which is available to authorized users. TheySpecifically, activities of daily living (ADL) function assessment consist of two scales: (i) the Barthel Index [BI])  and (ii)Combining the two indices seems inefficient because together they require more than 20 min to complete , 15, 16.maximum likelihood estimation [MLE] [a posteriori estimation [EAP] [maximum a posteriori estimation [MAP]  , expecteon [EAP] , 28, andon [MAP] ).The aims of the current study were to (i) compare CAT and NAT precision and efficiency, (ii) determine the cutpoints of ADL person strata, and (iii) design an online ADL-CAT assessment APP for smartphones.http://ptjournal.apta.org/content/93/5/681/F1.large.jpg). When 1,000 persons’ true scores ]) and item difficulties (retrieved from previously published articles  for the 23-item CADL, 0.90  for the Male ADL, and 0.90  for the Female ADL   can be well separated  An online ADL-CAT graphical representation for smart phones is feasible for classifying ADL strata in patients who have had a stroke.Using three CAT estimation methods shows that (i) both CAT and NAT person scores have high correlation coefficients and low different number ratios for the three scales, and that the item length is shorter than that of the NAT scores on both the CADL scale and the ADL scale. This implies that CAT is more efficient than NAT without compromising its precision. (ii) The T scores of cutpoints were determined with high specificity and sensitivity (> 0.90), and were suggested at 45, 55, and 65 to separate person ADL function strata with Our findings in Task 1 (to compare CAT precision and efficiency) are consistent with the literature , 38, 41,IRT-based CAT is generally different from the traditional pen-and-pencil test for which all items are answered while providing little information to use for analyzing the CAT users’ responses. For instance, outfit MNSQ values of ≥ 2.0 can be a threshold when examining whether patient responses are distorted or abnormal, i.e., whether many responses unexpectedly do not fit the model’s requirements and are deemed highly possibly careless, mistaken, cheating, or awkward , 42  before the study. Many studies in their Limitations sections caution that their results cannot be generalized to other workplace sites or to other types of patients.The norm-referred method was thus introduced in this study based on suggestions found in the literature –37. ThatWhen we know the means and standard deviations of any two adjacent groups, the cutpoints of person strata can be then determined by using a norm referred method, whereas means are obtained from K-mean cluster analysis, standard deviations are yielded from data of the specific group. The illustration can be seen in worksheet Ch09 in Additional file T scores of cutpoints were then determined. Interested readers are recommended to read Additional file The There are two major forms of standardized assessments in clinical settings : (i) a lIt is very easy to set up any form  and health communication technology are rapid . Mobile Our study has some limitations. First, although we, like Hsueh et al. , believeT scores of 45, 55, and 65.Second, although the scale’s Cronbach’s α coefficients were 0.94 for CADL  and 0.93Third, the study was based on a previously published paper . All of Fourth, the original ADL-CAT paper assessed gender as a differential item functioning (DIF) factor , and proWe found that ADL-CAT is efficient, reliable, and valid. The online ADL-CAT module used for smartphones is promising for assessing the full spectrum of ADL functions in outpatients with stroke. The visualized presentation of the ADL-CAT module shows that it is feasible for helping both physicians and patients in clinical settings.


Hearing screening tests based on pure-tone audiometry may be conducted on mobile devices, provided that the devices are specially calibrated for the purpose. Calibration consists of determining the reference sound level and can be performed in relation to the hearing threshold of normal-hearing persons. In the case of devices provided by the manufacturer, together with bundled headphones, the reference sound level can be calculated once for all devices of the same model.This study aimed to compare the hearing threshold measured by a mobile device that was calibrated using a model-specific, biologically determined reference sound level with the hearing threshold obtained in pure-tone audiometry.Trial participants were recruited offline using face-to-face prompting from among Otolaryngology Clinic patients, who own Android-based mobile devices with bundled headphones. The hearing threshold was obtained on a mobile device by means of an open access app, Hearing Test, with incorporated model-specific reference sound levels. These reference sound levels were previously determined in uncontrolled conditions in relation to the hearing threshold of normal-hearing persons. An audiologist-assisted self-measurement was conducted by the participants in a sound booth, and it involved determining the lowest audible sound generated by the device within the frequency range of 250 Hz to 8 kHz. The results were compared with pure-tone audiometry.A total of 70 subjects, 34 men and 36 women, aged 18-71 years  participated in the trial. The hearing threshold obtained on mobile devices was significantly different from the one determined by pure-tone audiometry with a mean difference of 2.6 dB (95% CI 2.0-3.1) and SD of 8.3 dB (95% CI 7.9-8.7). The number of differences not greater than 10 dB reached 89% (95% CI 88-91), whereas the mean absolute difference was obtained at 6.5 dB (95% CI 6.2-6.9). Sensitivity and specificity for a mobile-based screening method were calculated at 98% (95% CI 93-100.0) and 79% (95% CI 71-87), respectively.The method of hearing self-test carried out on mobile devices with bundled headphones demonstrates high compatibility with pure-tone audiometry, which confirms its potential application in hearing monitoring, screening tests, or epidemiological examinations on a large scale. This study investigated the accuracy of the hearing tests conducted on mobile devices calibrated by means of the biological method, that is, in relation to the hearing threshold of a normal-hearing person. This study constitutes the second part of the planned research. The calibration method was adopted from a previous study , and it Hearing loss is a disorder widely encountered among the world population. It is estimated that it affects 5.3% of population, which totals 360 million patients suffering from hearing loss around the world . MonitorAutomated audiometry involves self-determining the hearing threshold and is a valuable diagnostic tool in the case of limited access to medical personnel -8. The mAudiometric tests can be conducted on specialized equipment as well as on generally accessible electronic devices such as personal computers ,22,23 orBesides applications typical for automated audiometry such as preliminary evaluation of audiological patients and screening tests -8, testsThe objective of this trial was to determine the accuracy of automated audiometry conducted on Android-based mobile sets including the device and the bundled headphones that were calibrated semiautomatically via a biological method. Android-based devices constitute 80% of all mobile devices around the world, and their number is estimated to be 1.4 billion . The preCalibration of mobile devices conducted by means of a biological method involves determining reference sound level in relation to the hearing threshold of normal-hearing persons ,34. CaliThis study involved a comparison of hearing thresholds determined by pure-tone audiometry with the hearing thresholds determined on Android-based mobile devices calibrated biologically in uncontrolled conditions. It was a single-center, crossover trial carried out on patients of Otolaryngology Clinic. The consent to conduct the trial has been granted by the Bioethics Committee of Wroclaw Medical University.Study participants were recruited offline, using face-to-face prompting. Eligibility assessment was conducted among subjects who owned an Android-based device with bundled headphones. Eligibility criterion, apart from the willingness to participate in the study, included owning the device, for which model-specific calibration coefficient has been previously determined by means of biological method . All theMeasurements involved conducting pure-tone audiometry and the test on a mobile device. The order was arranged in a counterbalanced manner. The measurements for both methods were conducted in a sound booth for the frequencies 250 Hz, 500 Hz, 1 kHz, 2 kHz, 4 kHz, 6 kHz, and 8 kHz.Pure-tone audiometry was conducted by means of conventional 10 dB down and 5 dB up bracketing method (modified Hughson-Westlake method) in accordance with the recommendations of the British Society of Audiology . The meaHearing examinations on mobile devices were conducted using a free app Hearing Test ,37 availCalibration of mobile devices was described in detail in the previous paper . The objCalibration measurements involved self-determining the hearing thresholds by means of Bekesy’s method ,11,22,34Sample size was determined on the basis of the standard deviation (SD) between the hearing thresholds in pure-tone audiometry and thresholds determined on mobile devices estimated at 8.42 dB . With thIn the period between November 11, 2015, and November 2, 2016, 89 subjects were assessed for eligibility from among patients of Otolaryngology Department who owned a mobile device with bundled headphones. Out of 89 subjects, 7 (8%) were not interested in the examination and did not give their consent; 12 out of the remaining 82 subjects (15%) owned devices that were not yet calibrated .A total of 70 subjects, including 34 men and 36 women, aged 18-71 years  participated in the trial. Among the participants were both normal-hearing subjects and hearing-impaired patients. P=.05, no differences were found between groups, and thus, further analyses were conducted jointly  were first tested by pure-tone audiometry, whereas the other half by the mobile device. Out of the range measurements were discarded from further analysis: 13 of 980 (1.3%), 14 of 966 (1.4%), and 10 of 980 (1.0%) in the case of test, retest, and pure-tone audiometry, respectively. Hearing thresholds determined through pure-tone audiometry were compared with thresholds obtained on mobile devices separately for both groups . At the  jointly  and 4. TP=.05, no differences in hearing threshold were found at any frequency (Retest was conducted on a mobile device in 69 of 70 subjects (99%). At the level of statistical significance of requency . The mearequency  and 8.The assessment of specificity and sensitivity of hearing loss detection was conducted based on the criterion  adopted P=.05, no differences in relation to the test order were observed. The mean hearing threshold difference of 2.6 dB (SD 8.3 dB) confirms the reliability of the method. Additionally, the mean test-retest difference of −0.1 dB (SD 4.4) indicates its high repeatability.In this paper, hearing thresholds determined by pure-tone audiometry were compared with hearing thresholds determined on Android-based mobile devices previously calibrated biologically in uncontrolled conditions. At the level of statistical significance The results are consistent with the research presented in previous works. The SD of the difference at 8.3 dB 95% CI 7.9-8.7) corresponds to the value estimated for this calibration method of 8.42 dB  and is c.9-8.7 coSD of the difference for the proposed method was 8.3 dB (95% CI 7.9-8.7) with the number of differences no higher than 10 dB at 89% (95% CI 88-91). These values are comparable with the results determined on a set calibrated by a normal-hearing person with verified hearing threshold (SD 6.9 and 8.29 dB ) and areSD of test-retest difference was obtained at 4.4 dB (95% CI 4.2-4.6) with the number of differences no greater than 10 dB at 99% (95% CI 99-100). The results are consistent with other works  at 8 kHz. The reason for such discrepancies may be related to the literature-based median values of the hearing threshold of normal-hearing subjects, which were adopted to determine 0 dB HL. The mean hearing threshold estimated on the basis of literature data for people aged between 18 and 35 years displays considerable differences  38,40-4-440-44. The method of hearing self-test carried out on mobile devices with bundled headphones calibrated by model-specific coefficients determined in relation to the hearing thresholds of normal-hearing persons demonstrates high compatibility with pure-tone audiometry, which confirms its potential application in hearing monitoring, screening tests, or epidemiological examinations on a large scale. However, one must acknowledge its limitations resulting mainly from the calibration method. Further evaluation of the efficiency of the method, especially in particular applications, is justified and required.


Cognitive impairment due to dementia decreases functionality in Activities of Daily Living (ADL). Its assessment is useful to identify care needs, risks and monitor disease progression. This study investigates differences in ADL pattern-performance between dementia patients and healthy controls using unobtrusive sensors. Around 9,600 person-hours of activity data were collected from the home of ten dementia patients and ten healthy controls using a wireless-unobtrusive sensors and analysed to detect ADL. Recognised ADL were visualized using activity maps, the heterogeneity and accuracy to discriminate patients from healthy were analysed. Activity maps of dementia patients reveal unorganised behaviour patterns and heterogeneity differed significantly between the healthy and diseased. The discriminating accuracy increases with observation duration (0.95 for 20 days). Unobtrusive sensors quantify ADL-relevant behaviour, useful to uncover the effect of cognitive impairment, to quantify ADL-relevant changes in the course of dementia and to measure outcomes of anti-dementia treatments. Cognitive impairment due to Alzheimer’s disease and other forms of dementia affect patient’s ability to maintain activities of daily living (ADL)ADL refers to self-care tasks, comprising of activities performed on a daily basis4437Sensor-based technologies for quantifying ADL can add new dimensions to existing clinical assessment. Based on constant monitoring, it can help in earlier disease and risk detection1214Recognizing ADL in home settings using sensor systems has been well-reported in literature1718192019The use of sensor-based measurement generates large amounts of data, which requires recognition techniques to infer an activity. ADL recognition from ambient data is usually done using training data or prior knowledge based algorithms such as probabilistic based232119In this study, we used a wireless unobtrusive  sensor network to capture ambient environmental data in the home of ten dementia patients and ten age-matched healthy controls for twenty consecutive days. To date, sensor-based ADL recognition studies generally include healthy elderly subjects in home setups or living lab setups, while the scope of our trial includes ten dementia patients with moderate to severe dementia living in a community setup. Qualitatively, the recognized ADL are visualized using colour coded ambulatograms for the cumulative measurement duration, to generate activity maps28The classification process recognized 4562 ADL in total for both patients and healthy controls. An example of the PP for a healthy subject and an Alzheimer patient for the complete measurement duration is shown in With the aid of the ROCIn this observational study, we investigated ADL behaviour patterns and ADL performances of ten healthy controls and ten patients with dementia from data collected using an unobtrusive wireless sensor network in the home of the participants for 20 consecutive days. As hypothesized, the irregularities in ADL performance, as well as dysfunctions in daily routine can be recognized and quantified using unobtrusive sensor-based recognition system and activity map based visualization techniques. Differences in ADL patterns were significant between healthy controls and patients and the accuracy of the classification performance increased with the duration of measurement. There were no drop-outs from the recruitment group and infers the acceptance of the unobtrusive sensor system by healthy older adults and dementia patients. Such sensor-based recognition systems can be vital for monitoring changes in health status, which are needed to optimize formal and informal care as well as apprise medical treatmentVery few studies have reported monitoring dementia patients in their home using wireless multi-sensor systems2721For statistical and clinical validation, it is important to discriminate the ADL behaviour between healthy controls and patients using quantitative values. Our results show that PP techniques which have already been established to study heart rate variability in other diseases28et al.et al.Studies in the neuropsychological field have shown that it is possible to distinguish between healthy and cognitively impaired subjects based on differences in their behavioural patternset al.To date, the functional capability of dementia patients is traditionally assessed using questionnaires in a brief clinic visit. In contrast, sensor-based measurement systems allow to continuously monitor patients in their natural environment, provide ecologically valid feedback on their functional capacity and also offers an opportunity to gain valuable and fine-grained information  that cannot be obtained through paper and pencil measures. The large pool of monitoring data can give rise to finger prints of patient behaviour, trends and anomaliesThe average CDR (1.2 ± 0.4) of the patient population in our study supports the discrimination in ADL performance between healthy and moderate to severe dementia patients. The discriminatory power for early dementia patients or early transition to MCI is questionable due to the subtle and small changes in ADL patterns. The best approach, irrespective of the outcome of future studies, might be a cutoff derived in concurrence with the clinical values such as MMSEIn summary, unobtrusive sensor-based recognition systems are economical, reliable and promising technique for detecting decline in cognitive abilities via ADL monitoring. It has the potential to provide doctors and patients with tools to predict and detect changes in health status. Longitudinal and follow-up studies are required to study ADL patterns which can be potential surrogate markers of a person’s dementia and to be able to predict clinically significant changes in the course of the patient’s disease. Furthermore, these systems provide an additional value for families who require information regarding the need for support within the home to facilitate the independence of their family memberWe conducted an observational study with ten dementia patients recruited via the Memory Clinic of the University Hospital of Old Age Psychiatry, Bern, Switzerland and ten healthy controls recruited via advertisement in the Senior University of Bern. The study was carried in accordance with the current version of the Declaration of Helsinki and approved by the Ethics Committee of the Canton of Bern, Switzerland. All procedures related to the study were explained to the participants and a written informed consent was obtained prior to participation. No compensation for participation was provided. All data collected were anonymized at source.Probable dementia was diagnosed either using ICD-10The main inclusion criteria were age > 60 years and living alone in community. In addition, the inclusion criteria for healthy controls were no cognitive impairment (MMSE score > 26), or no significant motor impairment (“timed Up & Go” Test < 12 s). Patients and healthy controls were age- and gender- matched, while the cognitive and executive parameters differed significantly between the two groups .l × w × h = 15 mm × 30 mm × 60 mm, weight = 80 g) comprising of five sensors , humidity [g/m3] , luminescence [lx] , presence [V] , acceleration [m/s2]  capture ambient data with a sampling frequency of 1/5 Hz and transmits them to the CCU using a wireless protocol. The sensor boxes were installed at a height of 1.8–2.2 m such that there was no obstruction of view, facing towards the middle of the room as illustrated in An unobtrusive sensor network comprising of ten wireless sensor boxes and a central computer unit (CCU)Eight ADL namely “Sleeping”, “Grooming”, “Toileting”, “Getting ready for bed”, “Cooking”, “Eating”, “Watching TV” and “Seated activity”As a pre-analysis step, the ambient data was sorted room-based, followed by a chronological sort of the individual room-related dataThe recognized ADL were then plotted against the time period of twenty days to generate an activity maptime) plotted against the preceding recognised ADL . The PP technique summarizes the data, at the same time allowing to extract the information on short- and long-time behaviour of the participantsThe difference in the ADL performed by the healthy controls and patients were quantified using the Poincaré plot (PP)si) and length N (number of recognised ADL datasets over the complete measurement duration)The PP for a subject’s ADL data vector , composeconsists of ordered pairs  such thaThe PP technique was applied on the recognised eight ADL related datasets from dementia patients and healthy controls, whereby elongated cloud of points oriented along a line of identity were obtained . In caseTo quantify the discriminative power of the ADL recognition system the accuracy, sensitivity and specificity were analysed over time. With the aid of the ROC analysisAll algorithms were implemented in Matlab R2007b .Statistical analysis was performed using the Statistical Package for Social Sciences . Normal distribution of data was examined using Q-Q plots. Means and standard deviations (SD) were calculated. Chi-square tests and one-way analysis of variance (ANOVA) were used for the demographics. The heterogeneity in ADL performance (PP centroids) was analyzed using the Mann-Whitney U Test. All reported p-values are two-tailed and a p < 0.05 was considered significant for comparing demographics, while p < 0.01 was considered significant for comparing ADL performance.How to cite this article: Urwyler, P. et al. Cognitive impairment categorized in community-dwelling older adults with and without dementia using in-home sensors that recognise activities of daily living. Sci. Rep.7, 42084; doi: 10.1038/srep42084 (2017).Publisher's note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.