Background: The world’s age-related health concerns continue to rise. Audio-vestibular disorders, such as hearing loss, tinnitus, and vertigo, are common complaints in the elderly and are associated with social and public health burdens. Various preventative measures can ease their impact, including healthy food consumption, nutritional supplementation, and lifestyle modification. We aim to provide a comprehensive summary of current possible strategies for preventing the age-related audio-vestibular dysfunction. Methods: A PubMed, Embase, and Cochrane review databases search was conducted to identify the relationship between diet, lifestyle, and audio-vestibular dysfunction. “Diet”, “nutritional supplement”, “lifestyle”, “exercise”, “physical activity”, “tinnitus”, “vertigo” and “age-related hearing loss” were used as keywords. Results: Audio-vestibular dysfunction develops and progresses as a result of age-related inflammation and oxidative stress. Diets with anti-inflammatory and antioxidant effects have been proposed to alleviate this illness. A high-fat diet may induce oxidative stress and low protein intake is associated with hearing discomfort in the elderly. Increased carbohydrate and sugar intake positively correlate with the incidence of audio-vestibular dysfunction, whereas a Mediterranean-style diet can protect against the disease. Antioxidants in the form of vitamins A, C, and E; physical activity; good sleep quality; smoking cessation; moderate alcohol consumption; and avoiding noise exposure are also beneficial. Conclusions: Adequate diet or nutritional interventions with lifestyle modification may protect against developing audio-vestibular dysfunction in elderly individuals. The elderly population is the fastest growing population globally. The World Health Organization estimated that the proportion of people over the age of 60 will nearly double between 2015 and 2050, and by 2030, 20% of the population will be 65 years of age or older (1). This trend is of medical concern as aging causes a decline in multiple organ system functions, such as hearing loss, refractive errors, depression, dementia, and multiple chronic disorders [Age-related hearing loss (ARHL) and age-related vestibular loss (ARVL) are common conditions that have deleterious consequences on patients’ health and quality of life. ARHL or presbycusis usually affects both ears gradually and equally and is frequently reported in the elderly, with a prevalence ranging from 30% of individuals aged 65–74 years to more than 40–60% of people aged 75 years or older [Dizziness and imbalance are major complaints among the elderly population, and peripheral vestibular dysfunction is one of their most common causes . Age-relARHL and ARVL lead to significant health burdens and reduced quality of life . DizzinePrevention and treatment strategies for these diseases are limited; however, patient nutritional status has been identified as a modifiable risk factor. A previous article ever depicted the possible association between nutritional status and ARHL. However, the article did not mention ARVL and the association of lifestyle and ARHL and ARVL . TherefoTwo authors (Chen HL and Tan CT) independently searched PubMed, Embase, and Cochrane review databases for relevant articles published from database inception to December 2021. The database search was conducted to identify the relationship between diet, lifestyle, and audio-vestibular dysfunction. “Diet,” “nutritional supplement,” “lifestyle,” “exercise,” “physical activity,” “tinnitus,” “dizziness,” “vertigo,” “age-related hearing loss,” “age-related vestibular loss,” and “aging” were included as keywords. We imposed no language or temporal restrictions on any of the searches. The databases were searched by 2 authors (Chen HL and Tan CT) independently and were reviewed by the 2 corresponding authors (Wu CC and Liu TC). The quality of the included studies was measured using the Newcastle–Ottawa Scale (NOS) . The NOSThe quality assessment of the included studies was conducted using the NOS, with scores ranging from 0 (lowest) to 9 (highest) points. First of all, we make a simple review of pathophysiology and etiology of age-related hearing and vestibular loss, which may be related to inflammation and oxidative stress causing by the aging process. ARHL and ARVL development are also largely influenced by genetic and environmental factors such as eating habits and lifestyle. ARHL etiology has been extensively studied; however, little is known about the mechanism of ARVL. The auditory and vestibular systems rely on the same sensory organs in the inner ear. The inner ear comprises the cochlea, which is responsible for hearing, and the vestibular end organs, which are responsible for balance. The inner ear is also susceptible to aging effects. Primary age-related cochlear changes include decreased hair cell and neuron levels in the cochlear nuclei and auditory center of the brain. In contrast, changes in the peripheral vestibular system include loss of neurons and hair cells in the otolith organs and semicircular canals ,17.Insufficient cochlear blood flow is thought to be responsible for hair cell damage and hearing loss in the elderly. Free radical formation, which results from increased oxidative stress, and inflammation typically occur with age and can lead to impaired vascular function, as well as cochlear and vestibular damage . AlthougInflammation is a hallmark of aging. The term “inflammaging” is defined as chronic low-grade inflammation that worsens with age and contributes to various age-related pathologies . InflammImmune surveillance occurs in the cochlea ,23 and sHowever, the exact role of inflammation in ARVL has not yet been investigated; however, inflammatory molecular mediators are present in the vestibular end organs . To dateOxidative damage results in age-related damage by forming free radicals and reactive oxygen species (ROS) . ROS andGrowing evidence suggests that the effect of oxidative stress can induce macromolecule damage, such as mitochondrial DNA (mtDNA) mutations. mtDNA accumulates mutations/deletions which impairs mitochondrial function and induces cochlear cell apoptosis and ARHL .Several studies have implicated the role of oxidative stress in initiating and progressing inner ear damage in animal models . HoweverILDR1, ZNF318, NID2, and ARHGEF28 [Genetic studies have identified several genes that contributed to ARHL and ARVL pathogenesis, including those related to antioxidant defense and atherosclerosis ,36. TwinARHGEF28 ,39,40. AARHGEF28 .In contrast, no definite genes are directly linked to ARVL; however, genetic predisposition to antioxidant defense and atherosclerosis may play an important role in age-related vestibular end-organ dysfunction, due to oxidative stress and mutations in mtDNA ,42,43. FIn addition, other extrinsic modifiable factors, such as diet  and exerAging induces inflammation and oxidative stress and affects microcirculation throughout the body. Chronic inflammation is observed during aging and has been linked to ARHL and ARVL severity. Furthermore, ARHL and ARVL development has also been largely influenced by genetic and environmental factors such as eating habits and lifestyle. Diet has been documented to heavily influence hearing and balance status since it can mediate age-related changes in the inner ear  by moduld-galactose injection [Several studies have revealed the harmful effects of a high-fat diet on the inner ear, wherein it induces oxidative stress, mitochondrial damage, and apoptosis . This hinjection . Thus, anjection . Moreover, cholesterol-rich diets have been shown to affect hearing loss . ElevateAdiponectin is the most abundant adipose tissue-derived cytokine in the body, and low levels reflect obesity-induced adipose dysfunction . AdiponeThe four main subtypes of dietary fats are as follows: polyunsaturated, mono-unsaturated, trans, and saturated. Mono-unsaturated fatty acids (MUFA) and polyunsaturated fatty acids (PUFA) are considered beneficial, whereas saturated and trans fats are considered unhealthy since they increase low-density lipoprotein (LDL) levels. Also, a low-saturated fat diet may protect against hearing loss , whereinInsufficient protein intake results in ototoxic side effects . PreviouA dietary pattern characterized by high protein intake is also associated with a reduced risk of tinnitus  . SimilarAlthough a low-protein diet may impair audio-vestibular function, no current study has specified the amount of protein required in the diet. A high-protein diet is defined as acquiring 20% or more of the total daily calories from proteins. Most high-protein diets are simultaneously high in saturated fat and severely restrict carbohydrate intake . MoreovePeople who consume high amounts of carbohydrates, especially simple carbohydrates and added sugars, tend to become obese, which results in other comorbidities, such as cardiovascular diseases, dyslipidemia, and diabetes mellitus . High bld-Galactose is a common reducing sugar in the body, and when present at high levels, it can be oxidized to aldehydes and H2O2 in the presence of galactose oxidase, thereby inducing oxidative stress [e stress . Animal-e stress .High carbohydrate and sugar intake are associated with an increased incidence of hearing loss. Glucose-rich and total-carbohydrate-rich diets are predictors of incident hearing loss . High poAs previously discussed, several comorbidities, such as obesity and cardiovascular diseases, may accelerate hearing loss by disrupting blood flow in the inner ear ,95. GopiIn contrast, Spankovich et al. demonstrated that a high carbohydrate intake protects against hearing loss in older adults . This isCaloric restriction (CR) extends the lifespan, improves health, and slows ARHL progression in older adults . FurtherThe Mediterranean diet (MedDiet) has attracted considerable attention and has been widely promoted in recent years. It is a plant-based eating plan that includes a daily intake of whole grains, olive oil, fruits, vegetables, beans and other legumes, nuts, herbs, and spices. This dietary pattern contains complex and abundant bioactive compounds, such as several vitamins, minerals, polyphenols, fibers, nitrates, and mono-unsaturated and polyunsaturated fatty acids . MedDietThe composition of the MedDiet is multivariate and cannot be explained by a single factor. Nevertheless, previous studies have shown that fibers and polyunsaturated fats may be beneficial components of the MedDiet. Given that aging damages cochlear and vestibular function via inflammaging and oxidative stress, the components of the MedDiet carry anti-inflammatory  and antiIn short, a diet rich in fruits, vegetables, and meat but low in fat is associated with reduced odds of hearing difficulties .A wide variety of supplements and herbal remedies are easily accessible to consumers. Certain nutrients and vitamins, such as vitamins A and B , C, and E, positively influence hearing ,122,123.Folic acid/folate (vitamin B9) plays a crucial role in DNA synthesis and cell proliferation. One study suggested that total folic acid/folate intake is associated with an overall reduced risk of hearing loss in men over the age of 60 . In a ral-carnitine, and vitamin C [High vitamin D intake is associated with a reduced risk of hearing difficulties. In addition, provitamin A carotenoid and vitamins A, C, and E are known to have antioxidant effects that help prevent and treat hearing loss ,125. An itamin C . Furtheritamin C ,127. Minerals, such as magnesium, zinc, and selenium, are also thought to play a role in the hearing process ,128. MagNevertheless, inconsistent results exist between micronutrients, including vitamins A, B, C, and E, magnesium, and hearing loss. Shargorodsky et al. prospectively evaluated the association between vitamin C, E, B12, and β-carotene intake and the incidence of hearing loss. They found that a high intake of vitamins C, E, B12, or β-carotene does not reduce the risk of hearing loss . FurtherPreliminary studies have examined the potential beneficial effects of vinpocetine against memory loss, cancer, and Alzheimer’s disease ,135. A cCoenzyme Q10 is an antioxidant that may prevent and treat certain diseases and improve physical performance, and its supplementation may treat sudden sensorineural hearing loss . Ginkgo biloba is the most studied dietary supplement for tinnitus treatment. It is believed to improve tinnitus by increasing inner ear and cerebral blood circulation and protecting against free radicals. However, several clinical trials evaluating its effect on tinnitus have yielded conflicting results ,141. Tinnitus and sleep are closely related. Melatonin is an essential hormone that regulates the circadian rhythm and protects against free radicals and ototoxic drugs by its antioxidant effects. A review of studies assessing the role of melatonin in tinnitus treatment concluded that it could improve sleep problems caused by tinnitus .Coffee is one of the most common beverages consumed worldwide. Increased coffee consumption had a statistically significant inverse correlation with bilateral hearing loss in the 40–64 years age group, suggesting its protective effect against hearing loss and tinnitus . HoweverExercise is beneficial for health as it improves cardiovascular function, physical fitness, and psychosocial health. Regular exercise can also reduce multiple cardiovascular risk factors, such as correcting lipoprotein profiles and lowering fat mass and blood pressure . SarcopeDizziness and imbalance are the most common complaints among older adults. Their etiologies are multifactorial; however, peripheral vestibular dysfunction is one of the most commonly reported causes. Age-related vestibular function impairment has also been shown to correlate with the age-related decrease in vestibular hair cell and neuron levels ,156,157.Adequate sleep is a subjective issue that varies among individuals. Sleep hygiene is defined as a set of behavioral and environmental recommendations intended to promote healthy sleep. Several sleep pattern changes are associated with aging and include longer times to fall asleep, increased awakenings during the night, and earlier awakenings in the morning. Approximately half of the older population complains of sleep disturbances . A margiSmoking may affect the auditory system via the direct ototoxic effects of nicotine and other substances found in cigarette smoke  or via vAlcohol consumption has also been linked to hearing loss. One alcoholic drink equivalent contains 14 g of pure alcohol. According to the Dietary Guidelines for Americans, 2020–2025, “drinking in moderation” is defined as a daily alcohol intake of two drinks or less for men and one drink or less for women . ModeratSeveral studies have established the relationship between noise exposure and age-related hearing loss. A cross-sectional and longitudinal study showed that workplace noise exposure increases the risk of incidental hearing loss in older adults . FernandNoise can also damage the vestibular system . An earlThe inner ear is susceptible to aging effects. Free radical formation, which results from increased oxidative stress, and inflammation typically occur with age and can lead to impaired vascular function, as well as cochlear and vestibular damage. Several studies have revealed the harmful effects of a high-fat diet on the inner ear, wherein it induces oxidative stress, mitochondrial damage, and apoptosis. High saturated fat intake was linked to hearing loss, possibly via cardiovascular disease pathways. Obesity and other comorbidities contribute to ARHL by decreasing adiponectin levels. Our previous clinical cohort study highlighted the protective role of adiponectin against ARHL development. On the other hand, a low-saturated fat diet may protect against hearing loss, wherein high polyunsaturated fat intake decreases the incidence of subjective and audiometric hearing loss. Insufficient protein intake results in ototoxic side effects, and low protein intake may impair neural function in the auditory system. Some studies have revealed the relationship between protein intake, aural symptoms, and vestibular dysfunction. However, most of the studies were not specific to ARHL and ARVL. No detailed mechanisms have been depicted.High blood sugar levels can damage small blood vessels and nerves in the inner ear, causing pathological changes in outer hair cells and spiral ganglion cells. High carbohydrate and sugar intake are associated with an increased incidence of hearing loss. Glucose-rich and total-carbohydrate-rich diets are predictors of incident hearing loss. The Mediterranean diet has attracted considerable attention and has been widely promoted in recent years. This dietary pattern contains complex and abundant bioactive compounds, such as several vitamins, minerals, polyphenols, fibers, nitrates, and mono-unsaturated and polyunsaturated fatty acids. MedDiet can reduce the risk of several age-related chronic diseases. However, no definitive studies have deciphered the exact role of the Mediterranean diet in the pathophysiological mechanisms of ARHL and ARVL.A wide variety of supplements and herbal remedies are easily accessible to consumers. Certain nutrients and vitamins positively influence hearing. Nevertheless, inconsistent results exist between micronutrients, including vitamins A, B, C, and E, magnesium, and hearing loss.Exercise is beneficial for health as it improves cardiovascular function, physical fitness, and psychosocial health. Sarcopenia commonly occurs in the older population and few studies have revealed a potential association between sensory impairments and a greater likelihood of sarcopenia, especially relating to hearing and vision loss. A recent study showed that the prevalence of mild or moderate-to-profound hearing loss was significantly lower in the control group than in the sarcopenia group. Age-related vestibular function impairment has also been shown to correlate with the age-related decrease in vestibular hair cell and neuron levels. Vestibular rehabilitation can effectively treat unilateral and bilateral vestibular dysfunction and induce faster recovery of posture-locomotor deficits. Several studies have suggested an association between sleep-disordered breathing (SDB) and worse cardiovascular, cognitive, and functional outcomes. It has been hypothesized that sleep disturbances could impair hearing through disturbed energy metabolism and disrupted cochlear blood flow.Smoking may affect the auditory system via the direct ototoxic effects of nicotine and other substances found in cigarette smoke. Current smokers showed a significantly increased risk of hearing loss compared to non-smokers. Smoking is also associated with peripheral vestibular disorder events. As for alcohol, moderate alcohol consumption protects against cardiovascular disease; however, high alcohol consumption is associated with an increased risk.Several studies have established the relationship between noise exposure and age-related hearing loss. It can also damage the vestibular system.There are several limitations in this review article. Different populations were included in both animal and human studies. Some studies focus on aural symptoms or vestibular symptoms but are not specific to ARHL or ARVL. Some studies enrolled different age groups; not all the studies related to nutrition or lifestyle restricted to the elderly or unified age grouping. The evaluation of nutrition status and lifestyle were extremely complex and multiplex. The exposures and risk factors in each study were limited because most of the exposures and risk factors were mostly evaluated by a questionnaire which was difficult to be quantified or qualified. We did not perform a meta-analysis because during the process, the population, the study design, and the scale of the study were full of heterogeneity which made it unachievable.With a continually aging society, the burdens of ARHL and ARVL continue to rise. Thus, preventing rapid auditory and vestibular functional deterioration can greatly improve the quality of life. A fat-rich diet may induce oxidative stress, and low protein intake is associated with hearing discomfort in the elderly. Increased carbohydrate and sugar intake positively correlated with audio-vestibular dysfunction, whereas Mediterranean-style diets were inversely associated with it. Vitamins A, C, and E act as antioxidants that can also minimize the risk of ARHL and ARVL. Maintaining physical activity, fair sleep quality, moderate alcohol consumption, smoking cessation, and avoiding noise exposure are also beneficial. However, most studies have focused on ARHL, and little is known about ARVL. Furthermore, previous studies comprised mainly observational or interventional animal models. Therefore, additional large-scale studies are required for further verification, as human longitudinal studies are essential to understand individuals’ risk of diseases much earlier in life and to inform health choices and medical care options.


To investigate whether otolith dysfunction is related to hearing impairment in vertigo patients with normal semicircular canal function, and to clarify the types of hearing impairment that may be related to otolith organ damage.The demographic data, pure tone threshold audiometry (PTA) results (air-conduction), data of bithermal and video-head impulse test (vHIT), and vestibular evoked myogenic potential (VEMP) results  of patients with vertigo in outpatient clinic from April 2017 to January 2020 were collected. The clinical records of 51 vertigo patients with normal semicircular canal function were included in this study. Low-frequency, speech-frequency, high-frequency, full-frequency PTA were defined as the average of PTA in different frequency bands, respectively . The correlations between hearing impairment in different frequency bands and otolith function impairment were analyzed.P = 0.01) and P1–N1 amplitude (P = 0.028). There were not significant linear correlations between the mean threshold in each frequency band of PTA and o-VEMP threshold  or P1–N1 amplitude .The mean thresholds of 51 patients (102 ears) in low-PTA, speech-PTA, high-PTA, full-PTA were 20.95 ± 6.01, 21.92 ± 6.90, 40.12 ± 17.47, 26.97 ± 8.53 dB nHL, respectively. Among 102 ears, 87 ears (85.3%) could elicit c-VEMP waveforms and 65 ears (63.7%) had o-VEMP waveforms. The mean threshold and P1–N1 amplitude of c-VEMP were 83.10 ± 6.96 dB nHL and 176.79 ± 103.10 uV, while those of o-VEMP were 87.92 ± 5.99 dB nHL and 21.45 ± 32.22 uV. The mean threshold in high-PTA was significantly linearly correlated with c-VEMP threshold (There is a positive linear correlation between saccule dysfunction and high-frequency hearing impairment in vertigo patients with normal semi-circular canal function. High frequency hearing loss can be expected in patients who have saccular damage. It suggests that high frequency hearing loss in PTA may act as a screening index that otolith organ function should be comprehensively evaluated. Vertigo is one of the most common symptoms of nervous system diseases, which is often encountered in neurology, otolaryngology, and general medical practice . VertigoThree semicircular canals (SCCs) and otolith organs containing saccule and utricule constitute the terminal organs of vestibular system. Vertigo is mainly considered to be caused by the dysfunction of SCC sensing the stimulation of rotational acceleration, and the function of SCCs is usually evaluated by Bithermal and video-head impulse tests (vHIT) . In clinOn account of the close physical connection between cochlea and otolith organs, they are frequently affected by the same factors , 9. It iWe collected and reviewed the medical records of 235 consecutive vertigo patients with detail evaluation results of VEMPs testing to air-conducted sound (ACS VEMP), caloric test and vHIT test between April 2017 and January 2020 at the outpatient clinic of the Eye, Ear, Nose, and Throat Hospital affiliated with Fudan University. Fifty-one cases met the following inclusion criteria were included in this study: (a) without abnormal SCC function evaluated by bithermal test and vHIT test; (b) no obvious sudden hearing loss which could be self-perceived; (c) with detail results of PTA test and VEMP test. Exclusion criteria: (1) combined/previous history of sudden hearing loss, head trauma, ear surgery, psychological diseases and mental diseases; (2) significant air-bone gap in PTA; (3) the other obvious health problems that could affect the test results (such as gravis myasthenia).The study was approved by the research ethics committee of the Eye, Ear, Nose, and Throat Hospital affiliated with Fudan University (No. 2017025-1). All patients provided signed informed consent.The mean threshold values at different frequency bands were calculated as follow: low-frequency PTA (low-PTA) was gained by averaging air conduction threshold at 0.125, 0.25, 0.5 kHz; speech-frequency PTA (speech-PTA) was the average of threshold values at 0.5, 1, and 2 kHz; high-frequency PTA (high-PTA) was that at 4 and 8 kHz; full-frequency PTA (full-PTA) was the average of threshold values from 0.125 to 8 kHz. The classification of hearing loss refers to the standard issued by WHO in 2021: normal hearing <20 dB, mild loss 20 to <35 dB, moderate loss 35 to <50 dB, moderately severe loss 50 to <65 dB, severe loss 65 to <80 dB, profound 80 to <95 dB, complete or total loss 95 dB or greater.via calibrated insert headphones. The electromyography signals were amplified in a Bio-Logic Navigator PRO system . Exact location and detailed method of electrode placement in the test of VEMPs have been described in our previous study , a total of 120 auditory stimuli  were applied to each ear us study , 10.The starting stimulus intensity was 95 dB nHL to confirm a VEMP response, then decreased in 5 dB nHL per step until the VEMP responses were not detected. Response thresholds were defined as the minimum stimulus intensities of the characteristic waveform. The elicitation of cVEMP was confirmed when the characteristic P13–N23 (positive-negative waveform) appeared. An absence of cVEMP was determined when the typical waveforms could not be elicited or were unrepeatable. The elicitation of oVEMP was defined as the occurrence of the characteristic N10–P15 (negative-positive waveform). An absence of oVEMP was established when the typical waveforms could not be elicited or were unrepeatable. The amplitudes of cVEMP and oVEMP were recorded as the voltage difference between the first and second peaks of the response, that is, P13–N23 for cVEMP, and N10–P15 for oVEMP .t-test and 1-way ANOVA. The diagnostic accuracy of PTAs of different frequency bands in patients with severe otolith organ damage (no cVEMP/oVEMP response) were evaluated using receiver operating characteristic (ROC) curve analysis. The correlations between PTAs of different frequency bands and VEMP results were analyzed by linear regression. Statistical significance was set at p < 0.05.Data were analyzed using IBM SPSS Statistics 25. All continuous data were presented as the mean ± standard deviation (SD). The mean values were compared by independent sample Fifty-one patients who met the criteria were enrolled in this study, including 30 females and 21 males. Their ages ranged from 15 to 81 years, with a mean age of 53.06 ± 13.71 years. The majority (88.24%) of the subjects were between 30 and 70 years old. The gender and age characteristics of all patients are shown in According to the WHO classification standard for hearing loss in 2021, 21 cases (41.18%) had normal hearing, 27 (52.94%) had mild hearing loss and 3 (5.88%) had moderate hearing loss. A total of 58 (56.86%) ears appeared abnormal hearing threshold in low frequency band, 61 (59.80%) ears in speech band, 92 (90.20%) ears in high frequency band and 79 (77.45%) ears in full frequency band. The majority of patients have normal or slight decrease in low-frequency and speech frequency hearing, and the proportion and damage degree of high frequency hearing loss are relatively higher than those of low-frequency and speech frequency hearing loss. The hearing thresholds at different frequency bands of 102 ears are shown in In all 102 ears, 87 ears (85.29%) could elicit cVEMP and 65 ears (63.72%) could elicit oVEMP. The mean threshold and the average P1–N1 amplitude of c-VEMP were 83.10 ± 6.96 dB nHL and 176.79 ± 103.10 uV, and those of o-VEMP were 87.92 ± 5.99 dB nHL and 21.45 ± 32.22 uV. The detail results of cVEMP and oVEMP were listed in All 102 ears were divided into evoked group and non-evoked group according to whether the waveforms of cVEMP could be recorded. There was significant difference between these two groups by comparing the mean hearing threshold values of low frequency, speech frequency, high frequency and full frequency. The same results were also found in the groups divided by the oVEMP results . ROC anaIn 87 ears which could induce c-VEMP, there was statistically significant correlation between the mean threshold in full-frequency PTA and c-VEMP threshold, so did P1–N1 amplitude of c-VEMP. Further analysis found that high-PTA was significantly linearly correlated with c-VEMP threshold and P1–N1 amplitude, while the statistically significant correlations were not found in low-PTA, speech-PTA compared with c-VEMP threshold or P1–N1 amplitude. PTAs of different frequency ranges were not significantly linearly correlated with o-VEMP threshold or P1–N1 amplitude. Correlation analysis between PTAs at different frequency bands and VEMP results were listed in Otolith organs play an important role in maintaining balance, orientation and cognitive function –14. PatiVEMP, a common method to evaluate otolith organs, needs high technique requirement, takes a long test time, and is relatively expensive, which limits the wide application of this technique in clinic. How to simply and quickly screen out patients with otolith organ dysfunction or potential damage and intervene in time is a problem worthy of discussion. The cochlea and saccule are adjacent in anatomy and homologous in the development of the inner ear, which suggesting that they may have some correlation in function. In previous studies, we found that patients with severe sensorineural deafness were often accompanied by otolith organ dysfunction –22.In this study, vertigo patients with normal semicircular canal function were enrolled. It was found that otolith organ dysfunction and hearing loss detected by VEMP and PTA in some patients, which means that vertigo patients with normal semicircular canal function do have the state of impaired cochlea and otolith organ function. By comparing the mean hearing threshold values of low frequency, speech frequency, high frequency and full frequency in patients with evoked and non-evoked VEMP normal waveform, it was found that there were significant differences between these two groups, which suggested that auditory function of each frequency band may have abnormal performance in vertigo patients with severe otolith organ damage. ROC analysis also showed that it had certain diagnostic significance for the hint of severe otolith organ damage by assessing full band auditory function.cVEMP and oVEMP can reflect the function of saccule and utricule, respectively. Further analysis was made about the relationship between hearing threshold values of each frequency band in PTA and the results of cVEMP/oVEMP, respectively. It was found that there was a significant linear correlation between hearing threshold in high frequency band and cVEMP results, including reaction threshold and P1–N1 amplitude. The more obvious the high-frequency hearing loss was, the more seriously the saccule function was damaged, which suggested that there was a consistency between the function state of cochlear hair cells in the basal turn of cochlea that can feel high-frequency sound stimulation and the functional state of saccule. Cochlea and Saccule are anatomically adjacent. Meanwhile, they are homologous and developed from the cochlear sac , 24. ThoVEMP is a relatively expensive test. It takes a long time to fulfill the examination and requires patients to cooperate perfectly in order to obtain accurate results. Therefore, it could not be widely used in the function screening of otolith organs in clinic. This study found that the results of PTA in high-frequency band are linear correlation to the results of cVEMP. Patients with high-frequency hearing loss are easy to be combined with the increase of cVEMP response threshold and the decrease of P1–N1 amplitude. Therefore, PTA may be used as a basic test for otolith organ function screening, and the mean hearing threshold in high-frequency area may be used as a predictor to indicate whether saccule function probably decline, so as to screen out the patients with otolith organ function impairment in the early stage, or monitor the disease progression for those patients who have potential problem and probably develop into otolith organ dysfunction.This study confirmed that there is a linear correlation between the hearing threshold in high frequency band of PTA and cVEMP results, including the threshold and P1–N1 amplitude. It suggested that there is a correlation between cochlea and saccule function. High frequency hearing loss can be expected in patients who have saccular damage. Hence, PTA may be used as a basic test for otolith organ function screening, and high frequency hearing loss may be used as an index to comprehensively evaluate otolith organ function in vertigo patients with normal semicircular canals function.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by Ethics Committee of the Eye, Ear, Nose, and Throat Hospital affiliated with Fudan University (No. 2017025-1). The patients/participants provided their written informed consent to participate in this study.JingW designed the study and reviewed the manuscript. LT, ZC, JinyW, and LZ collected and analyzed the data and drafted the manuscript. HZ and FC collected the data and performed the statistical analysis. All authors were responsible for the final approval of the version to be published.This study was supported by the General Program of National Natural Science Foundation of China (NSFC 81870724), the Innovation Project of Shanghai Municipal Science and Technology Commission (19441900400), and the Shanghai Municipal Health Commission (201740018).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Otitis media (OM) is an infection that occurs in the middle ear and can affect the structures around the ear, as well as the auditory system. It is one of the most frequent diseases affecting young children each year, especially those aged around six years, due to the anatomical structure and developing immune system.Although some cases of OM resolve spontaneously, children often need medical care since difficulties persist with such infections. The incidence of OM is higher among children than adults, and therefore, their speaking, hearing, and learning capabilities and general development are impaired by recurring middle ear infections.The literature over the last 40 years has documented the impact of early auditory deprivation produced by early OM with effusion (OME) on central auditory processing (CAP). This study aimed to review the impact of acute ear infections on hearing capacity, assess the complications of OM, and document the scientific evidence around the implications of early OME-induced hearing loss in children.Studies have reported the association between hearing loss owing to early OME and alterations in CAP in both children and adolescents. The auditory foundation enables hearing capacity, but this is continually depleted. Therefore, the use of strong antibiotics, sound amplification, hearing rehabilitation, and ear surgery in children must be improved. A middle ear infection is referred to as acute otitis media (AOM). Otitis media with effusion (OME), chronic suppurative otitis media (CSOM), and AOM all fall under this spectrum of illnesses. After upper respiratory infections, AOM is the second-most frequent paediatric diagnosis in the emergency room. Otitis media (OM) can strike at any age, however, it is most frequently diagnosed in infants between the ages of six and 24 months .The incidence of AOM, which is typically self-limited, is 10.9%. Chronic OM (COM), which has an incidence of 4.8%, -4 is morConsequently, this study aimed to consider the effects of ear infections on hearing abilities and the repercussions of OM.Ear infections and OMMedical problems due to viral or bacterial infections in the middle ear, like acute nonsuppurative OM and acute suppurative OM, are known as ear infections. OM is frequently caused by other disorders, such as allergies, colds, or influenza, which cause congestion in the auditory, nasal, and throat passages. Infection can arise in the middle ear, which is a tiny space within the ear below the eardrum that divides the middle ear from the outer ear (eardrum) when bacteria from the nose and throat enter. Ear pain (that can vary in severity and tolerability), discomfort and nervousness, malaise, sleep disturbances, discharge of a yellow sticky liquid from the ears when an ear infection is caused by tympanic membrane rupture, higher body temperature, hearing problems, and a feeling of pressure in the ears are all common symptoms of OM. Otitis is a general term for ear inflammation or infection, which encompasses both human and animal ear diseases. Infections are classified into three categories: otitis externa, OM, and otitis interna .Otitis externa, sometimes known as “swimmer’s ear,” is an inflammatory condition that affects the outer ear and ear canal. Ear tugging or touching is painful when this ailment is present.OM, as defined earlier, is an inflammation of the middle ear. The ear is infected  or obstructed in OM, which affects the middle ear, due to fluid accumulation behind the space behind the eardrum, which is normally filled with air and sterile. This damage most commonly affects youngsters, and it may necessitate surgical intervention in the form of eardrum surgery, which involves inserting a tube into the eardrum to reach the required location.A sudden onset of this disease is referred to as AOM. AOM occurs when pus and mucus deposit behind the eardrum, obstructing the eustachian tube, and is caused by colds, allergies, or bacteria/viruses. This may cause ear pain and fever. The disease is referred to as OME when the fluid remains in the middle ear for weeks after the ear infection has been treated. OME often occurs after AOM, but it also may occur as a result of eustachian tube dysfunction in young children in the absence of a preceding AOM. The fluid may remain in the ear for several weeks to months. Persistent ear infections, if left untreated, can have catastrophic implications, including temporary hearing loss .The inner ear contains sensory organs that are important for hearing and balance. When the inner ear becomes infected, it can cause dizziness, which is a common symptom .Infections of the middle ear  are common in children. By the age of three, it is believed that at least half of all children have had at least one bout of ear infection . BecauseOne of the most common side effects of OM is conductive hearing loss . HearingOM adversely affects children’s quality of life, and depending on illness severity, it may also have a greater influence on medical care and service providers .Complications of OMOM occurs when the tube that links the ear to the neck swells for various reasons, including the common cold, causing fluids to become trapped inside the ear (providing a good environment for the reproduction of ear infection-causing germs). Because newborns and young children’s ears are tiny and prone to obstruction, this facilitates OM. While most ear infections do not have long-term consequences, repeated ear infections can result in the following catastrophic consequences :1-Mild hearing loss: Mild hearing loss that comes and goes is a typical co-occurring disease with ear infections; however, hearing normally recovers after the infection is cleared. Hearing loss can be worsened by ear infections or fluid accumulation in the middle ear. Permanent hearing loss can be caused by permanent injury to the eardrum or other components of the middle ear.2-Delay in social skill or speech development: Infants and young children with temporary or permanent hearing loss may experience delays in social skills or speech development.3-Infection spread: If an infection is left untreated or does not respond to therapy, it can spread to neighboring tissues. Mastoiditis  can cause bone deterioration or pus-filled cysts to grow. A serious middle ear infection can spread to other tissues in the skull, such as the brain or membranes surrounding the brain, in rare circumstances (meningitis).4-Eardrum rupture: Most eardrum ruptures heal within 72 hours, while surgery may be necessary in some situations.5-Inflammation and disintegration of the mastoid: Inflammation and disintegration of the mastoid (airy bone cells behind the ear) are further issues that can be medically treated with antibiotics or surgically. The inflammation can extend to the inner ear, causing dizziness, ringing in the ears, hearing loss that is nearly irreversible, and even meningitis  .6-Hearing and facilitating body balance are principal functions of the human ear. The outer ear receives sound through the pinna; the middle ear transfers sound from the outer ear as vibrations to the interior; and the inner ear conveys sound vibrations from the middle ear to the brain via nerves .7-The body secretes a mucous fluid that collects behind the eardrum in OM owing to bacterial or viral infections, causing increased pressure on the middle ear and drum bulging, which produces discomfort. Infections can also be caused by dysfunction of the eustachian tube, which links the middle ear to the throat and balances pressure between the outer and middle ear. The existence of a defect in this tube hinders its normal functioning, inhibiting normal fluid outflow from the middle ear and causing fluid collection behind the eardrum. Bacteria and viruses can proliferate in the ear, producing inflammation .OM is one of the most frequent childhood illnesses. Because children are more susceptible to OM than adults due to severe cold and weaker immune systems; OM causes significant discomfort in young children, which worsens as they sleep. When the pressure in the middle ear increases and treatment is delayed, problems such as eardrum rupture or hearing loss can occur.Antibiotics must be given to children with a severe bacterial infection . Scarring in the middle ear develops when the infection recurs, reducing hearing capacity. When a child’s hearing is impaired and fluid lingers behind the eardrum, a tiny incision is made in the eardrum and a small ear tube is inserted to clear the fluid .The collected water in the form of mucus is drained since its presence for an extended length of time may induce chronic OM, and a tube is inserted into the ear to ventilate it. Due to their incapacity to pinpoint discomfort, newborns have a tough time detecting ear infections. As a result, sleep difficulties, appetite loss, and behaviors, such as pulling ears or refusing a bottle of milk because the pressure on their ears makes swallowing difficult, must all be monitored. Most ear infections resolve in three days, however, symptoms may continue for up to a week .OM is not very different between adults and children. When fluid congestion and buildup develop in the eustachian tube because of allergies or colds, inflammation ensues. Whereas the eustachian tube should typically solely contain air, bacteria and viruses proliferate and spread to the middle ear because of fluid buildup and pressure on the eardrum. When an infection is left untreated, intense pressure builds up, resulting in a hole in the eardrum, pus leakage, and suppurations that spread to other body parts. In certain circumstances, this hole may close; if it does not, microbes and water from the outside may enter the ear. Disease symptoms in adults vary depending on whether the infection is viral or bacterial or in the throat or nose; ear pain occurs, with a hearing problem or a sound-like ringing in the ear. Fever appears, with headache and dizziness; nausea, upset stomach, and vomiting may occur, and in the case of infection, the eardrum may rupture .Recurring ear infections can lead to major problems such as hearing loss. This is common with middle ear infections and mild hearing loss but disappears once the infection heals; repeated ear infections cause severe hearing loss due to the presence of fluid in the middle ear, which can lead to permanent hearing loss if the middle ear drum or other parts of the middle ear are damaged.Hearing loss, whether temporary or permanent, affects a child’s capacity to communicate and understand their surroundings. Non-responsiveness to therapy can cause viral infection to spread to the projecting bone behind the ear . The infection may spread to the brain or nearby tissues, causing bone damage or pus production. Eardrum rupture is a possible side effect; however, the infection normally clears in a few days. Surgical intervention may be necessary for rare circumstances .In summary, middle ear infections usually occur during or after upper viral respiratory infections, particularly the common cold. Inflammation and swelling at the back of the throat, particularly the eustachian tube, are symptoms of the condition. The eustachian tube swells and is unable to equalize the pressure in the middle ear space. Because of the pressure buildup within a tiny region of the middle ear, regular secretions are unable to be flushed out as they typically would. Pain, dizziness, and temporary hearing loss can be caused by negative pressure and excess fluid buildup .Middle ear infections can occur in anyone with a cold. Middle ear infections are more common in younger children for two reasons. Their immune systems are less developed, making it more difficult for them to combat respiratory infections, and their eustachian tube is more horizontal, making it more difficult to empty fluid. Chronic infection of the adenoids or tonsils is another risk factor for middle ear infection. Viral or bacterial invaders can readily travel to the middle ear since these glands are near the eustachian tube. An otolaryngologist may recommend surgical removal of these glands (tonsillectomy or adenoidectomy) to prevent infections from spreading in the future. Middle ear infections are likely to improve once the surgical region has healed and the middle ear space has been aired .The pneumatic otoscope, which allows viewing of the ear, can be used by the physician to assess the condition of the outer ear and eardrum. A puff of air in the ear can also be used to detect problems, and the movement of the drum can be studied. When an infection recurs, the physician performs a hearing test to check whether there is hearing impairment .Physicians recommend cleaning the ear with care and gentleness, especially while using cotton buds to clear wax. Sharp equipment should not be used for cleaning the ear, and the ears should be thoroughly dried after each shower, since water left in the ears may encourage bacteria and other microbes to enter. Personal hygiene is essential for maintaining health and preventing colds and flu. In general, a physician should be consulted if high temperature is accompanied by shivering or discomfort in the ear that lasts for many days without improvement, especially if there is a tumor or fluid discharge or if hearing impairment or loss, severe sore throat, or dizziness is present. Treatment  is recommended based on the patient's condition, and chronic infections, as well as hearing issues owing to permanent weakening or complete loss, may need the implantation of tiny tubes in the eardrum .Hearing abilityAuditory experience is critical for the development of the central nervous system. Although sensory functions can be determined naturally, hearing tests require training .OME is one of the most prevalent pediatric disorders . It is dAnimal research into conductive hearing loss has demonstrated that OM events can cause major alterations in the structure and function of the central auditory nervous system (CANS). Tucci et al. investigated the effect of sonic exposure during the 2-deoxyglucose (2-DG) integration phase on 2-DG uptake levels in CANS in jerboas with unilateral conductive hearing loss caused by the removal of the malleus . They diThe long-latency auditory evoked potential (LLAEP) exhibits the activities of discrimination, attention, and integration by reflecting the neuronal electrical activity of sites in the thalamus and auditory cortex. P300 is an endogenous LLAEP that consists of a positive wave with a post-stimulus delay of around 300 ms, suggesting activity in brain areas that control certain activities such as attention and memory [Despite this, few studies have measured P300 in children with OM to investigate the consequences of early-onset middle ear infection on the cortical level in these individuals .Effects of ear infections on hearing abilityOM is a fairly widespread ailment that affects approximately 11% of the world’s population (about 700 million people) on an annual basis . ChildreInflammation is most prevalent in childhood and adolescence and gradually fades with maturity. Between the ages of one and five years, about two-thirds of children have had at least one episode of secretory OM (SOM). Because of eustachian tube flattening, this disease is quite frequent in young children, resulting in recurring bouts of OM . If mediNumerous studies have shown that children with and without OM have substantially different voice problems. Generally, children with OM perform worse in cognitive and auditory processing tests than children without OM, and they have a higher rate of scholastic issues, owing to alterations in reading and writing . The criHowever, a single surgery for SOM is insufficient to achieve appropriate CANS stimulation. In addition to genetic variables, cognitive and linguistic development is influenced by social  and behavioral factors  . Due to Curi and Menezes-Filho noted that school choice is influenced by the family’s economic status and educational level, as assessed by the public’s capacity to send their children to the school of their choice. There is a link between parental education and school choice, according to the researchers . In BrazSOM is a clinical condition defined by middle ear effusion without eardrum perforation and a three-month-long acute infectious phase. It affects children between the ages of three and nine years.The most common sign is hearing loss, which is frequently detected by parents or instructors as a lack of attention and interest, repeated requests for the message, and poor academic achievement. The pathogenesis is complex, with eustachian tube dysfunction and upper airway infections of allergic, viral, or infectious origin having the highest prevalence. The immune system matures and the auditory tube strengthens with age, lowering the disease incidence .Otoscopy was used for diagnosis, which was then confirmed by audiological assessment. Otoscopy can reveal eardrum retraction, which is characterized by limited mobility, opaque appearance, and aberrant color. Mild-to-severe conductive hearing loss, generally bilateral, with a type B tympanic curve is diagnosed on auditory assessment. Hearing loss is sporadic, transient, and asymmetric .Depending on the health of the middle ear and the patient’s medical history, treatment may be clinical or surgical. The most frequent therapy for a middle ear infection is tympanostomy, which involves inserting a tube into the middle ear to drain fluid and restore hearing .Even years after the OM has cleared and pure-tone thresholds have recovered to normal, children with SOM may show deficiencies in binaural hearing and auditory ability .The central auditory processing (CAP) battery assesses how well the central nervous system can process changing sound stimuli . To measSince children are deprived of appropriate auditory input early in life, their CANS may shift, and their perceptual sensitivity to auditory information processing may be diminished later in life.Recent research in people and animals has found that sensory deprivation during development causes long-term cellular abnormalities in the auditory cortex as well as a decrease in behavioral performance .OME is a middle ear inflammation defined by middle ear fluid and the absence of signs or symptoms of acute infection or tympanic membrane rupture. The tympanic membrane’s mobility is reduced, and sound waves are transmitted more slowly . BecauseSeveral studies  have souThe wider perspective AOM is uncommon in European and North American children older than seven years. It is more likely to occur within the first year of life and becomes less prevalent in succeeding years.It is a frequent ailment that leads to many doctor appointments and antibiotic prescriptions. Clinically, it is diagnosed based on objective findings on physical examination (otoscopy), as well as the patient’s history and current signs and symptoms. To help in the diagnosis of OM, diagnostic equipment such as a pneumatic otoscope, tympanometry, and acoustic reflectometry are available. When compared with ordinary otoscopy, pneumatic otoscopy is the most trustworthy and has greater sensitivity and specificity, while tympanometry, as well as other modalities, can help with the diagnosis if pneumatic otoscopy is not available.The burden of AOM varies significantly among countries, as it does with most infectious diseases, with the primary distinctions being the prevalence of suppurative complications such as mastoiditis and meningitis, as well as sequelae such as hearing loss owing to CSOM. CSOM is a leading cause of preventable loss of hearing, especially in developing countries, and a cause for serious concern, especially in children, because it has long-term implications on early communication, auditory processing, language development, educational progress and achievement, and psychosocial and cognitive development.The World Health Organization (WHO) estimates that 28,000 fatalities per year are caused by OM complications, based on prevalence studies that differ substantially in illness definition, sample methodologies, and methodological quality. Meningitis and brain abscess are the most common causes of mortality in OM and CSOM. Furthermore, the WHO estimates that between 65 and 330 million people have CSOM (display indications of CSOM), with 50% of them having hearing loss.Hearing loss  is the third most common chronic illness in older individuals in developed countries, behind hypertension and arthropathy, with significant physical and mental health consequences. There is a scarcity of data on the adult population of less developed countries.By the age of four years, it is estimated that up to 80% of children will have OM. Early onset of OM has been linked to a higher risk of recurrent episodes, which are likely to have long-term consequences. To properly assess the need for treatments targeted at lowering acute OM incidence, and the health, social, and economic impact, a better understanding of the incidence and prevalence of acute OM and its consequences across ages and geographical areas is required.


Sistema Único de Saúde—SUS), according to quality indicators. Methods: Historical cohort study with data analysis of newborns attending prestigious hearing-health SUS services from January 2017 to December 2021, in Santa Catarina, Brazil. The quality of screening coverage was assessed based on the quality indicators proposed by the Brazilian neonatal-hearing-screening-care guidelines . Logistic-regression analysis, crude OR calculations, Cochran–Mantel–Haenszel OR calculation, and chi-square test were performed to estimate the association between risk indicators for hearing loss and UNHS failure. Results: In the last five years, the prestigious services performed UNHS on 34,801 newborns and met the DATAN quality indicators. Congenital syphilis was the most frequent (1.59%) congenital infection in newborns, followed by HIV (0.87%), whereas the least frequent was rubella (0.029%). Conclusion: Prestigious UNHS services reached ≥95% hearing screening coverage. Considering all congenital infections, the prevalence was 2.87%, with congenital syphilis the most frequent. Newborns with congenital syphilis or HIV are more likely to fail UNHS.Objective: to verify the frequency of congenital infections in newborns and their possible associations with the universal-neonatal-hearing-screening (UNHS) results, and evaluate a reference UNHS service in the Unified Health System ( One of the public policies implemented by the Ministry of Health of Brazil  is calleIn the epidemiological scenario, congenital and perinatal infections  are important risk indicators for hearing loss (RIHL) ,10. In BFurthermore, several studies and institutions, including Joint Committee on Infant Hearing (JCIH) guidelines, report that other RIHL in newborns include neonatal-intensive-care unit (NICU) stay of more than 5 days, duration of assisted ventilation, low Apgar scores, ototoxic drug exposure, craniofacial anomalies, and so forth ,23,24,25Sistema Único de Saúde—SUS) [Universal neonatal hearing screening (UNHS), which is essential to the early detection of hearing loss, also provides comprehensive, pediatric hearing-health-care with hearing and language monitoring and follow-up, diagnosis, and (re)habilitation. The Care Network for People with Disabilities recommends using it to organize healthcare, focusing on the needs of people with hearing loss at different levels of complexity of the Unified Health System (úde—SUS) ,21.Comitê Multiprofissional de Saúde Auditiva—COMUSA) [Diretrizes de Atenção da Triagem Auditiva Neonatal—DATAN) [UNHS programs may adopt the following scientific institutions’ protocols: JCIH ,20, the —COMUSA) , and thel—DATAN)  to deterl—DATAN) ,24. DATAN  recommenGiven this context, this study aimed to estimate the prevalence of communicable diseases in newborns and their possible associations with UNHS results, and to evaluate a prestigious UNHS service in SUS, according to international quality indicators. The study used data on UNHS regarding babies born in the Carmela Dutra Maternity Hospital (MCD)  and the São José Regional Hospital (HRSJ) (São José—SC). UNHS is preferably performed in the first 24 to 48 h of life, in the maternity hospitals, or within 30 days from birth at the Otovida Institute . Newborns are to be registered in the service database and evaluated with transient-evoked otoacoustic emission (TEOAE) in both ears and/or automated auditory brainstem response (AABR) according to RIHL ,21. In tData were analyzed based on the Otovida Institute database, a prestigious hearing-health service in SC responsible for conducting UNHS in public maternity hospitals (MCD and HRSJ). Information about the following aspects was collected: prenatal care, childbirth, puerperium, the mothers’ and newborns’ sociodemographic characteristics, TEOAE and/or AABR test results (satisfactory “PASS” or unsatisfactory “FAIL”), and RIHL ; hyperbilirubinemia, severe perinatal anoxia, 1-min Apgar score of 0 to 4, or 5-min score of 0 to 6, birth weight less than 1500 g, communicable diseases (infectious diseases), craniofacial anomalies involving the ear and temporal bone, genetic syndromes that usually cause disabilities, and neurodegenerative disorders).UNHS data were analyzed to evaluate the quality of the service, as proposed by DATAN , includiUNHS, categorized as “pass” or “fail”, was assessed as the outcome variable. Newborns who failed the TEOAE and/or AABR in only one or both ears were considered “fail”.The main research variables were toxoplasmosis, congenital rubella, cytomegalovirus, congenital syphilis, herpes, and HIV (no or yes). The covariates consisted of year of birth , maternal age , RIHL  (no or yes). The prestigious hearing-health service controlled the tests to meet UNHS quality parameters .® spreadsheets and then exported to and analyzed in StataMP® software, version 14.0 . Descriptive analyses were presented with absolute and relative frequencies and their 95% confidence intervals (95% CI). The association between UNHS failure (outcome) and communicable diseases (main exposure) and research covariates was analyzed. The odds ratio (OR) was used as a measure of association for both the crude (bivariate) and adjusted analysis, estimated with logistic-regression analysis.The data were organized in Microsoft Excel® Statistical Software, version 20.027. The categorical variables of the sample were described in absolute and relative frequencies, with their 95% confidence intervals (95% CI). The association between the outcome (UNHS) and the main exposure  and research covariates was analyzed with the chi-square test, which, when possible, was also applied to evaluate trends . The OR was used as a measure of association in the crude (bivariate) and adjusted analyses, estimated with logistic-regression analysis and 2 × 2 table calculations (crude OR) or with the Cochran–Mantel–Haenszel test. The program-effectiveness evaluation results were described according to DATAN quality indicators [Subsequently, the data were organized in Microsoft Excel spreadsheets and then exported to and analyzed in MedCalcdicators .This study was approved by the Research Ethics Committee. CAAE: 39562720.8.0000.0121.Regarding data analysis of the prestigious services of SC, the coverage in both MCD and HRSJ was greater than the recommended 95% .UNHS data regarding 34,801 patients were analyzed, and only 1.106% (95% CI 1.001–1.226%) of the newborns were referred for retesting at the prestigious service, due to hearing-screening failure.Congenital syphilis was the most frequent (average 1.59%) congenital infection in newborns who underwent UNHS between 2017 and 2021, followed by HIV (average of 0.87%). The least frequent was rubella (average of 0.029%) .The RIHL varied between newborns  and yearThere were mostly no significant differences between the frequencies of newborns with RIHL who failed and those who passed UNHS. The 0.09 OR shows that newborns born in 2021 were approximately 91% less likely to fail UNHS than those born in 2017. However, HIV-positive newborns were 388% to 1143% more likely to fail the UNHS .From 2017 to 2021, the UNHS was performed on 34,801 newborns in two maternity hospitals, representing 100.75% of the 34,720 live births, according to data from the SC State Department of Health. The number of screened newborns exceeds the number of live births in the two maternity hospitals in these years, which may be due to incomplete information, delay in updating the number of newborns on the official Brazilian birth notification websites, and newborns who were admitted to the NICU  of the sIt can be verified that UNHS coverage is efficient, according to DATAN . ResultsThe literature shows that the frequency of hearing loss is higher in newborns with RIHL ,23,36,37Another important and common RIHL is congenital infections . ConsideOur hypothesis regarding the fewer cases of congenital syphilis in 202 is that it is probably related to the public policies that increase primary prevention measures. These include the effectiveness of the multidisciplinary team and the interpretation of VDRL tests, primarily comparing exposed newborns with their mothers, after delivery.Despite the prevalence of risk indicators observed in the present study, only 1.1% of the newborns failed the hearing screening. Most of the time, no significant differences were observed between the frequencies of newborns with RIHL who failed and those who passed the UNHS, but, regarding infectious diseases, there was a higher proportion of failure in neonates when compared to neonates without infectious diseases, agreeing with findings of a previous study . HoweverThe prestigious UNHS service where this study was conducted achieved a screening coverage ≥95%.Considering all congenital infections , the prevalence of RIHL was 2.87%, with congenital syphilis being the most frequent.Newborns with congenital syphilis or HIV are more likely to fail the UNHS.The knowledge produced in this study is expected to raise awareness of health professionals’ performance in the three levels of health care, thus promoting comprehensive pediatric care, expanding access to health care, and implementing and strengthening UNHS to ensure continuity of care.


Etiological studies have shown genetic disorders to be a major cause of sensorineural hearing loss, but there are a limited number of comprehensive etiological reports based on genetic analysis. In the present study, the same platform using a diagnostic DNA panel carrying 63 deafness genes and the same filtering algorithm were applied to 10,047 samples obtained from social health insurance-based genetic testing of hearing loss. The most remarkable result obtained in this comprehensive study was that the data first clarified the genetic epidemiology from congenital/early-onset deafness to late-onset hearing loss. The overall diagnostic rate was 38.8%, with the rate differing for each age group; 48.6% for the congenital/early-onset group (~5y.o.), 33.5% for the juvenile/young adult-onset group, and 18.0% for the 40+ y.o. group. Interestingly, each group showed a different kind of causative gene. With regard to the mutational spectra, there are certain recurrent variants that may be due to founder effects or hot spots. A series of haplotype studies have shown many recurrent variants are due to founder effects, which is compatible with human migration. It should be noted that, regardless of differences in the mutational spectrum, the clinical characteristics caused by particular genes can be considered universal. This comprehensive review clarified the detailed clinical characteristics  of hearing loss caused by each gene, and will provide useful information for future clinical application, including genetic counseling and selection of appropriate interventions.The online version contains supplementary material available at 10.1007/s00439-021-02371-3. Hearing loss is an extremely heterogenous disorder, and more than 120 genes are currently considered to be implicated in non-syndromic hearing loss, making the screening strategy difficult. Targeted genome resequencing using massively parallel DNA sequencing (MPS) has become a powerful strategy for the identification of causative genes from among the large numbers of genes in rare Mendelian disorders such as deafness. This sequencing technology followed by an appropriate filtering algorithm will be able to identify rare responsible genes for individual hearing loss patients. Although genetic disorders are thought to be a major cause of sensorineural hearing loss, there are a limited number of comprehensive etiological reports based on genetic analysis. In addition, it is difficult to draw conclusions without using the same analysis platform, filtering method, and pathogenicity assessment for samples collected by the same criteria. Through collaborative study with 102 collaborative centers in Japan, over 10,000 samples obtained from social health insurance-based testing and detailed clinical data have been collected. In this paper, we not only reviewed our series of studies based on analysis by MPS conducted over the last decade, but also performed comprehensive verification using the same analytic method and criteria.Etiological studies have shown that genetic causes are the most common etiology of deafness, and approximately two-thirds of congenital/early-onset sensorineural hearing loss in developed countries is estimated to be due to genetic causes  has provided a powerful new strategy and revolutionized the elucidation of genetic defects causing monogenic disorders. We have shown that this approach is appropriate for identifying causative genes/variants and actually demonstrated that various genes/gene variants are involved in hearing loss in Japanese patients ; moderate hearing loss, 41–70 dB (n = 2746); severe hearing loss, 71–95 dB (n = 1622); and profound hearing loss, > 95 dB (n = 1660). All subjects had presumed non-syndromic sensorineural hearing loss (SNHL). The samples were obtained primarily from bilateral SNHL, but also contained 220 samples from unilateral SNHL patients. Written informed consent was obtained from all patients , and the study was approved by the Shinshu University Ethical Committee as well as the relevant bodies of the other participating institutions of the Deafness Gene Study Consortium. Clinical information and peripheral blood samples were obtained from each subject and from all their consenting relatives. This study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Shinshu University School of Medicine .The samples used in this review were as follows. With regard to inheritance mode, 2243 subjects were from autosomal dominant or mitochondrial inherited families, 6163 subjects from autosomal recessive families or sporadic cases, and 1641 showed unknown inheritance mode. Patients for whom the onset age (the age of awareness) was available numbered 3877 prelingual hearing loss (below age 6), 2698 post-lingual hearing loss (aged between 6 and 39), and 1057 late-onset hearing loss (after the age of 40) cases. Hearing levels were classified based on the better hearing ear as normal, < 20 dB; mild hearing loss, 21–40 dB (http://hereditaryhearingloss.org/), were analyzed in this study. The detailed protocols for targeted genome enrichment and massively parallel DNA sequencing have been described elsewhere , reported to be causative of non-syndromic hearing loss  allele frequency in a public database, (2) a disease-specific database, (3) variant type, and (4) in silico prediction score were used. For clinical setting and practical genetic diagnosis, a great deal of the above-mentioned information needs to be integrated and evaluated. To integrate (1)–(4), we have developed an integrated database of clinical information and genetic information from patients with genetic deafness  standards and guidelines . Further, using the criteria mentioned above, the overall diagnostic rate was 38.8% ; i.e., one causative variant in autosomal dominant or mitochondrial inheritance cases, and biallelic causative variants in recessive inheritance or sporadic cases  gene mutations causing deafness in 30–35% of cases, while the remaining cases of hearing loss are the result of various rare genes/mutations that have been efficiently diagnosed by the present sequencing and CNV detection approach , which was beneficial to survival associated with human evolution . Based on the gnomAD, in contrast to the other deafness genes where the number of “observed” LOFs (loss of function variants) is equal to that of “expected” LOFs, the number of “observed” LOFs (n = 17) in GJB2 is exceptionally high compared to that of “expected” LOFs (n = 6.5) (see GJB2 on the gnomAD home page), indicating that there was a certain benefit in having GJB2 mutations in ancient times.To determine which genes among those identified have the greatest impact on the etiology of deafness, the number of variants and variant types  were calculated. Results showed that the number of mutations in GJB2 are predominant across all ethnic groups, but there are also some exceptions as shown in Table MYO15A and TMC1 are predominant in consanguineous Egyptian families and Sephardi Jews, respectively , the number of mutated genes is somewhat limited (maximum: 57). These results converge to around 50–60 genes, even when many genes are analyzed. There probably are, however, many extremely rare genes in the various hearing loss populations.GJB2 (frequency of LOF: 76.7%), STRC (97.2%), MYO15A (44.8%), LOXHD1 (71.4%), USH2A (64.9%), and PCDH15 (75.0%). However, even in AR genes, if the founder mutation is a missense mutation, the number of LOF mutations is slightly lower; for example, SLC26A4  and OTOF . Also, CDH23 has a very low LOF percentage (9.5%), probably as mutations lead to Usher syndrome. In the case of the gene mutations in AD deafness, there are two patterns regarding variant type; (1) genes that have many missense and a low frequency of LOF mutations, such as TECTA (7.1%), WFS1 (0%), ACTG1 (0%), COCH (6.1%), and MYH9 (10.5%), and (2) genes that have a high frequency of LOF and few missense mutations, such as KCNQ4 (62.3%), MYO6 (75.9%), POU4F3 (51.3%), and EYA4 (86.3%). The mechanisms by which the mutations cause deafness are thought to differ; a dominant negative mechanism for the former and haploinsufficiency for the latter group.The present comprehensive study revealed certain tendencies in terms of variant type. In general, gene mutations in AR deafness tend to have more LOF mutations; GJB2, SLC26A4, CDH23, STRC, and MYO15A frequently observed. The diagnostic rate in the juvenile/young adult-onset group was lower than that in the congenital/early-onset group, but the responsible genes were detected in a significant portion of the patients , GJB2, CDH23, MYO6 and MYO7A were frequently found in the juvenile/young adult-onset group. The causative gene was found in only a few patients in the over 40 y.o. group   in the congenital group, compared to 52.9% (45/85) in the juvenile and young adult-onset (6–39 y.o.) group, supporting our previous results.Samples collected in a more unbiased manner from social health insurance-based testing cover a wide range of age groups and reveal the comprehensive genetic epidemiology in Japanese. With regard to age at onset, we divided the samples into 3 groups by age; congenital/early-onset (~ 5 y.o.), juvenile/young adult-onset (6–39 y.o.), and middle aged/aged-onset (40 y.o ~). The diagnostic rate was higher in the congenital/early-onset group (~ 5 y.o.)  Fig. A, with vGJB2, SLC26A4, CDH23, STRC, OTOF and MYO15A were commonly found to be the responsible genes in autosomal recessive/sporadic inheritance cases, and KCNQ4, mitochondrial m.3243A > G, MYO6, MYO7A, WFS1, POU4F3 and TECTA were frequently identified in autosomal dominant inheritance cases  out of the 220 unilateral hearing loss cases suggested that factors other than genetic factors were involved in unilateral hearing loss.The identified variants are shown in Supplemental Table S2, which shows that our series of studies revealed certain recurrent mutations, which is crucial for molecular diagnosis to allow decision-making with regard to the appropriate intervention , we concluded that the six variants were derived from founder effects as they were observed in a specific haplotype. The c.235delC variant, most frequently found in Japanese hearing loss population, was observed in countries in East and Central Asia, such as Japan, Korean, China, Mongolia, and Thailand, whereas it is rarely observed in other populations. Such an uneven distribution of this variant suggests that it was caused by a founder effect. The c.235delC variant is estimated to have first occurred at around 6500 years ago Supplementary file2 (XLSX 233 kb)Below is the link to the electronic supplementary material.


Helichrysum stoechas (L.) Moench (H. stoechas) is a medicinal plant traditionally used in the Iberian Peninsula to treat different disorders such as arterial hypertension. The aim of this study was to investigate the vascular effects of a polyphenolic methanolic extract of H. stoechas, which has high antioxidant activity, and its mechanism of action. Isometric myography studies were performed in an organ bath with rat aortic rings with intact endothelium. The H. stoechas extract produced vasorelaxation in the aortic rings that were precontracted by phenylephrine or KCl. L-NAME and Rp-8-Br-PET-cGMPS but not indomethacin or H-89; it also reduced the relaxant response evoked by H. stoechas extract on the phenylephrine-induced contractions. H. stoechas extract reduced the response to CaCl2 similar to verapamil and reduced the phenylephrine-induced contractions comparable with heparin. TRAM-34, apamin and glibenclamide reduced relaxation induced by the H. stoechas extract. The combination of L-NAME+TRAM-34+apamin almost completely inhibited the H. stoechas-induced effect. In conclusion, the relaxant effect of the H. stoechas extract is partially mediated by endothelium through the activation of the NO/PKG/cGMP pathway and the opening of Ca2+-activated K+ channels. Furthermore, the decrease in the cytosolic Ca2+ by the inhibition of Ca2+ influx through the L-type Ca2+ channels and by the reduction of Ca2+ release from the sarcoplasmic reticulum via the IP3 pathway is also involved. Since ancient times, natural products have been a valuable resource of therapeutic agents for the prevention and treatment of diseases, with many of the current and developing drugs being natural products or derivatives. These natural products have been gaining more and more popularity, being widely used by the population because of their therapeutic effects and because they are affordable .Natural products offer broad chemical and structural diversity, providing a wide range of nutrients and bioactive compounds including vitamins, minerals, fibre and phytochemical components, among others. Phytochemicals are very important from a health-promoting point of view because they are responsible for the medicinal properties of plants and act as functional components; these compounds are natural molecules derived from plants that are nonnutritive but biologically active and associated with the reduction of risk of important chronic diseases. So far, more than 5000 phytochemicals have been identified, but a high percentage remain to be isolated and identified. These compounds are obtained during the secondary metabolism of plants and are generally divided into polyphenols, terpenoids and alkaloids ,3. PolypNumerous studies support that phytochemicals have a beneficial effect on health due to their antioxidant, anti-inflammatory, antimicrobial, antiallergic, antispasmodic, anticancer, cardioprotective, neuroprotective, antidiabetic and antiobesity activity and because they maintain the homeostasis of the intestinal microbiota ,4,5. DueHelichrysum belongs to the Compositae (or Asteraceae) family and is characterized by a large number of species, approximately 500–600, that are widely distributed throughout southern Europe and Africa. Species of this genus have yellow flowers and a rich amount of secondary metabolites, which provide a great variety of bioactive properties. Within this genus, Helichrysum stoechas (L.) Moench (H. stoechas) is one of the least known. In the Iberian Peninsula, this species, commonly known as everlasting flower  is used in traditional medicine. Herbal teas of these flowers are used to treat disorders of the cardiovascular, digestive  and respiratory systems (influenza and cold) and have anti-urolithiatic and diuretic effects as well o = 50 mM). All buffers were adjusted to pH 7.4. Apamin (AP), arzanol, barium chloride dihydrate (BaCl2), glibenclamide (Glib), heparin (H), H-89 dihydrochloride hydrate, indomethacine, Nω-Nitro-L-arginine methyl ester hydrochloride (L-NAME), phenylephrine (PE), ruthenium red (RR) and verapamil (V) were obtained from Sigma .The compositions of the buffers used were as follows: Krebs buffer (in millimolar): NaCl 120, KCl 4.7, CaClTetraethylammonium (TEA), 1-[(2-chlorophenyl) diphenylmethyl]-1H-pyrazole (TRAM-34) and Rp-8-Br-PET-cGMPS were purchased from Tocris . AP was diluted in acetic acid. Glib, TRAM-34 and arzanol were dissolved in dimethyl sulfoxide (DMSO). All other chemicals were dissolved in distilled water.The care and use of animals were in accordance with the Spanish Policy for Animal Protection RD 53/2013, RD1386/2018 and RD118/2021, which meet the European Union Directive 2010/63 on the protection of animals used for experimental and other scientific purposes. All protocols were approved by the Ethics Committee for Animal Experiments of the University of Zaragoza (Spain) . Male Wistar albino rats (200–250 g) were purchased from Janvier  and were maintained with a standard feed and free access to water. The animals were euthanized by pentobarbital sodium (60 mg/Kg i.p.) followed by cervical dislocation.2–5% CO2. Tension was recorded and digitalized at a sample rate of 0.5 samples per second using a data acquisition system . An initial tension of 1 g was applied to the preparations to achieve spontaneous tone, and rings were allowed to equilibrate for 60 min with changing the bath buffer every 20 min.Myography on the rat aorta artery rings was performed as described previously . After sH. stoechas extract, methanol , arzanol and DMSO (solvent of the arzanol) were assessed, and cumulative concentration-response curves were constructed on endothelium-intact aortic rings. The vasorelaxant effect was calculated as the percentage change of precontraction to basal tone in the absence of the contractile agent.After the stabilization of spontaneous tone, PE (1 µM) or KCl (80 mM) were used to induce sustained contractions. Fifteen minutes thereafter, the effects of H. Stoechas extract was performed.To specifically measure endothelium-mediated vasorelaxation, the NO-synthase blocker L-NAME (10 µM) and the cyclooxygenase blocker indomethacin (10 µM) were added to the bath 20 min prior to the addition of PE. At stable PE-induced contraction, a concentration-response curve for the H. stoechas extract. 20 min before addition of PE (1 µM), aortic rings were preincubated with H-89 (200 nM), Rp-8-Br-PET-cGMPS (10 µM), TRAM-34 (1 µM), AP (1 µM), Glib (10 µM), BaCl2 (30 mM) and TEA . At stable contraction, the H. stoechas extract (0.3 and 1 mg/mL) was added for 15 min. The relaxant effect was compared with the response obtained by control .Next, the involvement was investigated of secondary messengers such as cAMP and cGMP and potassium channels in response to the H. stoechas extract on PE-induced contraction, the rings were preincubated with the extract or the solvent for 20 min, and a PE concentration-response curve was made. The contractile response of each concentration was compared to its control (baseline).To examine the effects of 2+ influx in relaxation to the H. stoechas extract was studied. After prior incubation with Krebs buffer, the medium was replaced with Ca2+-free Krebs buffer for 15 min and then with Ca2+-free high-K+ buffer. Then, the rings were preincubated with methanol, H. stoechas extract (0.3 and 1 mg/mL) or V (1 µM) for 15 min, and after that time, cumulative concentration-response curves for CaCl2 (10−5–10−2 M) were constructed. The responses obtained to CaCl2 in the presence of methanol served as control.The role of Ca2+, we evaluated the effect of the H. stoechas extract on the contractile response of PE (1 µM). For this, the rings were incubated for 15 min with verapamil (V) and the combination of V with RR and H before the addition of PE. Contractions were compared with controls.In order to know if the response of the extract involves intracellular CaEach protocol was performed on aortic rings from six or eight different animals.p values <0.05 were considered statistically significant. The concentration of compound that inhibited 50% of the maximal contraction (EC50) was calculated as the geometric mean with 95% confidence intervals (CI). All statistical analyses were performed and all figures were created with GraphPad Prism 6.Data are expressed as mean ± standard error of mean (SEM). Statistical significance was tested using one-way analysis of variance (ANOVA) followed by the Dunnett test (when parametric distribution is observed), Kruskal-Wallis test (nonparametric) and paired two-tailed Student’s t test, if appropriate. A two-way ANOVA was performed to assess the interaction between two variables and the effects of each one, separately. H. stoechas extract induced a concentration-dependent vasorelaxation in the PE- or KCl-precontracted rings, with EC50 of 0.49 mg/mL  and 0.87 mg/mL , respectively. However, at the maximum concentration, 3 mg/mL, the extract produced a similar relaxation in the PE- or KCl-precontracted rings (PE: 99.9 ± 1.9% vs. KCl: 95.1 ± 1.4%) (PE (1 µM) or KCl (80 mM) induced a sustained contraction over time in the rat aortic rings. The  ± 1.4%) a,b. To e ± 1.4%) a. H. stoechas extract was produced by one of its most characteristic components, an arzanol-concentration-response curve was performed (10−9 M–10−5 M) , arzanol showed the same effect as that obtained by the corresponding concentration of the solvent alone. Considering these results, arzanol was discarded as the main phenolic involved in the vasorelaxant effects, with other compounds being responsible for the observed activity.To test whether the relaxing effect of –10−5 M) c. To exc–10−5 M) c. The grH. stoechas extract on the PE-contracted rings, intact aortic rings were preincubated with the nitric oxide synthase inhibitor L-NAME (10 µM) and with the nonselective cyclooxygenase inhibitor indomethacin (10 µM). As shown in H. stoechas extract-induced vasorelaxation on rings contracted with PE. However, preincubation with L-NAME significantly inhibited H. stoechas extract-induced vasorelaxation compared with control. The maximum blocking response to the relaxing effect of H. stoechas extract by L-NAME was 30% at the concentration of 1 mg/mL (To study the involvement of endothelium-derived factors in the relaxation evoked by the  1 mg/mL .H. sotechas extract (0.3 and 1 mg/mL) in aortic rings precontracted with PE (control) and PE-precontracted rings in the presence of the protein kinase A inhibitor H-89 (200 nM) or the protein kinase G inhibitor Rp-8-Br-cGMP (10 µM). While Rp-8-Br-cGMP significantly reduced the vasorelaxation by 79.3% and 50.64% at 0.3 and 1 mg/mL H. stoechas extract, respectively, H-89 had no effect on the response.H. stoechas extract on a contractile agonist, we preincubated the rings with the extract (0.3 and 1 mg/mL) and then performed a cumulative PE curve (10−9–3 × 10−6 M). The contractile response of PE decreased in a concentration-dependent manner  receptor inhibitor heparin before the addition of PE by ≈22% (control). This response was not modified when ruthenium red was added along with verapamil. However, the addition of heparin induced a greater reduction in the contractile response to PE (31.7%). The decrease in the contractile response to PE in the presence of verapamil and heparin was similar to that produced by 3 mg/mL of H. stoechas extract (36.9%)  .+ channels in the relaxing response to H. stoechas extract was studied by preincubating the rings with various K+ channel blocking agents such as TRAM-34 (1 µM) or apamin  or selective inhibitors of Ca2+-activated K+ channels of either intermediate (IKCa) or small-conductance (SKCa): respectively, glibenclamide , an inhibitor of ATP-sensitive K+ channel (KATP); TEA (0.5 mM), a nonspecific K+ channel inhibitor; and barium chloride , a nonspecific inhibitor of inward rectifier K+ channels (KIR).The role of KH. stoechas extract at 0.3 and 1 mg/mL were inhibited by TRAM-34  and AP . Glib significantly reduced the vasorelaxant effect only at the highest concentration of extract (45.3%). In contrast, TEA and BaCl2 did not affected the vasorelaxation response of the H. stoechas extract  and the NO inhibitor, L-NAME, on the relaxant response evoked by the H. stoechas extract.We investigated possible additive effects of the combination of the K+ channel inhibitors  Moench is used in traditional medicine for the treatment of various pathologies, and especially those of the cardiovascular system. Until now, in vitro studies have shown that this plant has strong antioxidant and anti-inflammatory activities and antimicrobial capacity as well as antiproliferative and antidiabetic effects  < 8.5 nM) . In this2 and through the opening of K+ channels in the cells of the smooth muscle [2+ elicited by Ca2+ influx and from intracellular stores [In the same way as our extract, the flavonoid isoquercitrin induces both endothelium-dependent and endothelium-independent vasodilation in the arteries of the mesenteric vascular bed of rats, through the release of NO but not PGIh muscle . Anotherr stores .H. stoechas reported here remain to be elucidated in future studies.Still, the phenol or component(s), responsible for the vasorelaxation capability of 2+ in VSMCs as a result of excessive Ca2+ influx through Ca2+ channels and release from the SR; inhibition of the SERCA pump; and other impairments like modification of cytoskeletal proteins [2+ signaling and could therefore exert a cardiovascular protective effect.In phytopharmacology, polyphenols are considered beneficial for relieving harmful oxidative stress and enhanced contractility in the vasculature. This enhanced contractility caused by ROS probably relies on increased cytosolic Caproteins . It can proteins , could rH. stoechas, there are studies with other species of the same genus that suggest such cardioprotective utility. For instance, a crude aqueous extract of the root or leaves of Helicrysum ceres in rats induced hypotension and natriuresis [Helichrysum ceres leaves lowered blood pressure by producing negative inotropic and chronotropic effects in vivo experiments and evoked vasorelaxant effects in vascular tissue in isolated aortic rings involving both endothelium-dependent and endothelium-independent mechanisms [Helichrysum plicatum (500 mg/Kg/bw) and ethanolic extracts of Helichrysum graveolens (500 mg/Kg/bw) showed significant antihyperglycaemic and antioxidant activity in streptozotocin-induced-diabetic rats, possibly preventing the onset of cardiovascular pathologies [Helichrysum arenarium showed anti-atherosclerotic activities and fewer anti-inflammatory molecules [Artemisia campestris L. aerial parts showed a vasorelaxant effect on isolated rat aorta by activating the calmodulin-NO-cGC-PKG pathway and evoked a decrease in intracellular calcium by blocking VOCC channels and activating the SERCA pump. Kir, KATP, Kv and nonspecific K+ channels were not involved here [Achillea millefolium produced vasodilation through endothelium-dependent NO release by increasing cGMP levels and by calcium channel blockade [Tridax procumbens causes vasodiltation in the isolated rat aortic artery though the NO-cGMP and cAMP pathways and the dephosphorylation of MLC [Vernonia amygdalina Del. showed a pronounced vasorelaxant effect by activating the NO/cGMP and PGI2 pathways; reducing cytosolic calcium by blocking VOCC and inhibiting the intracellular release of calcium through IP3 receptor; opening K+ channels ; and activating the muscarinic and β2-adrenoreceptor pathways [Jasonia glutinosa extract produces a vasorelaxant effect by preventing increases in cytosolic calcium, mainly by blocking L-type calcium channels [Although there are no studies on the cardioprotective and vascular effects of riuresis . Moreovechanisms . The orahologies ,41. The olecules . Additioolecules . In moreved here . Anotherblockade . An aquen of MLC . An ethapathways . A Jasonchannels .Ca and SKCa channels. These signalling pathways not only play a role in endothelium-dependent vascular relaxation but also are important in neo-angiogenesis, as indicated elsewhere [H. stoechas promotes angiogenesis, particularly during tissue repair. In fact, there are already healing creams containing an extract of this plant. It is tempting to speculate that the healing effect could rely on the antioxidant and vasorelaxing properties of H. stoechas, which may help to improve blood circulation in the damaged tissue and may also help to vascularize the tissue by promoting angiogenesis.The endothelium is important for vasorelaxation and, of particular note, also for angiogenesis in tissue repair. Our extract produces vasorelaxation by activating the NO/cGMP pathway and by cellular hyperpolarization by opening endothelial IKlsewhere ,49. For H. stoechas has been shown to relax vascular smooth muscle mediated by the endothelium-dependent NO/cGMP pathway and endothelial IKCa and SKCa channels. Moreover, the extract’s relaxing actions also involves an endothelium-independent mechanism as it blocks increases in intracellular Ca2+ through the inhibition of Ca2+ influx via ROCCs or VDCCs as well as the Ca2+ release from intracellular stores through the IP3 pathway. Considering its relaxing capacity at the endothelial and smooth muscle levels, this medicinal plant could be a useful candidate for the development of herbal medicines for the treatment or prevention of hypertension and other cardiovascular pathologies.In this study, a methanolic extract of