Unilateral hearing impairment is characterized by asymmetric hearing input, which causes bilateral unbalanced auditory afferents and tinnitus of varying degrees. Long-term hearing imbalance can cause functional reorganization in the brain. However, differences between intrinsic functional changes in the brains of patients with left- and those with right-sided long-term hearing impairments are incompletely understood. This study included 67 patients with unilateral hearing impairments  and 32 healthy controls. All study participants underwent blood oxygenation level dependent resting-state functional magnetic resonance imaging and T1-weighted imaging with three-dimensional fast spoiled gradient-echo sequences. After data preprocessing, fractional amplitude of low frequency (fALFF) and functional connectivity (FC) analyses were used to evaluate differences between patients and healthy controls. When compared with the right-sided hearing impairment group, the left-sided hearing impairment group showed significantly higher fALFF values in the left superior parietal gyrus, right inferior parietal lobule, and right superior frontal gyrus, whereas it showed significantly lower fALFF values in the left Heschl’s gyrus, right supramarginal gyrus, and left superior frontal gyrus. In the left-sided hearing impairment group, paired brain regions with enhanced FC were the left Heschl’s gyrus and right supramarginal gyrus, left Heschl’s gyrus and left superior parietal gyrus, left superior parietal gyrus and right inferior parietal lobule, right inferior parietal lobule and right superior frontal gyrus, and left and right superior frontal gyri. In the left-sided hearing impairment group, the FC of the paired brain regions correlated negatively with the duration and pure tone audiometry were in the left Heschl’s gyrus and right supramarginal gyrus. In the right-sided hearing impairment group, the FC of the paired brain regions correlated negatively with the duration was in the left Heschl’s gyrus and superior parietal gyrus, and with pure tone audiometry was right inferior parietal lobule and superior frontal gyrus. The intrinsic reintegration mechanisms of the brain appeared to differ between patients with left-sided hearing impairment and those with right-sided hearing impairment, and the severity of hearing impairment was associated with differences in functional integration in certain brain regions. Hearing is an important advanced function of the human brain. The mechanisms underlying hearing and hearing disorders are very complicated . HearingThe incidence of unilateral hearing impairment increases with age. Long-term unilateral hearing impairment can lead to hearing problems, as well as behavioral and psychological deficits  . MoreoveAwareness has increased over the past decade regarding how the brain remodels itself in response to hearing impairment and the mechanisms underlying the processing and integration of auditory information; this increasing awareness is due to the development and advancement of neuroimaging technologies in auditory research, such as magnetoencephalography and functional magnetic resonance imaging (fMRI) . The comIn resting-state fMRI (R-fMRI), the amplitude of low frequency fluctuation (ALFF) and fractional amplitude of low frequency fluctuation (fALFF) reflect spontaneous activity in the brain . At low The purpose of our study was to explore differences in the intrinsic functional changes in the brain between patients with left- and right-sided hearing impairment using fALFF and FC. In this study, we hypothesized that patients with long-term unilateral hearing impairment would exhibit abnormal intrinsic functional activity in relevant areas of the brain and reconstruction of related functional networks. We also hypothesized that this would partially explain differences between patients and healthy controls. We tested this hypothesis using R-fMRI with fALFF and FC analysis. Furthermore, we analyzed the correlation between altered FC and the duration of illness and pure tone audiometry (PTA) scores in patients with left- and right-sided hearing impairments.This study included 67 patients with unilateral hearing impairments caused by idiopathic hearing loss. All patients were right-handed and aged between 28 and 54 years. Left-sided hearing impairment was present in 33 patients , and right-sided hearing impairment was present in 34 patients . Thirty-two healthy, right-handed controls, aged between 24 and 56 years, were also recruited . Patients were excluded for the following reasons: (1) congenital brain dysplasia or accidental brain trauma with structural deformation of the brain or loss of consciousness; (2) addiction or dependence on special substances ; (3) other neurological or psychiatric diseases, or somatic diseases that may lead to central nervous system dysfunction; (4) active breast-feeding or pregnancy; and (5) refusal to undergo magnetic resonance scanning. A previous study showed that cortical remodeling occurs in patients who have had unilateral hearing impairment for more than 2 years . Hence, 2, and number of excitations of 1, 34 slices, and 240 time points. The parameters of the 3D FSPGR included slice thickness of 1.0 mm, repetition time of 6.7 ms, echo time of Min Full, acquisition matrix of 256 × 256, field of view of 256 × 256 mm2, and number of excitations of 1. Participants were instructed to rest in the supine position with their eyes closed and to breathe calmly. Their heads were fixed to minimize movement, and they were provided with soft earplugs, and electrostatic headphones for both ears. They were also instructed to remain awake and not to think of anything specific.The participants underwent MRI using a 3.0T MR scanner  with a matched eight-channel phased array head coil, and parallel imaging of the brain was employed. The scan protocol included the following: (1) scout images; (2) T2-weighted images; (3) resting-state blood oxygenation level dependent fMRI with single-shot gradient recalled echo-planar echo imaging sequences (GRE-EPI); and (4) three-dimensional T1-weighted images with three-dimensional fast spoiled gradient-echo sequences (3D FSPGR). The parameters of the GRE-EPI included slice thickness of 3.5 mm, slice spacing of 0.7 mm, repetition time of 2000 ms, echo time of 30 ms, flip angle of 90°, matrix size of 64 × 64, field of view of 240 × 240 mm1 was used for data processing and analysis  was calculated, and intergroup multiple comparisons were analyzed.Fractional amplitude of low frequency fluctuation values from each voxel were obtained from preprocessed data. Differences between the left- and right-sided hearing impairment groups and the healthy controls were analyzed and compared to identify regions between the groups. These coordinates were used as the centers of 4-mm-sized spherical seed brain regions of interest (ROIs) that were created using the wfu_pickatlas tool in SPM12. First, FC analysis was performed by calculating the time serial correlation coefficients between each ROI and all the other non-ROI voxels (voxel-wise) in each participant. The t-tests were used to compare the duration of illness and PTA scores between the left- and right-sided hearing impairment groups. The chi-square test was applied to compare sex distributions. Demographic and clinical data were analyzed using SPSS .One-way analysis of variance was used to compare age and level of education among the three groups. Two-sample Post hoc tests were conducted to identify variations between each pair of groups. Intergroup comparisons of the overall FC of each brain region were conducted by independent two-sample t-tests. Multiple comparisons of FC between each pair of ROIs were performed, and false discovery rate correction was used for multiple comparison correction in the resulting data with a threshold of 0.05 . The duration of illness was comparable (P > 0.05) between patients with left-sided hearing impairment (mean ± standard deviation: 38.50 ± 12.57 months) and those with right-sided hearing impairment (mean ± standard deviation: 37.50 ± 11.72 months). There were no significant differences in the PTA of the affected ear between the left-sided hearing impairment group (mean ± standard deviation: 76.20 ± 24.28 dB) and right-sided hearing impairment group (mean ± standard deviation: 75.60 ± 23.11 dB) , left Heschl’s gyrus and left superior parietal gyrus (P < 0.001), left superior parietal gyrus and right inferior parietal lobule (P = 0.002), right inferior parietal lobule and superior frontal gyrus (P = 0.001), and left and right superior frontal gyri (P < 0.001)  .P < 0.001, r = -0.59; PTA scores: P < 0.01, r = -0.52). In the right-sided hearing impairment group, there were significant correlations between the FC of paired ROIs and duration of illness in the left Heschl’s gyrus and left superior parietal gyrus , and between the FC of ROIs and PTA scores in the right inferior parietal lobule and right superior frontal gyrus (P = 0.02, r = -0.54; In the left-sided hearing impairment group, there was a significant correlation between the FC of paired ROIs and the duration of illness, as well as between the FC of paired ROIs and PTA scores in the left Heschl’s gyrus and right supramarginal gyrus (duration: Long-term unilateral hearing impairment can lead to abnormal changes in brain function, which can lead to a variety of network abnormalities in the brain involving sensory, conductive, and cognitive functions . AwareneWe found that the left-sided hearing impairment group showed significantly higher fALFF values in the left superior parietal gyrus, right inferior parietal lobule, and right superior frontal gyrus, compared with those in the right-sided hearing impairment group; moreover, the left-sided hearing impairment group showed significantly lower fALFF values in the left Heschl’s gyrus, right supramarginal gyrus, and left superior frontal gyrus, compared with those in the right-sided hearing impairment group. Heschl’s gyrus, also known as the transverse temporal gyrus, is the primary cortical structure that processes incoming auditory information . A previOther brain regions that showed functional changes in patients with hearing impairments in this study have not previously been shown to play direct roles in auditory processing. The superior parietal lobule is associated with spatial orientation and receives visual and sensory inputs ; the infIn previous studies, altered functional activity in patients with hearing impairment has been reported in the inferior frontal gyrus, superior marginal gyrus, anterior central gyrus, and posterior central gyrus . FurtherIn the present study, the overall FC of each ROI was compared between the left- and right-sided hearing impairment groups. No differences were identified. The balance of overall connectivity strength in different functional regions of the brain might have been maintained because remodeling of the functional activity of the brain in these patients compensated for areas of the brain that were functionally damaged. Comparisons of FC between left- and right-sided hearing impairment groups showed that the paired regions with enhanced FC in the left-sided hearing impairment group were left Heschl’s gyrus and right supramarginal gyrus, left Heschl’s gyrus and left superior parietal gyrus, left superior parietal gyrus and right inferior parietal lobule, right inferior parietal lobule and right superior frontal gyrus, and left and right superior frontal gyrus. These results indicated that FC changes in these regions related to information input may contribute to remodeling of the sensory system. Furthermore, these results highlighted the role of Heschl’s gyrus in processing incoming auditory information . In addiIn patients with left-sided hearing impairment, the paired ROI that showed negative correlations with both the duration of illness and PTA scores was the left Heschl’s gyrus and right supramarginal gyrus. In patients with right-sided hearing impairment, the paired ROIs that showed respective negative correlations with duration and PTA scores were the left Heschl’s gyrus and left superior parietal gyrus, and the right inferior parietal lobule and superior frontal gyrus. The processing of auditory information is associated with sensory transmission. Therefore, we speculate that increased sensory afferent actions may accompany increased disease severity. This may explain the close relationship between disease severity and changes in the auditory information processing in patients with hearing impairment.This study had some limitations. First, the sample size was relatively small. Therefore, the validity of the statistical inferences is relatively low. Second, the noise of high-field magnetic resonance could not be completely eliminated with the earplugs and sponge pads that were placed on the head during the experiment; this may have been more obvious for the healthy control participants. Finally, we did not differentiate among etiologies for unilateral hearing impairment. In the future, we plan to increase our sample size, use etiological grouping, and eliminate the impact of noise from magnetic resonance, in order to confirm the findings of the present study.In summary, this R-fMRI study provided considerable evidence for abnormal intrinsic brain activity in patients with unilateral hearing impairment. Furthermore, our data indicated differences in the mechanism of reintegration between patients with left-sided hearing impairment and those with right-sided hearing impairment. Finally, we found that the disease severity was associated with differences in functional activity in certain regions of the brain. However, further studies are needed to explore the specific underlying mechanisms by which fALFF values and functional activity are altered in patients with hearing loss.The datasets generated for this study are available on request to the corresponding author.XX, YL, and XH acquired and analyzed the data, drafted and revised the manuscript. PL, XH, and HQ analyzed and explained the data. JL and HY revised the manuscript for extremely important intellectual content.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.


GJB2 mutation is the most common cause of genetic deafness. Many pathogenic variations have already been identified, and thus, fewer and fewer novel pathogenic variations remain to be identified. Here, we describe a novel pathogenic variation associated with dominant hereditary deafness in a Chinese family.  In this study, we examined four generations of a Chinese family (M127) with hearing loss. Temporal CT scan, complete physical examination (including skin and hair), and audiological tests were performed. Targeted next-generation and Sanger sequencing were used to identify pathogenic mutations in affected individuals.  All patients exhibited prelingual nonsyndromic sensorineural hearing loss, with severity ranging from moderate to severe. A novel dominant pathogenic variant c.205T > C (p.Phe69Leu) was identified in all patients in this family. GJB2 associated with prelingual nonsyndromic sensorineural hearing loss.GJB2 mutation is the most common cause of genetic deafness. Many pathogenic variations have already been identified, and thus, fewer and fewer novel pathogenic variations remain to be identified. Here, we describe a novel pathogenic variation associated with dominant hereditary deafness in a Chinese family.  c.205T > C (p.Phe69Leu) was identified as a novel dominant pathogenic variant of  GJB2, which encodes the gap junction protein connexin 26 (Cx26), is the most common cause of hearing loss in many populations. Pathogenic variants of GJB2 have been linked to both autosomal recessive hereditary sensorineural hearing loss (DFNB1) and autosomal dominant hereditary sensorineural hearing loss (DFNA3). Currently, more than 200 pathogenic variants have been identified, including both recessive and dominant mutations, related to nonsyndromic or syndromic deafness. For recessive pathogenic variants, differences in hotspot variants have been shown to be a characteristic of different nationalities. In contrast, there are currently 40 dominant pathogenic variants related to hearing loss or syndromic hearing loss [GJB2  associated with prelingual nonsyndromic sensorineural hearing loss in a Chinese family.Pathogenic mutation of loss DFNB and autoloss DFNA. CurrentIndividuals representing four generations of a single Chinese family (Family M217) were examined. A total of 16 family members, including 6 clinically affected with hearing loss and 10 unaffected members, were recruited in this study. Clinical information was gathered through multiple interviews with all participating members of the family. Medical history, otoscopy, physical examination, and pure tone audiometric examinations were performed for all patients. Computed tomography (CT) scans of the temporal bones of proband and his father were performed.Informed written consent was obtained from all subjects or their guardians for genetic analysis and publication. The study was approved by the Ethics Committee of Chinese PLA General Hospital. Genomic DNA was extracted from peripheral blood using a blood DNA extraction kit according to the manufacturer's instructions .The proband was tested with a panel containing 133 deafness genes, 6 mitochondrial regions associated with deafness, and 3 deafness-related microRNAs  amplification and Sanger sequencing.Homo sapiens, Mus musculus, Gorilla gorilla, Bos taurus, Rattus norvegicus, and Xenopus laevis.Amino acid conservation was evaluated using the HomoloGene database with the sequences of http://swissmodel.expasy.org).Amino acid changes within different protein domains were examined using the National Center for Biotechnology Information (NCBI) Conserved Domain Database. Three-dimensional models of human wild-type and mutant sequences were constructed with the program SWISS-MODEL (A family tree of family M217 is shown in One patient (II : 6) did not undergo a hearing test for this study although her son (III : 5) reported that the patient had hearing loss from childhood. In the absence of direct physical examination, medical records were investigated, revealing that a hearing test had been performed for this patient 10 years prior, demonstrating sensorineural hearing loss in the range of 60–70 dB nHL. Although the patient had been able to communicate normally with the use of hearing aids, her hearing ability gradually decreased over time, and hearing aids were no longer effective. Patient I : 2 also reported hearing abnormalities from childhood and was unable to communicate normally although no hearing test was performed. Based on these findings, it was concluded that all six affected members experienced prelingual nonsyndromic sensorineural hearing loss, with the degree of hearing loss ranging from moderate to severe.No obvious abnormalities were observed in temporal bone CT of patients III : 5 and IV : 2. No skin phenotypes or other systemic abnormalities were identified through physical examinations.GJB2. These variations were sequenced and verified by family members. Finally, two variations were identified in GJB2. The first variation, c.205T > C, conferred a phenylalanine to leucine substitution (p.Phe69Leu), whereas the second variation, c.109G > A resulted in a valine to isoleucine substitution   . The twoGJB2 variant analysis was performed in seven other family members, including three affected and four unaffected individuals, using Sanger sequencing , nor was it detected in the 600 individuals with normal hearing included in this study  , in It has been controversial about the relationship between c.109G > A variation and the hearing phenotype, but most viewpoints supported c.109G > A was a pathogenic variation. In the case of homozygous or compound heterozygous variations (c.109G > A and the other variations are located on different chromosomes), it was associated with a broad spectrum of hearing phenotypes, ranging from severe-to-profound hearing loss to normal hearing and from congenital onset to delayed onset –10. In tGJB2 c.205T > C (p.Phe69Leu) causes hearing impairment in this family. This study represents the first report of this dominant pathogenic variation in GJB2.These data, together with the clinical presentation of the affected siblings and consistent autosomal dominant inheritance of the mutations in the affected and unaffected members, indicate that Including the variation reported in this study, a total of 41 dominant pathogenic variations have been identified to date. Among these variations, 20 mutations are specific for deafness, whereas the remaining 21 are associated with deafness as well as other symptoms. This includes 10 variations associated with keratitis-ichthyosis-deafness syndrome, three variations associated with Vohwinkel syndrome, and eight variations associated with deafness and palmoplantar keratoderma . HoweverIn this study, patients harboring the c.205T > C variation showed prelingual deafness without other abnormalities, with a progressive decline in hearing ability over time. However, given the variability seen with other mutations, as more and more patients with the c.205T > C variation are found, phenotypic variations may also be found, such as in patients with postlingual deafness or other systemic abnormalities. Long-term follow-up of family M217 will be necessary to monitor the effects of this novel mutation on hearing loss.c.205T > C is a novel dominant nonsyndromic pathogenic variation associated with prelingual deafness. More cases are needed to determine whether other abnormalities may be caused by this mutation.


Papio spp), knowledge about the nature of grooming interactions and their regulation is generally lacking for the large, terrestrial species of mandrills (Mandrillus sphinx). We used a combination of social network analysis tools and well-established methods for assessing partner diversity and reciprocity to characterise grooming networks, partner choice and patterns of trade  among females in a captive group of mandrills, both within and across two separate observation periods. Our results suggest that, even though the relatively stable conditions of captivity allowed the studied females to maintain selective grooming interactions across time, small scale demographic changes affected the grooming dynamics of the group in accordance with the expectations of the Biological Markets theory. In particular, the maturation and consequent integration of a high ranking female into the group’s grooming network from one period to the next resulted in a more pronounced effect of rank on the regulation of grooming interactions. In addition, the influence of the maturation of a dependent infant on the grooming interactions of his mother were evident between periods. Our results also demonstrate that grooming networks are dynamic and that high ranking individuals are not necessarily the most central in grooming networks. Finally, we discuss the potential of social network analysis to identify cases of social exclusion and its consequences for captive management.A large body of evidence suggests that female Old World monkeys maintain selective long-term grooming interactions with fitness benefits. The last two decades have produced evidence that the regulation of social interactions among primates can be, in part, explained by the Biological Markets theory, with grooming behaviour as the focus of these studies. Grooming facilitates bonding between individuals, constituting an essential part of the regulation of social relationships among female cercopithecids. In contrast to the well-studied baboons ( Papio ursinus, Kerr, 1792), for example, engaging in stable focused grooming networks buffered their reaction to various external stressors  the highest ranking females are the most central in the grooming network.First, we use SNA to characterise the group’s grooming network within each period in order to understand how and if the grooming dynamics of the group changed from one period to the other in the light of demographic changes. Based on the results of the social network analysis conducted by (2) females engage in grooming interactions with only a few preferred partners, and partner choice is significantly maintained across observation periods, in common with prior studies on cercopithecoids (We predict that thecoids . The con(3) grooming is reciprocally traded in the studied colony. To allow for comparability with other studies on Old World monkeys, we investigated the levels of reciprocity both within and across grooming bouts.We predict that, even if grooming is traded for other commodities, it constitutes a valuable commodity on its own for captive female mandrills, and thus that, overall, (4) individuals that groom each other more are more socially tolerant of each other . Again based on the premise that primates trade grooming in a market place, with higher ranking individuals receiving grooming in exchange for other rank-related commodities, we predict that (5)grooming is directed up the hierarchy and that (6) higher ranking individuals receive more grooming than do lower ranking individuals  grooming is more reciprocally traded by individuals that occupy closer positions in the hierarchy than by individuals whose rank is further apart.We also examine the effect of rank on the trade of grooming in a market place, because, when primates trade grooming for other commodities, these exchanges are monopolised by higher ranking individuals . Due to Data were collected in a zoological park whose non-human primates are fully habituated to the presence of human individuals. Permission to conduct research was provided by the park’s Animal Department and, because data collection consisted only of observations of the colony with no direct contact or interventions with individuals, no further ethics approval was required. All procedures in this study were performed in accordance with the European law on humane care and use of laboratory animals and the ASAB guidelines for the observation of animals .period one, Nefertari had given birth to a male infant, who was still dependent on her for milk and transport during period one. Between periods, the number of mature females increased due to the maturation of Tania, and the total number of individuals of the colony changed due to the birth of Mogli. Lolaya gave birth to Mogli more than 15 weeks after we finished collecting data in period one, indicating that she was pregnant during period one in spite of being under contraception.The studied colony of mandrills was housed in the Badoca Safari Park, Herdade do Badoca, Setúbal, Portugal (38°02′26.5′N8°44′35.8′W) and consisted on 12–13 individuals. The sex, age, reproductive status and birthplace of all members of the colony were known see . The 6–7ad-libitum. Data were collected only in the outdoor enclosure, where the colony had approximately 1,674 m2 of available space with various enrichment devices. The indoor enclosure had an approximate size of 75 m2.Zookeepers distributed vegetables, fruit and seeds in the outdoor installations before letting the group out in the morning, and a mixture of vegetables, fruit and monkey chow in the indoors installation before the mandrills returned inside in the afternoon. Water was available period one, and 10.5 h in period two. Each sample was of 15 min duration, and the timing and duration of all behaviours by the focal individual were recorded. When interactions between the focal individual and other individual(s) occurred, the identity of the actor(s) and recipient(s) of the interactions(s), as well as its duration, were recorded. Observations were equally distributed across all individuals. The order of observation of focal individuals was randomly decided for each day of data collection to avoid time-specific skews in observations. 10 × 20 binoculars were used.A total of 96 h of observations were collected on the colony of mandrills between the 26th of May and the 1st of July of 2016 (period one), and a further 73.5 h were collected between the 26th of January and the 8th of February of 2018 (period two). Because the subjects of the study were in a controlled environment, we expected no seasonal difference in behaviour. Data were collected through individual focal samples  with 16 period one was based on 386 observed instances of supplant and avoidance and 33 instances of aggression/submission, whereas the hierarchy for period two was based on 619 supplants and avoidances with the addition of 43 aggression/submission interactions. The colony’s hierarchy was determined by calculating each individual’s average dominance index  of dyadic supplant and avoidance interactions, supplemented with a small number of aggressive and submissive interactions. Approach-retreat interactions allow for unambiguous observation of dominance display over the supplanted individual, which is not always the case when aggression results in redirection or coalitions . The domce index  and by oIn order to characterise the grooming network and structure of the group, we first conducted descriptive analyses. For each period we organised the total duration that each individual spent grooming another , we used the symmetric matrices to calculate centrality measures for each individual, including: degree ; reach centrality ; eigenvector centrality , and betweenness . These centrality measures allow us to evaluate the integration , social centrality/ power  and connectivity (measured by betweenness) of each female in the grooming network  so that significant positive relationships indicate that higher ranking individuals are more central and vice-versa. Finally, as a descriptive test to investigate how individual levels of centrality varied across periods, we used Spearman rank correlation tests to correlate the centrality values of all females present in both periods. We calculated all centrality measures with Ucinet 6 , we calculated the diversity of grooming partners for each female of the colony within both period one and two through the standardised Shannon–Weaver index , we constructed a directed binary matrix for each period where, for each female , “1” corresponded to all females groomed by her and “0” to all other females; and correlated them with each other through the tau Kr matrix correlation test .To test if partner choice was maintained across periods , we selected all grooming bouts where both members of the dyad groomed each other . We classified each participant in a grooming dyad as Groomer  and Reciprocator (the one who reciprocates grooming) and regressed the log-transformed duration of grooming directed from the Reciprocator towards the Groomer on the log-transformed duration of grooming directed by the Groomer to the Reciprocator (prediction 3), we used the tau Kr test to correlate matrices of grooming given and received , we tested for a correlation between the directed grooming matrix and an aggression, supplant and avoidance matrix using the tau Kr test , we calculated both the expected and the observed proportion of grooming that each female directed to higher ranking females and investigated whether there was a significant difference between these values for both grooming frequency and duration (based on prediction6) we divided the amount of grooming that each female received by the amount of grooming she gave  and compared these using Spearman’s rank correlation against female dominance rank (prediction 7), we calculated an index of reciprocity for each dyad  and 0 . We then constructed a symmetric matrix with each dyad’s value of the gRI and used the tau Kr test  to correMatrix permutation tests and the average dominance indices were calculated using the MatrixTester add-in for Microsoft Excel 16 . All other statistical analyses were conducted using Minitab 18 . All reported probabilities are two-tailed.period one, we observed grooming between 7 out of 15 possible dyads (46.67%) with one unidirectional partnership, in a total of 12,715 s of grooming distributed across 225 grooming bouts. In period two, we observed grooming between 9 out of 21 possible dyads (42.86%) with three unidirectional partnerships, in a total of 9,202 s of grooming distributed across 256 grooming bouts. In period two, Nefertari, the lowest ranking female, was not observed grooming or being groomed by any female. She died 10 days after we finished collecting data of a cardiopulmonary arrest and her autopsy found no indication of infection.In The dominance hierarchy changed between periods . In periperiod one, we identified a significant group structure with two clusters of three individuals each  or proximity in dominance rank . For period two, we also identified two clusters, one with two individuals and the other with four  or proximity in dominance rank .The grooming networks for periods one and two are represented in prediction 1 as, apart from a significant positive correlation between higher rank position and higher degree , reach centrality  and betweenness  in period two, there was no correlation between rank and any other centrality measures for period one  or period two . Individual centrality measures .Our results provide only limited support to our measures  for periprediction 2. In period one, the six mature females groomed only between one and three other individuals each, and grooming diversity index values were low (H′): mean = 0.299 ± 0.06; period two, the focal females groomed between zero and three other females and grooming diversity index values were also low (H′): mean = 0.317 ± 0.08; Kr = 0.576, N = 6, p = 0.006).The results provide strong support to period one  and period two , justifying our procedure of summing the given and received matrices for the grooming network analyses . However, given repeated hypotheses, when we corrected the expected probability to 0.025, prediction 3 was only partially supported. Within bouts, the effort put by the Groomer was not significantly reciprocated in period one , but was in period two . In period one, when bouts of immediately reciprocated grooming were excluded, there was reciprocity in grooming given and received across all grooming bouts of all dyads . In period two, the results for grooming frequency were similar ; however, grooming effort was not reciprocally traded when we excluded all instances of immediately reciprocated grooming .When all data were included in analyses, grooming was reciprocally traded in both period one: tau Kr =  − 0.209, N = 6, p = 0.020; period two: tau Kr =  − 0.531, N = 6, p = 0.005), confirming our prediction that females who groomed each other more were more tolerant of each other (prediction 4).We found a significant negative correlation between given and received grooming effort and given and received aggression, supplants and avoidance for both periods . In period two, 78.93% of total grooming effort and 60.94% of total grooming frequency was directed up the hierarchy. The difference between the observed values and the expected values was significantly greater than zero , and thus, significantly more grooming than expected was directed up the hierarchy.In ractions , we exclprediction 6 in period one, as we did not find evidence that high ranking females received more grooming than low ranking females . However, social rank affected the levels of received grooming in period two, with higher ranking females receiving more grooming than lower ranking females , partially confirming our prediction.We did not find support for prediction 7 as there was no relationship between proximity of ranks in the hierarchy and level of reciprocity in period one  or period two .Finally, we found no support for Primate social networks are dynamic, and the extent to which they remain stable over time and how long it takes for them to stabilise after change remains unclear . Due to period one, SNA indicated that the group was divided in two clusters, representing the low ranking branch and the high ranking branch of the matriline. Lisala and Lolaya’s partnership played a central role in connecting the network as theirs was the only partnership connecting both clusters , the most powerful individual was a high ranking female. Thus, regarding the effect of rank on the levels of centrality (prediction 1), it is clear that rank had a bigger influence in period two than in period one. Further supporting this observation, Mirinda (fifth in the rank in both observation periods), who was the most powerful individual in period one, was integrated in the network of period two only by a weak unidirectional partnership with Camila; and Nefertari (last in the rank in both periods) was totally excluded in period two.The SNA was useful to characterise the grooming network of the group within each period and to contextualise the individual partnerships at the group level. In clusters . Indeed,grooming . ContrarSNA-based studies in mandrills are still rare  and abseprediction 2), despite some variation in the dyads observed across periods, females had clear preferences within each period when it came to choosing their grooming partners, and partner choice was significantly maintained across periods, supporting the proposal that grooming only some specific individuals is a common strategy across Old World monkeys , our results for the immediacy of reciprocation of grooming in period one and the overall maintenance of partner choice across periods suggest that an emotional bookkeeping mechanism might have, in fact, been regulating the grooming interactions of the studied group. Our findings for period one replicate those obtained by period two are contrary to those of period one; however, it is likely that the positive emotions that contribute to the bookkeeping mechanism result from all interactions between individuals  was complex; the observed lack of reciprocity in the trade of grooming time across bouts in period two suggests that there was a stronger effect of rank on grooming trade in this period, associated with the inclusion of Tania into the hierarchy. With unbalanced dominance relationships, grooming given by higher ranking individuals is more valuable than that given by lower ranking individuals , the grooming trade model predicts that higher power differentials potentiate the trade of grooming for rank-related commodities  and the highest ranking females (Finally, our findings also have implications for the welfare and management of captive groups of primates. SNA tools provide useful insights regarding the cohesion of captive groups and have often been used to evaluate individuals’ well-being, establishing a basis for informed decision making in the management of captive groups  while al females , died frHere, we characterised the grooming interactions of female mandrills regarding three of its main aspects: grooming network, partner choice, and the trade of grooming in a marketplace. Even though not all our predictions were fully supported, our results provide evidence of how grooming interactions are regulated among the females in a single matriline of mandrills. Overall, our results suggest that female mandrills engage in grooming interactions with only a few partners, who are mostly maintained across time when demographic conditions remain relatively stable, that those interactions can be explained by the BMT and that grooming may be traded for social tolerance. Furthermore, we characterised how the presence of a dependent infant influenced its mother’s grooming interactions, and our results suggest that the predictions of a grooming-mediated baby market may also apply to groups of mandrills. Our results also suggest that the sexual maturation of a female increased the effect of rank on the observed patterns of grooming, supporting the BMT’s prediction that a higher rank differential between top ranking and low ranking individuals leads to overall unbalanced grooming interactions. Finally, we emphasise the potential of social network analysis to investigate the welfare of captive groups of mandrills, and particularly to identify cases of social exclusion. Due to the captive setting of the studied group, the small sample size and our focus on females, our capacity to generalise the obtained results to wild groups is limited. However, given that mandrills are very difficult to follow in the wild , that th10.7717/peerj.6332/supp-1Data S1Click here for additional data file.


Clinically, asthma in children under 5 years old is under estimated because lack of diagnostic criteria. The current study was, therefore, designed to identify the predicting factors for recurrent wheezing in infants.One hundred forty-five infants under 3-year old hospitalized with respiratory diseases were enrolled into this study. Patients were followed up for one-year period after being discharged from the hospital and were, then, divided into recurrent wheezing group and non-recurrent wheezing group based on whether there was recurrent wheezing or not. Wheezing or recurrent wheezing was specifically monitored in addition to blood tests for allergic and respiratory diseases.P < 0.05); the percentage of blood eosinophil and serum eosinophil-derived neurotoxin (EDN) concentration at admission were also higher in recurrent wheezing group than in control group . Multivariate logistic regression analysis on eosinophil count and serum EDN concentration in predicting recurrent wheezing revealed that the eosinophil count showed the lowest sensitivity (51.6%) and highest specificity (90.4%), with the area under the ROC curve (AUC) of 0.752 ± 0.041; and that, in contrast, the serum EDN showed the highest sensitivity (88.7%) and lowest specificity (56.6%), with AUC of 0.795 ± 0.037.The prevalence of eczema and respiratory syncytial virus (RSV) infection were significantly higher in recurrent wheezing group than in control group (74.2% vs 45.8%; 32.3% vs. 13.3%, respectively, both Combination of eosinophil count and serum EDN measurement may be better to predict the risk of recurrent wheezing in early life of childhood. Wheezing in young children is a common clinical symptom of pediatric respiratory system disease, which is characterized by the expiratory phase from the chest with a continuous and sonorous voice, but sometimes also appear in the inspiratory phase, leading to increased breathing rate . A prospRespiratory tract virus infection, especially respiratory syncytial virus (RSV), may cause symptomatic wheezing and asthma exacerbations , 6. SympEosinophil contains cytotoxic granule proteins, such as eosinophil cationic protein (ECP), eosinophil peroxidase (EPO), and eosinophil-derived neurotoxin (EDN), they are all major basic proteins (MBP). EDN, a single-chain polypeptide with a molecular mass of 18.6 kDa, has been considered to be involved in the recurrent wheezing and asthma development in later life . EDN expBecause of the complexity of recurrent wheeze in children, therapy choice for preventing severe exacerbation of asthma and episodic attack of wheezing is largely variable , 19. In Total 145 infants, who had various degree of wheezing and were hospitalized into the Internal Medicine Department, Tianjin Children’s Hospital from October 2015 to January 2016, were enrolled consecutively into this study. These patients were followed up for 1-year period after being discharged from the hospital. If the patient had at least 4 times wheezing within 1 year, it was defined as recurrent wheezing. Wheezing or recurrent wheezing was specifically monitored during the follow-up period.Inclusion criteria: 1). Age was 3 years old or younger. 2). Patients were hospitalized with wheezing, which was detected by a physician through physical examination, and diagnosed as bronchiolitis, asthmatic bronchitis or Bronchial pneumonia. 3). Patients were not treated with steroid or leukotriene receptor antagonists 1 week before the enrollment.Exclusion criteria: 1). Congestive deficient of bronchus and lung, primary or secondary airway stenosis, congestive heart disease, gastroesophageal reflux disease, bronchial foreign body. 2). Cancer or malignant diseases. 3). Primary or secondary immune deficiency or other immune-associated diseases. 4). Refuse to sign the consent or could not complete the follow-up examination due to either failed to show up or went to other hospitals.General information: gender, age, dwelling area (urban or countryside), full-term or pre-term (< 37 weeks) delivery, vaginal delivery or C-section, first child or not, days of hospitalization, eczema, and drug allergy.History of respiratory or other major disease, family history of asthma, allergic rhinitis or other allergic diseases.Recurrent wheezing or not during the 1-year follow-up.Blood samples were collected at admission and the following laboratory tests were done in all of the patients: serum total Ig E, antigen-specific Ig E, food allergy Ig G, serum EDN, blood cell count, serum antibodies to the airway pathogens , virus in nasopharynx fluid including influenza A and B, adenovirus, respiratory syncytial virus, and para-influenza type 1–3.Chest X-ray and CT, electrocardiogram, and echocardiography were also obtained in order to exclude potential causes of wheezing such as pneumonia, lung cysts, or tracheobronchomalacia.t test. Continuous data with non-normal distribution was expressed as median and quartile  and analyzed with Wilcoxon two samples test. Categorical data were expressed as frequency and analyzed with Chi square examination. A receiver operating characteristic (ROC) curve was plotted with the predicting factors of recurrent wheezing and value of area under the ROC curve (AUC) as well as Somers’ D were calculated. Optimal cutoff point was applied when Yuden Index achieved maximum. Mann-Whitney method was used to compare variable parameters that predict area under the ROC. After establishing a model of logistic regression, stepwise regression was performed to screen potential risk factors for recurrent wheezing. P < 0.05 was considered as significant.Data were analyzed with SAS 9.3 software. Distribution normality of continuous data was examined by Kolmogorov-Smirnov methods before the comparison. Data with normal distribution was expressed as mean ± SD and analyzed by Total 62 infants  with recurrent wheezing (as recurrent whoop group) were hospitalized for a median of 6 4,11) days, 40 of whom were living in urban; while 83 infants  without recurrent wheezing (as control group) were hospitalized for a median of 5  days, 52 of whom were living in urban . However, there was no significant difference in drug allergy between the two groups .Interestingly, prevalence of eczema was significantly higher in the infants with recurrent wheezing compared with those without recurrent wheezing . Specifically, prevalence of respiratory syncytial virus (RSV) infection was significantly higher in the infants with recurrent wheezing compared with the infants without recurrent wheezing . Differences of other pathogens including mycoplasma and influenza virus infection were not significant . In addition, C-reactive protein (CRP), ferritin, white cell count (WBC), lactate dehydrogenase (LDH), procalcitonin (PCT), and γ-globin were slightly, but not significantly, higher in the infants with recurrent wheezing than those in the infants without recurrent wheezing (Table The infants with recurrent wheezing showed significantly higher number of eosinophil and concentration of eosinophil-derived neurotoxin (EDN) compared with the infants without recurrent wheezing  of 1.040 , P < 0.001; eczema with OR (95% CI) of 4.313 , P = 0.004; and RSV infection with OR (95% CI) of 3.481 , P < 0.028.As shown in Table P < 0.001, Table P < 0.001, Table P < 0.001, Table P = 0.01, Table The value of the risk factors to predict recurrent wheezing was further analyzed by logistic multivariable regression and by receiver operating characteristic (ROC) curve. As presented in Fig. Recurrent wheezing and/or asthma are common chronic respiratory disease in children. In the current study, children at age of 3 years old or younger, who were hospitalized with wheezing, were followed-up for 1 year to analyze factors that may predict recurrent wheezing. Our results showed the four parameters of eczema, RSV infection, eosinophil count and EDN were all significantly higher in infants with recurrent wheezing than that in infants without recurrent wheezing, strongly suggesting they were the risk factors related to recurrent wheezing. Furthermore, EDN reached a better AUC of 0.795 and 0.752, even though the sensitivity of eosinophil count and the specificity of EDN were only 0.516 and 0.566, respectively. Thus, the combination of eosinophil count and serum EDN quantification may be served as one of the biomarkers to predict the recurrent wheezing in clinical practice.P = 0.003) of the treated and untreated groups, respectively [Several recent studies have reported that respiratory infections in infants or early in life may have profound impact for the development of respiratory diseases including wheezing and/or asthma , 20, 21.ectively . ConsistAllergic diseases may share common mechanisms in the pathogenesis , 26. In Eczema is a very common skin chronic inflammation in infancy, characterized by redness, itchiness and/or dryness. Although the infants with eczema may more frequently develop into allergies and asthma, correlation of eczema and recurrent wheezing in infants has not been thoroughly studied. It was found that among children within 1-year-old age, the correlation between allergy and eczema was strongest, and the correlation between allergy and asthma and rhinitis began at age 3 and gradually lasted until age 16 . Zinelli10) increased the risk of asthma in preschoolers, particularly in low birth-weight infants. Secondly, atopic sensitization to aeroallergens is well-recognized as a risk factor for the subsequent development of recurrent wheeze (and asthma) [We realized there were some limitations in the study. Firstly, the potential effect of environmental factors, such as parental smoking and air pollution, on recurrent wheezing was not assessed. In this regard, recent longitudinal studies have investigated potential associations of the onset of childhood wheezing illnesses with prenatal exposures including parental smoking, outdoor air pollution, and maternal stress on childhood wheezing illnesses –38. In a asthma) . Status The current study assessed potential predicting factors for the recurrent wheezing in children 3 years old or younger. The prevalence of respiratory syncytial virus (RSV) infection, the eosinophil percentage and serum level of eosinophil-derived neurotoxin (EDN) were the predominant risk factors and could be used to predict recurrent wheezing in infants. Of the three factors, eosinophil count showed the lowest sensitivity but highest specificity, and in contrast, the serum EDN showed the highest sensitivity and lowest specificity. Thus, combination of eosinophil count and serum EDN measurement may be better to predict the risk of recurrent wheezing in early life of childhood.


Previous studies showed that one of the complications of rheumatoid arthritis disease was auditory disorder. The goal of the present study was to compare the auditory status in patients with rheumatoid arthritis and healthy individuals.In the present case-control study, 30 normal persons and 60 persons with rheumatoid arthritis with mean age of 46.72 and standard deviation of 6.76 of both genders were appraised using pure tone audiometry, tympanometry and speech audiometry. The mean disease duration in patients with rheumatoid arthritis was 12.51±6.09 years.The frequency of hearing loss in rheumatoid arthritis group was significantly more than the control group (p=0.001). All patients had sensorineural hearing loss. Only in 5% of rheumatoid arthritis group, abnormal tympanometry (as type) was reported. Speech discrimination score analysis showed significant difference between the patients with rheumatoid arthritis and controls. In terms of hearing threshold level, the mean hearing threshold level  of the patients with rheumatoid arthritis was significantly higher than control group in both ears (p<0.05). A positive significant correlation was found among mean hearing threshold level in 4000 and 8000 Hz frequencies and rheumatoid arthritis duration in both ears.The frequency of hearing loss and the average hearing threshold in RA patients were higher than healthy individuals. The most common type hearing loss is sensorineural. Rheumatoid arthritis (RA) is a systemic long-lasting inflaming illness that impacts roughly 1% of the global people and is specified by fervor of the synovial coats of diarthrodial joints, which result in oncoming demolition of articular and periarticular textures . It is aAccording to the results, individuals with RA did not display any objective hearing threshold dissimilarity from subjects deprived of RA . HoweverSince the relationship among RA and hearing impairment is as again argumentative, 15, 16 On the other hand, in this study with the establishment of age limits, the elimination of presbycusis was achieved for the first time in Iran. In this study, based on previous similar study, 30 normal individuals and 60 patients with RA were evaluated. Normal individuals and patients with RA were selected from cases attending a rheumatology clinic at Ayatollah Rouhani Hospital, Babol.The patients with RA were not included in the study if there was any history of hearing aid use, familial hearing loss, neurological problems, congenital head and neck anomalies, convulsions, epilepsy, head trauma, ototoxic medications, brain surgery and RA more than 5 years according to medical records. In an age-matched control group, besides the mentioned items, absence of RA was also confirmed by a skilled rheumatologist. All patients and volunteers gave informed consent and this research was conducted with the approval of the Ethics Committee of Babol University of Medical Sciences. First, a comprehensive case history was gathered by an expert researcher via a definite questionnaire, covered the demographic, socioeconomic and clinical specifications of the study population, in the Otolaryngology Clinic of Ayatollah Rouhani Hospital. Then a thorough ENT inspection was done for every contributor with specific stress on hearing discontents. Otoscopic inspection was performed to examine the ear canal, cerumen, and healthy eardrum at the Otolaryngology Clinic of Ayatollah Rohani Hospital. If there was a cerumen, cleansing was done. Then audiological valuation was carried out in a sound-proof room and included evaluation of pure tone audiometry, speech audiometry and tympanometry was applied to all patients and controls via skilled audiologist who was sightless to the study group contributor. Pure tone audiometry was performed to check each person’s hearing status at frequencies of 250,500, 1000, 2000, 4000 and 8000 Hz using an ASTRA audiometer and TDH39 headphone. Hearing was accepted as abnormal if the hearing threshold was higher than 20 dB at each frequency. Speech audiometry included SRT and SDS using dissyllabic and monosyllabic words respectively, was also performed/evaluated. Tympanometric tests were performed to determine tympano-ossicular chain compliance and middle-ear pressure with a Zodiac (Madsen) impedance audiometer at a probe tone frequency of 226 Hz. Statistical analysis was conducted by SPSS 18 statistical software at significance level of p<0.05. Since the data distribution was normal, Pearson correlation coefficient, one way ANOVA, t-test and chi square were used for statistical analysis. .Our study was conducted on 60 patients with RA  with a mean age of 47.20 and standard deviation of 7.43 and 30 normal individuals  with mean age of 45. 76 and standard deviation of 5.17 years, aged between 18-60 yearsThe basic information of the control group and the group of people with RD showed frequency of hearing loss in rheumatoid arthritis group was significantly more than the control group (p=0.001) and all of whom showed a SNHL. The mean threshold value for both ears of the patients with RA and the controls were compared . A statistically significant difference was found between the average of hearing thresholds of both ears in the two groups.s tympanogram) was observed, 2 of whom showed bilateral As type, whereas 1 patient showed a unilateral as type. All persons in the control group showed normal tympanogram. As shown in In 3 (5%) patients of the RA group, an As-type tympanogram  , Lobo et al. (2016) , Rahne et al. (2017) , Galarza-Delgado et al. (2017) and Ahmadzade et al.’s (2017) studies which demonstrated no significant difference between the stiffness of ossicular chains and RA , Lobo e-30 .In 2. Accordingly, audiological assessment should be considered in routine evaluation of patients with RA, to prevent hearing-related handicap. In conclusion the present study showed that the frequency of hearing loss in rheumatoid arthritis group was significantly more than the control group


Age related hearing loss (presbycusis) is one of the most common sensory deficits in the aging population. The main subjective ailment in the elderly is the deterioration of speech understanding, especially in a noisy environment, which cannot solely be explained by increased hearing thresholds. The examination methods used in presbycusis are primarily focused on the peripheral pathologies , with only a limited capacity to detect the central lesion. In our study, auditory tests focused on central auditory abilities were used in addition to classical examination tests, with the aim to compare auditory abilities between an elderly group  and young controls  with clinically normal auditory thresholds, and to clarify the interactions between peripheral and central auditory impairments. Despite the fact that the elderly were selected to show natural age-related deterioration of hearing (auditory thresholds did not exceed 20 dB HL for main speech frequencies) and with clinically normal speech reception thresholds (SRTs), the detailed examination of their auditory functions revealed deteriorated processing of temporal parameters  which was partially responsible for the altered perception of distorted speech . An analysis of interactions between peripheral and central auditory abilities, showed a stronger influence of peripheral function than temporal processing ability on speech perception in silence in the elderly with normal cognitive function. However, in a more natural environment mimicked by the addition of background noise, the role of temporal processing increased rapidly. The goal was to improve characterization of age related hearing changes and its specific parameters at different levels of the auditory system in a group of elderly participants with normal hearing by a range of detailed auditory tests. Our battery of tests included examination of the processing of temporal auditory information, its relation to the processing of distorted speech and the possible interactions with cognitive abilities. In clinical practice, elderly patients quite commonly emerge with normal or close to normal hearing thresholds and complain of hearing difficulties related to speech processing, especially in background noise. These deficits cannot be explained by increased hearing thresholds and suggest a central component of the hearing pathology. We hypothesize that even healthy elderly subjects with minimal peripheral pathology and normal cognitive function will display some degree of supracochlear dysfunction, especially in their ability to process temporal parameters of sound.Fifty-six participants were examined in this study; 28 elderly participants  between the ages of 64–79 (mean age 70.4) and 28 young participants (10 men and 18 women) between 17 and 29 (mean age 24.36) were used as controls (young). The elderly participants included in this study had to meet the following criteria: age above 64 years, no subjective hearing loss, auditory thresholds not exceeding 25 dB on speech frequencies. All of the examined participants declined any previous otologic surgery: vestibular lesion, tinnitus, chronic exposure to loud noise, severe head trauma, lesion of the facial nerve, disorder of the cervical spine or had self-reported a central nervous system disorder. None of the participants were musical professionals, but several in the elderly group played musical instruments sporadically. An otoscopic examination, with removal of the cerumen and confirmation of an intact tympanic membrane, was performed on all of the participants. The examination procedures were approved by the Ethics Committee of the University Hospital Motol, in Prague. All participants signed written informed consent.via Sennheiser HDA 200 high-frequency audiometric headphones connected to a Madsen Orbiter 922 clinical audiometer. In the case of pure-tone audiometry, the tonal stimuli were generated by the audiometer. In the remaining tests, the signals were either played from a CD or generated by an external generator and routed to the audiometer. The measurements that related to temporal processing employed a custom-made gating device inserted between the signal generator or CD player and the audiometer.All acoustic stimuli, except for pure tone audiometry, laterogram and otoacoustic emission (OAE), were presented so that the same signal was delivered simultaneously to both ears. Apart from the measurement of OAEs, acoustic signals were delivered via USB from a standard PC using custom-made software. Each channel is provided with an attenuator (1 dB step) and variable rise/fall gating with a variable time shift between channels. The parameters can either be set manually or dedicated software modules can be used for the specific measurement tasks .The gating device provided click generation, white noise generation, precise gating of the input signal (used in the gap detection task and the gated speech task), and also a mutual temporal shift of the two auditory channels (used in the laterogram task). The gating device is equipped with two separate audio channels controlled by a PIC18F4550 controller and operated The audio equipment was calibrated using the Brüel and Kjær 2231 sound level meter and Brüel and Kjær 4153 Artificial Ear equipped with Brüel and Kjær 4134 pressure microphone. The pure tones were calibrated according to ISO 389-5, ISO 389-8. Clicks were measured as peak-to-peak equivalent SPL according to IEC 60645-3. The speech level was measured as C-weighted equivalent SPL according to IEC 60645-2. The OAEs were measured using the Otodynamics ILO 292 analyzer and calibrated using the 2 ccm cavity (coupler) supplied by the manufacturer.Pure tone audiometry was measured over an extended frequency range from 125 Hz to 16 kHz . Hearing thresholds were measured separately for each ear with a resolution of 2 dB. No significant differences between the left and right audiograms were found (see “Results” section), therefore the thresholds of both ears were analyzed together. Pure tone average (PTAV) was calculated as an average hearing loss at 0.5, 1, and 2 kHz. Hearing loss was also expressed in % according to Fowler correction  were periodically gated (cycle duration 200 ms) with a given duty cycle (approx. 30% to 70%); the percentage represents the proportion of the total cycle duration containing the speech signal, the remaining segment of the cycle was muted. The signal was ramped using a raised cosine ramp with 15 ms duration. Gated sentences were generated using a CD player and a custom-made gating device. Ten sentences were presented for each value of duty cycle and the recognition score (percentage of sentences understood) was recorded. The measurement proceeded from small duty cycles  to larger duty cycles in 10% steps until the recognition score reached nearly 100%. It should be noted that the ascending order of duty cycles provides different results than the descending order, hence it was important to strictly adhere to the procedure. This is due to the fact that the person learns during the test. In the case of an ascending order, when the person at first does not understand, his/her chance to learn is restricted. A correctly understood complete sentence was counted as 1; a partially understood sentence was counted as half. The recognition score was plotted as the function of the duty cycle, and the duty cycle corresponding to the 50% recognition score was taken as the result. Chopper is the most complicated speech test in our battery of tests and focuses on central speech processing and its integration with cognitive abilities .This measurement is employed to evaluate the ability to perceive interaural time (ITD) and interaural level differences (ILD) that the auditory system uses for space perception: when a sound source is deviated from the medial plane, the sound at the contralateral ear has a lower intensity than in the ipsilateral ear due to an acoustic shade of the head, and it arrives with a certain delay due to the longer path. Participants were exposed to stimuli with a different interaural time and intensity difference. The stimuli consisted of trains of 10 clicks . Each click pair had a certain ITD  and ILD  between the left and right ear. The time-intensity trading ratio allows us to compensate one parameter  by another parameter , resulting in the perception of the signal in the middle position. Other combinations lead to a lateralized perception. The participants had to indicate their subjective perception of sound source lateralization . The laterogram test was developed to evaluate the integration of bilateral auditory information, providing the possibility to separately evaluate its temporal and intensity aspects. Based on the physiological processing of the auditory signal, it enables the evaluation of the processing of acoustical signals at the subcortical levels.For the gap detection measurement, trains of three successive pauses in a continuous white noise at 70 dB SPL  were presented randomly in time. The subject had to indicate by pressing a button whenever he/she perceived the gaps. Starting at 10 ms, the gap duration was varied  until the approximate detection threshold was obtained. Close to the approximated threshold, a fine threshold was subsequently determined by varying the gap duration with 0.1 ms steps in a zig-zag manner. The resulting value of the threshold was the gap duration for which the subject’s detection scores equaled 50%, i.e., the duration at which the subject correctly responded in 50% of trials. Gap is widely used as the test for evaluating temporal processing abilities. Based on the results of animal experiments it is believed that it takes place in the auditory cortex. The comparison of gap (cortex) and ITD  results enables the differentiation between the two levels of auditory temporal processing.The auditory thresholds were also measured for clicks, with the aim to exclude frequency specificity and to take into account the processing of extremely short stimulus durations. The detection threshold of short clicks, depending on their level, was measured analogously to the measurement of detection thresholds of pure tones. Trains of three rectangular pulses  were presented to both ears. The intensity of the click trains was varied until the detection threshold was obtained. The initial intensity was estimated at approximately 20 dB above the expected threshold. The intensity of the click trains was varied until the detection threshold was obtained. The level of the click in dB was defined as a peak-to-peak equivalent value. The click threshold was used to minimize the effect of the frequency specific hearing pathology (high frequency hearing loss in elderly) on the cochlea.The hearing thresholds for tone at 1 kHz were measured as the function of tone duration. The procedure for obtaining the threshold was analogous to the measurement of the pure-tone hearing threshold however, for detection of short tones the signal was presented to both ears and the resolution was improved to 1 dB. The hearing threshold for tone durations of 70, 30, 20, 10, and 5 ms were measured. The short tones examination was used with the aim to exclude the high frequency hearing loss (there were no pathologies at the level of 1 kHz in the elderly group) and its integration with temporal processing (threshold for different duration). Stimulus duration coding is another temporal feature that, based on the data from animal experiments, occurs at the level of cochlea and cochlear nerve.1-f2 were two primary tones (f2/f1 = 1.22 with L1 = 70 and L2 = 70 dB SPL). Both TEOAE and DPOAE provide information about the function of the outer hair cell population. The addition of contralateral suppression allows the evaluation of the function of the efferent auditory pathway.The distortion product OAE (DPOAE) and the transiently evoked OAE (TEOAE) with and without contralateral white noise of 70 dB SPL were recorded in both ears. The difference between the response with and without the noise was considered as the suppression. The stimulus for the TEOAEs was the conventional, broadband nonlinear click (0.5–6.0 kHz), with stimulus gain adjusted to 81 dB peak. The stimuli for eliciting DPOAEs at 2fMontreal Cognitive Assessment  and evaluated by means of non-linear surface fitting. Lateralization responses were assigned numerical values  to create a real function of two variables, ITD and ILD. This function was interpolated using a 2D smoothing cubic spline interpolation, to obtain a smooth and high-resolution approximation of the subject’s lateralization responses over the whole range of ITDs and ILDs see . First, Aexp(-kt) and both parameters A and k were taken as the results. This approach allowed us to quantify the steepness of the dependence between the tone duration and its detection threshold independently of the absolute detection thresholds.The analysis of short tone detection utilized the fact that the thresholds increase with shorter durations; the shape and steepness of this dependence was quantified using an exponential fit. The worsening of the threshold relative to the threshold for the 70 ms tone was plotted as the function of the tone duration, obtaining a decreasing curve converging to zero. The function was fitted with a single exponential curve in the form of Normality of distributions of the data sets was tested using the Lilliefors test prior to subsequent analyses. Some data sets were found to have a distribution significantly deviating from the normality. For this reason, two-sided Wilcoxon rank sum tests were computed for comparisons of the medians of two data sets. For easier interpretation of the results however, the data are presented as mean ± SEM rather than medians. The possible relationships between the selected parameters were tested using Spearman’s correlation coefficient. In all cases, the alpha level was set to 0.05. Statistical analyses were performed using Matlab software .p = 0.25, Wilcoxon sign rank test). The auditory thresholds of the elderly volunteers were elevated compared to the young, particularly above ca. 2 kHz , however from a clinical point of view such a difference is considered non-significant. Similar differences were present when expressed using Fowler weighting coefficients  were higher compared to mean PTAV due to different measuring techniques and units , the age-related elevation of hearing thresholds measured using clicks is similar as in the case of PTAV (click: 7.29 dB vs. PTAV: 9.43 dB), indicating that both quantities convey similar information about the state of hearing. Therefore, despite its simplicity, the PTAV correlated strongly with the weighted average of hearing loss across the whole frequency range , with the Fowler’s coefficient , and with the thresholds for click . Therefore it seems that in the case of the normal aging process, the PTAV conveys very similar information as the other measures of hearing thresholds. For this reason, we chose the PTAV for further joint analyses. In the case of 1 kHz threshold dependent on the tone duration, the difference between the groups was not significant for any of the exponential parameters , suggesting minimal age related pathology . The contralateral suppression of OAEs showed the effectiveness of the efferent auditory pathway. In both groups the decrease of amplitude caused by the contralateral stimulation, was similar for TE  and also for DP .The function of the outer hair cells was examined by recording TEOAE and DPOAE. Overall, the presence of measurable TE was 100% in young vs. 76% in elderly and in the case of DP was again 100% in young vs. 92% in elderly. Both types of OAE showed significant differences in their respective amplitudes, with lower values in elderly , confirming the finding that the elderly participants exhibit poorer temporal processing, as already observed with the ITD-based lateralization. Gap detection is processed at the level of the temporal cortex  and that besides people with both parameters, either good or bad, there also exist participants with physiological peripheral processing and deteriorated central processing (top-left corner) or participants with physiological central processing and deteriorated peripheral processing (bottom-right corner). The combined analysis of PTAV and GDT appears to be a promising method for a more detailed characterization of presbycustic subpopulations.To further investigate the processing of the temporal parameters of the sound, a gap detection threshold (GDT) test was used . Signifip < 0.01, Wilcoxon rank sum test), the lowest score in the young was 26 and in elderly was 23 (three participants scored lower then 26 within the elderly).The cognitive abilities of volunteers from both groups were assessed by a MoCA questionnaire. The average scores were 28.79 ± 0.29 in young and 27.06 ± 0.44 in elderly . However, the speech comprehension measures, especially the SRT, were all correlated with the PTAV . Hence it appears that the hearing threshold is a strong predictor of speech comprehension ability. The GDT was found to be weakly correlated with the ITD lateralization slope , the correlation is nevertheless at the edge of statistical significance and therefore these two temporal measures could most likely be taken as independent. The GDT was also not correlated with the speech recognition threshold . On the other hand, the GDT significantly correlated with the ability to understand distorted speech, especially the speech in babble noise  was not correlated with either of them . It was also not correlated with GDT , ITD slope , and age . However, the MoCA depended on PTAV—the larger the hearing loss, the lower the MoCA index . In the case of age within the elderly group, only the ITD slope changes significantly ; all the other tested parameters  do not depend on age within the elderly . Considering that these parameters all differ between the elderly and young, it can be assumed that age-related changes do occur, but either more slowly than can be displayed by the variability of age within the elderly, or that the progress of changes with age is not linear or gradual.From the non-auditory parameters, we focused on the MoCA index and age. Interestingly, the MoCA index was not related to speech comprehension ability  of the tested parameters in comparison with the group of the worst hearing participants (bottom-left quadrant). When compared with the worst hearing participants (top-right quadrant), these GDT impaired participants have better SRT  and therefore the difference might potentially be important. The other parameters were not significantly different   . OverallIn the current study we have investigated the auditory function in elderly volunteers with clinically normal hearing thresholds with the aim to identify possible central auditory dysfunctions and explore its interactions with peripheral impairments. Regular auditory tests  were complemented by additional audiometric tests  and by cognitive screening (MoCA). Although the auditory thresholds of our elderly (up to 6 kHz) only show a very mild elevation due to normal aging with only minimal clinical signs of hearing pathology, our data show otherwise. Even in the elderly population without subjective hearing pathology and with only minor elevation of auditory thresholds, supracochlear structures of the auditory system show deteriorated functions. The results of the laterogram, and specifically ITD sensitivity, express altered integration of the binaural information, especially with respect of the temporal parameter. GDTs provide information about the ability of central processing of the temporal parameters of sound, which is altered independently of the function of the inner ear. Speech audiometry in babble noise and chopper, integrate the auditory information with cognitive processing and both tests show a clear deterioration with age, while the MoCA results are within the physiologic range with the exception of three borderline participants.Pure tone audiogram represents the “gold standard” of audiometric examinations, providing basic information about the hearing ability of the subject. Under standard conditions, hearing thresholds are measured up to 8 kHz and the elevation of auditory thresholds above 25 dB HL are considered by the majority of clinicians, and also according to WHO, to be mild hearing loss. In our elderly participants, hearing thresholds up to 8 kHz showed clinically normal values, according to ISO 7029. High frequency pure tone audiometry (HFA) examines hearing thresholds up to 16 (in our case) or 20 kHz. Our elderly participants demonstrated significant deterioration of hearing above 8 kHz, which is in agreement with Matthews et al. , therefoThe examination of click hearing thresholds also provides a comparison of auditory thresholds, but without the frequency dependency. It also takes into account the short duration of clicks. Considering the click duration and the altered ability to track temporal changes, we expected a greater impairment of the click thresholds with aging compared to pure tone thresholds, nonetheless our results show otherwise. Although clicks are regularly used as a stimulus for brainstem audiometry, in the case of subjective audiometry the click hearing thresholds do not seem to provide any additional information to PTAV.The analysis of the effect of stimulus duration on the auditory threshold (in our case 1 kHz tone) allows the examination of temporal processing within the inner ear and also possibly the synchrony of the auditory nerve activity , which is a sign of hypofunction of the outer hair cell populations common in aging , which is in agreement with the auditory threshold examination. However, the difference between young and elderly becomes apparent in SIN and seems even more profound in the understanding of temporally degraded speech, where the elderly participants need a significantly larger proportion of speech signal to understand the sentence than the young. Speech signal carries several types of information: phonetic, phonemic and syllabic and lexicosyntactics , clear differences are present. There is variability at the level of the inner ear, auditory pathway and also at the level of auditory cortex and in interactions with the cognitive network. For the purpose of improved identification of SNHL, we correlated a basic inner ear parameter—PTAV—with a basic central hearing parameter—GDT. The auditory periphery/center correlation proposes at least four possible subgroups: the real “golden ears” with almost perfect function of the auditory periphery and center, groups with either good periphery and declined central auditory function or declined peripheral auditory function and good central function, and a fourth group with both functions deteriorated. Another finding is that in our elderly the relatively minor degree of purely central pathology represented by higher GDT (GDT impaired subgroup of elderly) has only limited influence on speech processing, especially in comparison with the effect of peripheral function represented by PTAV. Additional comprehensive examination is needed, especially in the elderly with a more profound hearing deterioration, to further stress this classification and potentially add more presbycustic subpopulations. Our approach might complete the missing pieces in several theories of presbycusis as proposed by CHABA .Our data present a new insight  into auditory processing in humans with a potential impact on the diagnosis of SNHL. This is especially in contrast with the classic clinical approach to the diagnosis of hearing loss that uses only limited examination. As presented above, none of our elderly participants had an auditory function that would be considered by clinical standards as pathological, however our detailed tests show otherwise. We believe that in specific diagnosis such as presbycusis or potentially tinnitus, a more thorough examination is necessary. We aim to use our battery of tests to further classify the different subtypes of presbycusis that might eventually lead to a different approach of how to rehabilitate hearing impairment. Nonetheless, at this point there is no clear clinical recommendation for the use of a novel part of the test battery since more data is needed for validation. Among the clinically available tests in specific cases when a patient’s subjective feeling does not correlate with the results of basic audiometric examination, HFA, SIN and the effect of contralateral suppression on OAE should be complemented.Although our results provide a new insight into the pathophysiology of the age related changes in the auditory system, it is necessary to point out that the novel tests  have not been validated yet. However, based on the results of these tests and their correlation with the standardized auditory and cognitive measurements, convergent validity approach can be implemented. Nonetheless, in the near future, we plan to produce validated results of these tests for each age group  that would provide reference data and allow a more general use of these tests.Presbycusis is a complex disorder affecting different parts of the auditory system. Although the elevation of hearing thresholds is its most common expression indicating inner ear  pathology, several other central auditory features are affected as well. The presented data demonstrate the deterioration of the interaural auditory processing (laterogram), specifically of temporal information (ITD), decreased ability of auditory cortex to identify fast signal changes (GDT) and an overall decline of the integration of auditory and cognitive abilities . The analysis of the interactions of peripheral and central auditory abilities showed a stronger influence of peripheral function (expressed as hearing thresholds) than temporal processing ability on speech perception in silence, however in a more natural environment such as with the addition of noise to speech, the role of temporal processing increases rapidly. Our data reveal several pathologies causing presbycusis and suggest that they are to some extent independent of each other and, in particular, that hearing threshold elevation does not predict the state of the supracochlear auditory function.All datasets generated for this study are included in the manuscript.OP: manuscript preparation, examination, auditory tests creation, statistical analysis, work load ca 25%. MJ: examination, software preparation, auditory tests creation, work load ca 15%. ZB: software preparation, auditory tests creation, statistical statistical analysis, manuscript preparation, work load ca 15%. VV: examination, software preparation, work load ca 10%. DK and VS: examination, database administration, work load ca 10%. JK: software preparation, work load ca 5%. JS: manuscript preparation, auditory test creation, project overview, work load 10%.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.


To determine the effectiveness and benefit of a universal newborn hearing screening programme at four different hospitals in southern Thailand, between January and July 2017.One screener per hospital recorded demographic data of all newborns and their exposure to risk of hearing loss, and evaluated their hearing by transient otoacoustic emission technology. Those who demonstrated bilateral moderate to profound hearing loss at both a first and second screening were referred for diagnostic assessment. Those with confirmed hearing loss received treatment and regular follow-up appointments, and their speech development was assessed at 1 year of age. We determined effectiveness by comparing our achieved coverage and proportion of follow-up and referrals with benchmarks set by the American Academy of Pediatrics , and determined benefit by calculating the composite language scores of hearing-impaired infants who received early intervention.We screened 6140 eligible newborns, and achieved a screening coverage of 95.4% (5859/6140), lost 25.7% (63/245) and 22.0% (9/41) to follow-up at the second screening and diagnostic assessment stages, respectively, and obtained an overall proportion of referrals of 0.7% (41/6140). Twelve infants were confirmed as having hearing loss and received early intervention; nine (75%) demonstrated normal speech development by their first birthday. Our universal hearing screening yielded a prevalence of sensorineural hearing loss of less than 0.1% (3/6140).Although ineffective by American Academy of Pediatrics standards, we demonstrated the benefit of early intervention in infants diagnosed with hearing loss. The provision of such programmes is dependent on resources, legislative support and the availability of qualified personnel and competent audiological services. In the United States of America, screening coverage in 2016 was approximately 98% of all live births.A universal newborn hearing screening programme is not included in the public health service in Thailand. Although the Royal College of Otolaryngologists-Head and Neck Surgeons of Thailand and the Ministry of Public Health discussed and promoted such a programme in 2017, no commitment on the date of its launch was provided due to a lack of resources. The number of qualified audiology providers in Thailand is severely limited. Only 226 audiologists and 98 speech-language pathologists–Previous studies of hearing screening for newborns in Thailand have focused on the incidence of and risk factors related to hearing loss,We conducted our longitudinal descriptive study within the tertiary-care Songklanagarind Hospital, Prince of Songkla University, and the three secondary-care hospitals of Songkhla, Satun and Phatthalung, all located in southern Thailand. Songklanagarind Hospital has a competent audiological service, providing appropriate diagnostic assessment and early intervention. Songkhla, Satun and Phatthalung hospitals are located 21, 105 and 103 km from Songklanagarind Hospital, respectively, and all have effective referral systems. The average birth rate is similar across all four hospitals, at approximately 3000 newborns per hospital per year . Before implementing our screening programme, we provided documents describing the background of universal newborn hearing screening and its importance to the administrators, heads of departments and ward staff of these four hospitals.We recruited all infants born during January to July 2017. According to the American Academy of Pediatrics,,Our target group was newborns with sensorineural hearing loss,For details of the technology used in our programme, please see the data repository.We recruited three nursing assistants  and one nurse  to implement our screening programme. We trained our screeners to inform the parents of newborns of the importance of the early detection of hearing loss, provide parents with an information brochure, obtain written consent forms, perform the screening test(s), complete the case record forms, and make appointment dates for further screening and diagnosis, if relevant. Two otologists and a hospital audiologist delivered a 1-day training course at Songklanagarind Hospital for the four screeners. The course covered ear anatomy, basic physiological tests and hands-on training on correct probe insertion in a settled newborn, monitoring stimulus stability, checking response reproducibility and assigning pass/referral outcome. The otologists and audiologist were available to support the screeners during the implementation of the programme with instant messaging and video calls via a free smartphone application. The screeners recorded and shared the details of any screening issues and comments, enabling simple and effective communication between the four sites.Using the case record forms, each screener recorded the demographic data of all newborns as well as their exposure to any risk factors associated with sensorineural hearing loss,All newborns with any type of moderate to profound bilateral hearing loss were referred for a second screening 1 month later at the ear, nose and throat outpatient clinic of their hospital, conducted by the same screener. Screeners referred infants who failed the hearing test in both ears twice, directly to the audiovestibular clinic of Songklanagarind Hospital for diagnostic assessment and scheduled the appointment with the diagnosing audiologist. Fast-tracking of infants to this diagnostic clinic, without first attending the ear, nose and throat clinic of Songklanagarind Hospital , was accomplished by the screener writing “UNHS”  on an information brochure. The screener instructed parents to take this brochure with them to the diagnostic appointment.Parents were reminded of their diagnostic appointment a few days in advance by a phone call from the audiologist. Any cancellations were rescheduled and replaced by the next infant in the queue. Parents who failed to attend a scheduled second screening or diagnostic appointment were contacted by telephone and/or text message by their site screener, who recorded their reason for non-attendance.All infants diagnosed with hearing loss received treatment  and regular follow-up appointments at Songklanagarind Hospital. One of the otologists assessed infants’ speech development at 1 year of age using the Bayley Scales of Infant and Toddler Development, Third Edition, Thai version .All data were transferred to an Excel spreadsheet  for basic statistical analysis and a review meeting was held to correct any data errors. Two research assistants were recruited for double data entry, and separately entered all data into an Excel spreadsheet. Only the two otologists and the two research assistants could access the password-protected data. For the targeted hearing screening analysis, the filter facility in Excel was used to select only newborns exposed to risks of hearing loss.Ethical approval was obtained from the Research Ethic Committees of the Faculty of Medicine, Prince of Songkla University before the beginning of the study. Written and informed consent was obtained from the parents of all subjects before they were enrolled in the study.Of the total of 6234 live births across the four sites during the study period, 94 neonates died before screening. Of the 6140 infants eligible for screening , 218 infOf the infants screened a second time, 41 failed the test and were referred to a comprehensive audiological evaluation at the tertiary-care hospital, giving a proportion of referrals of 0.7% (41/6140). Of the infants referred, nine did not attend for diagnostic assessment, resulting in a 22.0% loss to follow-up.Of the 32 infants attending a diagnostic assessment, the audiologist confirmed hearing loss in 18 infants, comprising five infants with conductive hearing loss, four with mixed hearing loss  and nine with sensorineural hearing loss (six mild). When only the targeted group is considered, this gives an overall prevalence of less than 0.1% (3/6140). A total of 14 infants failed both screening tests but had normal hearing at the diagnostic assessment, yielding a false-positive proportion of 0.2% (14/6140) for the two-stage screening approach.In the targeted hearing screening analysis, 310 of the 5922 newborns screened were considered to have been exposed to at least one of the risk factors for hearing loss . Of thesAmong the 12 infants who received early intervention, nine showed good speech and language outcomes 1 year later (scores of 91–109); the remaining three had poor outcomes  and US$ 4.5 per infant screened .In terms of effectiveness, our study only achieved two out of the three American Academy of Pediatrics benchmarks,We lost almost one quarter of infants to follow-up at different stages of our study, exceeding the benchmark of 5% maximum set by the American Academy of Pediatrics. The main reasons given by parents for failing to attend either a second screening or a diagnostic appointment included: work constraints, a belief that their infants did not have a hearing problem or lack of transport. These reasons indicate that our methods of informing parents of the importance of hearing screening for newborns at the initial stage of the programme were inadequate; this issue could be addressed by providing better maternal education regarding hearing loss during antenatal care. Other methods of increasing the percentage of follow-up include: obtaining details of a designated regular contact (such as a relative or close friend), as well as of parents; using a computer-based system to manage and monitor multiple requests to attend appointments via letter, email and telephone; or scheduling hearing appointments with immunization programmes, which has been shown to improve the follow-up in low- and middle-income countries.Our high loss to follow-up could also have lowered our calculated prevalence of sensorineural hearing loss in newborns (less than 0.1%), which was lower than that reported from Thailand ,Regarding the ≤ 4% referral benchmark of the American Academy of Paediatrics, we obtained a proportion of referrals of 0.7% in our study. We do not believe that our low referral rate was a result of inadequate training of screeners, as it has been shown that 2–4 hours of training in such studies is sufficient.,In terms of benefit, our study demonstrates that prompt intervention provides good speech outcomes for most infants diagnosed at a young age with hearing loss. Despite receiving prompt treatment, three infants had poor speech outcomes. However, two of these infants had the additional disabilities of trisomy 18 with global delayed development and generalized cerebral palsy with cognitive impairment, which are barriers to the development of normal speech regardless of hearing ability.,Researchers have shown in EgyptAs well as informing policy-makers, our study benefited from good communication between the four hospitals involved, an efficient fast-tracking service for participants and the low cost calculated per infant screened for the programme.Although we did not demonstrate the complete effectiveness of universal screening, the confirmed benefits of early intervention, in terms of speech and language development, warrant further research and increased efforts to procure the required public health funding.