P < .0001). Multivariable modeling assessed associations of risk factors and treatment with hearing impairment, tinnitus, peripheral neuropathy, and Raynaud phenomenon. Risk for each AHO statistically increased with both increasing chemotherapy burden (P < .0001) and selected modifiable risk factors (P < .05): hypertension (odds ratio [OR] = 2.40) and noise exposure (OR ≥ 2.3) for hearing impairment; noise exposure for tinnitus (OR ≥ 1.69); peripheral vascular disease for neuropathy (OR = 8.72); and current smoking for Raynaud phenomenon (OR = 2.41). Clinicians should manage modifiable risk factors for AHOs among TCS. We evaluated for the first time, to our knowledge, adverse health outcomes (AHOs) among US testicular cancer survivors (TCS) given chemotherapy (n = 381) vs surgery-only patients (n = 98) managed at a single institution, accounting for non-treatment-related risk factors to delineate chemotherapy’s impact. Chemotherapy consisted largely of bleomycin-etoposide-cisplatin (BEP) administered in three or four cycles . Incidence of at least 3 AHOs was lowest in surgery-only TCS and increased with BEPx3, BEPx4, and other cisplatin-based regimens (12.2%, 40.8%, 52.5%, 54.8%;  Testicular cancer is the most common cancer in men aged 18–39 years , the oveP < .05 defined statistical significance.In view of these gaps, our goal was to study AHOs among US TCS after contemporary cisplatin-based chemotherapy compared with a surgery-only cohort. The study was institutional review board-approved at Indiana University. Eligible TCS had a histologic or serological germ cell tumor diagnosis at 55 years or younger; all administered treatment and management was completed at least 1 year before enrollment. All participants were disease-free at routine follow-up and completed AHO-focused health questionnaires. AHO definitions and statistical methods are provided in the 2 (BEPx3) and 400 mg/m2 (BEPx4 and Other Plat). A total of 98 patients were managed only surgically. No patient received radiotherapy.Overall, 479 patients were evaluated . ChemothP < .0001) and were more likely to have primary testicular germ cell tumor . Other clinical characteristics, physical examination results, and health behaviors were similar between groups, but more surgery-only TCS reported the absence of noise exposure than did chemotherapy-treated TCS . The median number of AHOs increased from 1 (range = 0–11) after surgery-only to 2 (range = 0–10) after BEPx3 and 3 (range = 0–9) after BEPx4 and Other Plat. Fewer TCS had at least 3 AHOs after surgery-only (12.2%) than after BEPx3 (40.8%), BEPx4 (52.5%), and Other Plat (54.8%) (P < .0001). Significant differences between surgery-only, BEPx3, BEPx4, and Other Plat were observed for the following AHOs (each P < .05): hearing impairment ; tinnitus ; peripheral neuropathy ; hypertension ; Raynaud phenomenon ; and balance/vertigo/dizziness . For cardiovascular disease (CVD), differences were of borderline significance .Median age at evaluation  and median time since chemotherapy or surgery completion  were similar between groups. Surgery-only patients had a smaller percentage of nonseminomatous histology compared with chemotherapy-treated TCS receiving BEPx3, BEPx4, and Other Plat , with risk increased by 1.44-fold (P < .0001) for each 100 mg/m2 of cisplatin. Prior work-related , non-work-related , and cumulative  noise exposures were associated with statistically increased twofold tinnitus risks, but no interaction with cisplatin dose existed (P = .5892). P = .0259), hypertension , and in each chemotherapy group (P < .01 each). With each 100-mg/m2 increase in cisplatin, hearing loss increased by 1.4-fold (P = .0002). Work-related , non-work-related , and cumulative  noise exposures conferred increased hearing loss, but no interaction with cisplatin dose existed (P = .3672).Hearing loss increased statistically with increasing age at clinical evaluation  and 21-fold (P < .0001) following BEPx3 and BEPx4, respectively, and 12-fold after Other Plat (P = .0018). Risk increased with increasing bleomycin dose . Current smoking was associated with statistically increased 2.4-fold risks.Raynaud phenomenon was increased 12-fold (P < .0001 each). Increasing age at assessment , higher cumulative cisplatin dose , and peripheral vascular disease  were associated with higher neuropathy risks.Peripheral neuropathy was increased by 9-, 13-, and 18-fold, respectively, after BEPx3, BEPx4, and Other Plat . A similar trend of borderline significance was noted for CVD.It is noteworthy that even after a short median follow-up, about 1 in 7 TCS in each chemotherapy group had hypertension compared with no cases after surgery-only  had a lower disease burden initially than did chemotherapy-treated TCS, no TCS had active disease at the time of study enrollment. We cannot rule out, however, any potential influence of initial disease burden on AHO development.Nonetheless, we provide for the first time, to our knowledge, estimates of the magnitude of AHOs associated with current chemotherapy in US TCS compared with surgery-only patients. This may potentially guide clinical decision-making, such as recommending surgical approaches with primary retroperitoneal lymph node dissection in patients with low-bulk stage II disease in an attempt to avoid chemotherapy-related AHOs. Future studies should address AHO incidence when adjuvant chemotherapy is applied in early-stage disease or in guiding decisions regarding primary retroperitoneal lymph node dissection vs chemotherapy in early stage II disease.The incidence of several AHOs  will likely increase with the aging process . Thus, pThis work was supported by the National Cancer Institute (1R01 CA157823 to LBT) and funds provided by Indiana University to NA.The authors of this study do not have any conflicts of interest to disclose in the subject matter or materials discussed in this article.Our results were presented in part at the American Society of Clinical Oncology Annual Meeting, June 2018.pkz079_Supplementary_DataClick here for additional data file.


Age-related hearing impairment (ARHI) is very common in older adults and has major impact on quality of life. The heritability of ARHI has been estimated to be around 50%. The present study aimed to estimate heritability and environmental contributions to liability of ARHI and the extent to which a polygenic risk score (PRS) derived from a recent genome-wide association study of questionnaire items regarding hearing loss using the UK Biobank is predictive of hearing loss in other samples. We examined (1) a sample from TwinsUK who have had hearing ability measured by pure-tone audiogram and the speech-to-noise ratio test as well as questionnaire measures that are comparable with the UK Biobank questionnaire items and (2) European and non-European samples from the UK Biobank which were not part of the original GWAS. Results indicated that the questionnaire items were over 50% heritable in TwinsUK and comparable with the objective hearing measures. In addition, we found very high genetic correlation (0.30–0.84) between the questionnaire responses and objective hearing measures in the TwinsUK sample. Finally, PRS computed from weighted UK Biobank GWAS results were predictive of both questionnaire and objective measures of hearing loss in the TwinsUK sample, as well as questionnaire-measured hearing loss in Europeans but not non-European subpopulations. These results demonstrate the utility of questionnaire-based methods in genetic association studies of hearing loss in adults and highlight the differences in genetic predisposition to ARHI by ethnic background. Age-related hearing impairment (ARHI) is prevalent in older adults, affecting at least 60% of people by the time they reach 71–80 years of age . HearingARHI results from the cumulative effects of individual environmental and lifestyle-related experiences that interact with genetic factors to make some people more susceptible to hearing loss than others. Variable susceptibility results in wide variation in the severity of ARHI, so that some people will experience significant, disabling levels of hearing loss while others retain good hearing ability well into old age . GeneticEYA4, CDH23, KLHDC7B, and TRIOBP genes, while 25 lie within introns. Loci common to both traits were NID2, ARHGEF28, and EYA4. EYA4 variants have been implicated previously in other forms of hearing loss [NID2 and ARHGEF28 were novel associations [Two novel loci for ARHI have recently been identified in an analysis of the non-Hispanic whites in a large  cohort, Genetic Epidemiology Research on Adult Health and Aging (GERA) . These ling loss , but NIDciations . Across Identifying fewer loci with HAID than with HD suggests that HD is a more stringent measure of hearing ability for detecting genetic associations in the UK, at least within the age range examined. The HD analysis may be more highly powered than HAID due to difference in prevalence of positive response for the hearing difficulty question (35% in the white British) being much higher than for the wearing a HAID question (5.2%) ; as prevThe polygenic risk score (PRS) provides a way of predicting likelihood of developing a trait based on results obtained from large GWAS . Rather The present study aimed to (1) estimate heritability and environmental contribution of liability to ARHI in multiple samples using different objective and subjective measures of hearing and examine their degree of overlap and (2) examine the extent to which PRS from the recent UKB GWAS is predictive of hearing loss in other samples, both ethnically similar and different, and tested with various different measures of hearing ability. To achieve these aims, we used (1) an ethnically similar sample of twins from the TwinsUK Bioresource who have the questionnaire measures analogous to the UKB HAID and HD measures, as well as hearing ability measured by objective tests and (2) European and non-European  samples from the UKB that were not part of the original GWAS.n = 52,936 individuals), African origin (n = 938), South-East Asian (predominantly Chinese) origin (n = 2548) and non-Chinese South Asian origin . Samples were genotyped using one of two custom and highly similar Affymetrix SNP arrays and imputed to the 1000 Genomes reference panel, yielding 9,740,198 SNPs in total. Further details are presented elsewhere [The UKB comprises 487,401 individuals, the majority of whom are ethnic Northern European . Multiple additional populations are also present in the UKB, as defined by genetic PCs analysis, including individuals of non-northern European origin  derived from the triple digit test and the laboratory-administered pure-tone audiogram (PTA), both previously described . In the Table AD), shared environment (VSB), and non-shared or random environment (VRS), along with the affection threshold τ on a liability scale. MAN was also used to estimate variance components for quantitative traits and covariance between traits. These parameters were allowed to vary by sex and the linear effect of age on the phenotypes was simultaneously modelled and tested. This was performed for the TwinsUK and the UKB samples. For the UKB first-degree relatives and MZ twins were identified by estimating kinship matrix among all individuals and selecting those with kinship coefficients > 0.495—suggesting MZ twins—and >0.25 implying first-degree relatives. Overall, 3275 individuals with phenotypes had first-degree relatives and of those 70 were members of an MZ pair.We employed the MAN package  to perfop value significance in the base GWAS and the optimal threshold, in terms of maximum variance explained in the target sample, was estimated. The significance test of that optimal p value was adjusted by permutation  to correct for the effective number of cutoffs examined as well as underlying correlated errors due to familial relationships . We used PRSice-2 to predict the four hearing measures in the TwinsUK sample and two hearing measures in the four UKB subsamples from weights derived from the two GWAS performed in the UKB on the ethnic British sample [r2 > 0.1 with the target were clumped to adjust for LD in the target population. A SNP was considered part of a region of clumped SNPs if it had an r2 > 0.8 with any SNP in that region. For TwinsUK, we analysed one member of each MZ twin pair and both members of DZ twin pairs. After removing duplicate and ambiguous variants from the base GWAS, 5,416,754 SNPs were available in the TwinsUK sample, which were also present in the base sample and survived filtering. For the UKB samples, 8,724,365 SNPs were included for the AA sample; 4,731,237 for CH; 7,399,812 for EA; and 5,711,698 for SA. Numbers of SNPs available after LD clumping are presented in Supplementary Table PRS analysis was performed using the PRSice-2 package , 25. Brih sample . We filtWe estimated heritability of HAID and HD in TwinsUK using the genome-wide GCTA-GREML approach –29. Becaχ2 = 22.8, p < 1.8 × 10–6 vs model assuming no additive genetic effect). In addition, age and sex made a statistically significant contribution to HD liability variation . For HAID in TwinsUK, sex differences exerted no effect, but age accounted for 26.17% of the variance in liability . The contribution of the additive genetic component was impressive: 52.6%, with heritability equal to 71.2% . Shared environment was estimated to be zero for both phenotypes , but for SNR only 19.7% and not quite statistically significant . Shared environmental variance was again estimated at 0 for both variables , with heritability (covariates variance not in the denominator) of 55.7%  to 0.86 ± 0.07  and HAID (p < 0.0034), implying significant familial correlation in the sample: whether the source is genetic or shared environmental factors cannot be distinguished. Assuming that as in the TwinsUK sample the major factor is genetic, constraining the shared environment to 0 in the most parsimonious models produced a significant estimate of heritability in HD (0.317 ± 0.097), with age and sex explaining 7.02% of liability variation. Similarly, for HAID heritability was estimated to be 0.646 ± 0.217, with age and sex explaining 8.71% of the variance.In the UKB sample, the proportion of MZ twins was very small (2.4%), so clear-cut discrimination between the shared environment and additive genetic components was not possible. However, the 2-df tests for heritability plus shared environmental variance were significant for both HD . The odds ratios presented in the corresponding quantile plot in Fig. p = 0.146; Fig. p = 0.0022; Fig. p value was just < 0.05.In general, PRS generated from the UKB GWAS was predictive of TwinsUK hearing phenotypes , despite the small sample size. Note here that the estimate of the SNR heritability was not significant (see above).We also examined whether the UKB PRS could predict the objective quantitative measures of hearing available, SNR and PTA. Neither HAID nor HD significantly predicted SNR, but HD significantly predicted PTA  and HAID to be 2.9% (SE = 0.1%), and a bit higher using the liability scale  . In the The substantial genetic correlations among the four phenotypes explored in TwinsUK suggests that a simple question of whether or not one experiences hearing difficulty or uses an HAID is a useful proxy for the more elaborate tests of hearing ability. The PTA has long been considered the gold standard measure of hearing but it requires expensive equipment and trained personnel to administer it. Our work further validates the GWAS findings from UKB hearing questions and justifies the use of the simple binary questionnaire responses, lending support to the accepted view that quality of phenotype is less of a concern if a very large sample is available, as demonstrated early on by the personal genomics company 23andMe . They shIt is disappointing, but perhaps not surprising, that PRS generated in one population (ethnic Northern European) are not useful predictors of phenotype in ethnically distinct populations. This is possibly due to the small sample size, as well as allele frequency and LD differences between populations. It is generally accepted that cross-population PRS is not a powerful approach and a comprehensive review of PRS published from 2008 to 2017 demonstrated this . FurtherCross-population prediction is likely somewhat affected by power due to small sample size. While the size of the European sample was large, the other population groups had relatively small sample sizes. It is likely that much larger samples are needed to overcome the mismatch in population origin and corresponding differences in allele frequencies. In fact, the estimates of variance explained by PRS in the samples of Asian and African origin were not appreciably different from those found in Europeans, so if the estimates remain the same and a larger sample were available prediction could be significant across populations.While the proportion of variance explained by the PRS was uniformly small at 2%, despite high trait heritability estimated from familial correlations, such PRS may still be useful for identifying those at risk for hearing loss. For instance, in our European target population, knowing that someone is 1.8 times more at risk than the general population, as is the case for 1% of the population, could have important utility in identifying people at young age who should take extra precaution in exposure to loud noise, for example. With the current trend of large-scale sequencing efforts being undertaken in multiple countries, prediction will only improve and the utility of PRS for predicting ARHI, as with other complex diseases, will increase. In summary, our work demonstrates that questionnaire-based methods to phenotype adults for hearing loss in gene finding studies is robust and paves the way for many existing genotyped bioresources to collect simple information which could revolutionise the study of genetic variants causing ARHI.Supplementary Material


Global resource reallocation is an established critical strategy through which organisms deal with environmental stress. The regulation of intracellular lipid storage or utilization is one of the most important strategies for maintaining energy homeostasis and optimizing growth. Oleaginous microorganisms respond to nitrogen deprivation by inducing lipid hyper accumulation; however, the associations between resource allocation and lipid accumulation are poorly understood.M. alpina. The subsequent accumulation of TAG under nitrogen deprivation was a consequence of the reallocation of carbon, nitrogen sources, and lipids, rather than an up-regulation of TAG biosynthesis genes. On one hand, nitrogen deprivation induced the down-regulation of isocitrate dehydrogenase level in TCA cycle and redirected glycolytic flux of carbon from amino acid biosynthesis into fatty acids’ synthesis; on the other hand, nitrogen deprivation induced the up-regulation of cell autophagy and ubiquitin-mediated protein proteolysis which resulted in a recycling of preformed protein nitrogen and carbon. Combining with the up-regulation of glutamate decarboxylase and succinic semialdehyde dehydrogenase in GABA shunt, and the phosphoenolpyruvate carboxykinase in the central hub involving pyruvate/phosphoenolpyruvate/oxaloacetate, the products from nitrogen-containing compounds degradation were recycled to be intermediates of TCA cycle and be shunted toward de novo biosynthesis of fatty acids. We found that nitrogen deprivation increased the protein level of phospholipase C/D that contributes to degradation of phosphatidylcholine and phosphatidylethanolamine, and supplied acyl chains for TAG biosynthesis pathway. In addition, ATP from substrate phosphorylation was presumed to be a critical factor regulation of the global resource allocation and fatty acids’ synthesis rate.Here, the time-resolved metabolomics, lipidomics, and proteomics data were generated in response to nutrient availability to examine how metabolic alternations induced by nitrogen deprivation drive the triacylglycerols (TAG) accumulation in M. alpina in response to nutrient stress and revealed a set of intriguing associations between resource reallocation and TAG accumulation. This system-level insight provides a rich resource with which to explore in-depth functional characterization and gain information about the strategic combination of strain development and process integration to achieve optimal lipid productivity under nutrient stress.The present findings offer a panoramic view of resource allocation by  Organisms ranging from bacteria to mammalian cells use diverse protection mechanisms to adjust metabolism according to environmental stress. These regulatory strategies reflect an inherent trade-off between the benefit and cost of resource investment under stress. Several investigators have recently suggested that cells deal with challenges to growth-limiting perturbations by regulating the allocation of metabolic resources –6.Nutrients serve not only as the resources required by cells to increase mass and generate energy to propel biosynthetic activity, but also as the signals that dictate metabolic, transcriptional, and developmental programs , 8. CellLipids are the storehouses of carbon and energy resources; thus, intracellular lipid storage and utilization are critical for maintaining cellular metabolic homeostasis and survival . DynamicM. alpina is an optimal organism for studying lipid metabolism because not only can it be easily cultured and harvested, but also it can accumulate > 50% of its cell mass as lipids under nitrogen limitation [M. alpina harbors the standard components of the desaturation–elongation pathway of long-chain polyunsaturated fatty acids (LC-PUFA) [M. alpina is also a promising host for the sustainable generation of high-value LC-PUFA, such as arachidonic (ARA), eicosapentaenoic (EPA), and docosahexaenoic (DHA) acids [M. alpina as a model species has facilitated the identification of key strategies of resource allocation under nutrient stress and of the critical biosynthetic nodes governing global metabolic flux and lipid biosynthesis. We previously showed that carbon flux, nitrogen metabolism and NADPH generation considerably vary in M. alpina under nitrogen limitation [Compelling evidence has suggested that nutrient stress promotes TAG accumulation in various model oleaginous microorganisms –21. Advamitation , 25. OurLC-PUFA) . FurtherA) acids , 28. Themitation , 30. HowM. alpina and determined how M. alpina globally allocates resources in response to nutrient stress. The applied strategies can quantitatively and temporally account for all apparent behaviors including changes in the characteristics of bio-physiological parameters and lipid contents throughout fermentation. Our findings will contribute to a deeper understanding of the fundamental mechanisms of cellular responses to nutrient stress, and support the development of new strategies that will achieve more biomass and maximal lipid productivity.The present bio-physiological study integrated time-resolved phenotypes with multi-omics to quantify global resource allocation by the oleaginous fungus M. alpina cells had decreased within 48 h and was completely exhausted between 36 and 48 h. The extracellular glucose concentration decreased rapidly up to 96 h, and continued to decrease slowly thereafter. This was accompanied by a rapid increase in biomass that peaked with 48 h  during fermentation under nitrogen deprivation (48–216 h). Taking together, these results indicate that the products of lipid-free substrate degradation induced by nitrogen deprivation play a vital role in fatty acids’ accumulation, especially during the early stages of nitrogen deprivation [Figure 8 h Fig. b. Intrac8 h Fig. b. The am8 h Fig. b. There rivation , 32. Thetion 48–26 h. TakiM. alpina cultured under nutrient stress  , phosphofructokinase (PFK), and pyruvate kinase (PK), were decreased under nitrogen deprivation Fig. a, togethMost of the enzymes involved in the TCA cycle, especially isocitrate dehydrogenase (IDH), were rapidly decreased in response to nitrogen deprivation Fig. a. HoweveM. alpina, nitrogen deprivation induces metabolic reprogramming of central carbon metabolism to utilize carbon skeletons that enter the TCA cycle, leading to an accumulation of citric acid for fatty acids’ synthesis.Phosphoenolpyruvate (PEP) level was significantly increased during fermentation Fig. b, even tProteomic findings show that enzymes involved in TAG and fatty acid biosynthesis pathways were downregulated or slightly altered under nitrogen deprivation, while phospholipases C (PLC) and D (PLD) which catalyze phosphatidylcholine (PC) and phosphatidylethanolamine (PE) into TAG in the biosynthesis pathway were significantly increased throughout the fermentation process Fig. c. Lipidol-arginine and urea, two critical intermediates involved in the urea cycle, were increased after nitrogen exhaustion  protein Fig. d, which Gene ontology enrichment of the highly correlated proteins shown in Fig. M. alpina proteomics, we individually analyzed specific GO subcategories using volcano plots and compared the protein profiles from 24 to 96 h . The role of membrane lipid turnover in TAG synthesis has been widely investigated [M.alpina, TAG accumulation in response to nitrogen deprivation is also a consequence of recycling and reallocating acyl chains in different lipid classes [M.alpina and other species [Perhaps the most noteworthy change in the lipid profiles of nitrogen-stressed stigated , 39. In  classes , rather  species , 55.M. alpina is the upregulation of proteolysis and amino acid degradation. UPS is an important protein degradation system in organisms in which proteins are degraded in highly specific ways. UPS and ERAD are coupled to the targeted degradation of damaged or defective proteins [The most notable change in the protein profiles of nitrogen-stressed proteins . Regardlproteins –59. The M. alpina is continuously upregulated from nitrogen-replete to nitrogen-deprived . Roswitha Krick et al. found that CDC48 and its substrate-recruiting cofactor SHP1 regulate autophagosome biogenesis in concert with ubiquitin-like Atg8 . FurtherM. alpina. Instead, substrate level phosphorylation is the most likely source of ATP that drives lipid accumulation under nutrient deprivation in M. alpina [M. alpina synthesizes more fatty acids.In the current study, TFA content was found to be continuously increasing during the fermentation, but the rate of TFA accumulation decreases after 96 h Fig. . Under n. alpina . ChangesM. alpina has the ability to convert pre-formed carbon sources into fatty acids under nitrogen deprivation, while substrate restriction limits the efficiency of this important conversion process.Our findings revealed that a considerable amount of degradation products from UPS/cell autophagy pathways and membrane lipids is critical metabolites for the provision of fatty acids and/or lipid precursors for TAG synthesis under nitrogen deprivation. However, most of the degradation products, namely amino acids, nucleotides, and intermediates involved in PPP, the GABA shunt, the TCA cycle, and DAG, are significantly decreased. This indicates a state of disequilibrium between supply and demand under nitrogen deprivation, especially after 96 h. All of this can be explained by an imbalance between biosynthesis and catabolism and can be attributed to the continuous shutting down of the TCA cycle. Thus, a dynamic trade-off in IDH expression level in the TCA cycle using inducible promoters or biosensors could be an efficient strategy for regulating cell biomass and lipid synthesis, thereby assuring that lipids can be continuously synthesized at a high rate.M. alpina can remodel its intracellular metabolism temporally to respond to changes in environmental cues during fermentation, and revealed the key hubs, metabolic pathways and biological processes governing this resource allocation, which played an important role in fatty acid accumulation. The present findings revealed a global metabolic landscape of resource allocation by M. alpina in response to nutrient stress, and the relationship between such allocation and TAG accumulation. The insights afforded here provide an important reference for the development of more efficient engineering strains and diverse control strategies for smart fermentation processes to produce microbe-based functional oils.We used multivariate empirical Bayes analyses (MEBA), trend cluster and subcellular organelle analysis to elucidate dynamic changes in metabolic and protein profiles throughout fermentation from nitrogen-replete to nitrogen-free conditions. We found that nitrogen deprivation induced TAG accumulation as a consequence of nitrogen and carbon reallocation mediated by ubiquitination modification and autophagy. The TCA cycle is a hub of carbohydrate, lipid, and amino acid metabolism. When nitrogen availability decreases, the sink for TCA cycle metabolites can be shunted toward fatty acid biosynthesis through the downregulation of IDH, which blocks the TCA cycle. Therefore, intracellular protein content decreases, whereas storage lipids increase under nitrogen stress. We also uncovered some factors produced under long-term nitrogen deprivation that could limit the efficient biosynthesis of TAG, such as imbalanced energy metabolism, the beta-oxidation of LC-PUFA in peroxisomes. Our results showed that M. alpina strain  was cultured as we described in our previous publications [All HPLC-grade solvents and standards were purchased from Merck KGaA  and Sigma-Aldrich Corp.  unless otherwise noted. The ications  and in AGlucose and ammonia in the medium, mycelial dry weigh and fatty acid methyl esters (FAME) were determined as described previously , and addSamples preparation and metabolites extraction were proceed as our previous described . In brieg for 20 min. The precipitates were washed three times with acetone, dried at room temperature, lysed in denaturing lysis buffer  in a warm water bath for 30 min, and then separated by centrifugation at 15,000g for 30 min. Proteins in the supernatant were precipitated with acetone, reconstituted in UA buffer, quantified, portioned, and stored at − 80 °C. Total protein contents were quantified using the BCA method with bovine serum albumin (BSA) as the reference. Protein samples were resolved by SDS-PAGE.Samples (150 mg) of cell pellets ground into a fine powder in liquid nitrogen were added to chilled 1.5-mL Eppendorf centrifuge tubes containing two clean glass beads and sonicated in 1.5 mL of 10% trichloroacetic acid/acetone containing 0.1% PMSF. The samples were vortex mixed for 60 s, then precipitated at − 20 °C overnight. The samples were vortex mixed again and separated by centrifugation at 4 °C and 15,000×4HCO3, then 100 μL of 50 mm DTT was added to the protein concentrators  which were then placed in a water bath at 56 °C for 30 min. The filter was washed three times with 100 μL of 50 mM NH4HCO3. Next, 100 μL of a 50 mM iodoacetamide in UA buffer was added to the samples and incubated for 30 min in darkness. The filter was washed three times with 100 μL of UA buffer and three times with 100 μL of 50 mM NH4HCO3. The proteins were digested with sequencing grade trypsin (Thermo Fisher Scientific Inc.) at a final substrate/enzyme ratio of 50:1 (w/w) at 37 °C for 16 h. The digest was passed through an ultrafiltration unit (Thermo Fisher Scientific Inc.) with a molecular weight cut-off of 10 kDa, and collected peptides were assayed using a kit. The peptides in each sample were desalted on the C18 pipet-tipped columns (Thermo Fisher Scientific Inc.), concentrated by vacuum centrifugation, and reconstituted in 8 μL of 0.1% formic acid containing 2% acetonitrile for mass spectrum analysis.The proteins were assessed using a label-free quantitative proteomic procedure as described. Purified proteins (150 μg) were diluted in UA buffer to a concentration of 1.5 μg/μL. Diluent (100 μL) was added to protein concentrators and ultrafiltration was repeated three times. The filter was washed three times with 100 μL of 50 mM NHTryptic peptides were dissolved in 0.1% formic acid containing 2% acetonitrile (solvent A), directly loaded onto a custom-made reverse-phase analytical column (1.9 µm × 100 µm × 20 cm). The gradient comprised 5% to 25% solvent B (0.1% formic acid in 98% acetonitrile) over 40 min, 25% to 35% in 12 min, 35% to 80% in 4 min, hold at 80% for 4 min, at a constant flow rate of 450 nL/min on an EASY-nLC 1200 UPLC system.The peptides were analyzed using a nanospray ionization (NSI) source followed by tandem mass spectrometry (MS/MS) in an Orbitrap Fusion Lumos (Thermo Fisher Scientific Inc.) coupled online to the UPLC. The electrospray voltage was 2.0 kV. The m/z scan range was 350 to 1550 for a full scan, and intact peptides were detected in the Orbitrap at a resolution of 60,000. Peptides were then selected for MS/MS using NCE setting 32, and the fragments were detected in the Orbitrap at a resolution of 15,000. A data-dependent procedure alternated between one MS scan followed by 20 MS/MS scans with 15.0-s dynamic exclusion. Automatic gain control (AGC) was set at 5E4. The fixed first mass was set at 100 m/z.M. alpina ATCC32222 genome (Accession no. ADAG01000000) [A protein sequence database was constructed from all predicted proteins in the 1000000) . The MS 1000000) , 77 and R > 0.75) in the same cluster were included in GO-term or pathway enrichment analysis, respectively. The functional annotations  of the proteome database of M. alpina ATCC32222 were achieved using EggNOG mapper 5.0 based on our previously reported genome information [M. alpina ATCC32222 v1.0 database and a new GO database was constructed. Gene ontology enrichment was identified using TBtool [M. alpina ATCC32222 GO_v1.0 database. All detected metabolite and protein profiles were ranked using multivariate empirical Bayes analyses and pathway enrichment was analyzed using MetaboAnalyst 4.0  [Proteins or metabolites with similar change trends were grouped using k-means clustering with the Pearson correlation distance metric , 78–80. ormation , 81. Theg TBtool  combinedyst.ca/) , 83. AllAdditional file 1. Additional Table S1 and Figures S1–S10.Additional file 2. Qualitative and quantitative of multi-omics data.Additional file 3. MEBA analysis for time-resolved metabolomics and proteomics datasets.Additional file 4. Unsupervised time-resolved trend clustering analyses.Additional file 5. Proteins distributed in four different organelles.Additional file 6. Additional Methods.


Background: Patients often need multiple fine-tuning appointments with their hearing health care provider to achieve satisfactory hearing aid outcomes. A smartphone app that enables patients to remotely request and receive new hearing aid settings could improve hearing health care access and efficiency.Introduction: We assessed the usability of ReSound Assist™,  the remote communication feature of a hearing aid app, and investigated whether hearing aid outcomes are influenced by app-based versus in-person patient-provider communication.Materials and Methods: Thirty adults were fit bilaterally with hearing aids and randomized to intervention and control groups. During a 6-week field trial, participants reported hearing aid problems via ReSound Assist (intervention) or at a scheduled face-to-face follow-up appointment (control). Usability of ReSound Assist was assessed with a questionnaire and interview. Hearing aid performance, benefit, satisfaction, and daily usage were compared for both groups.Results: ReSound Assist was rated as highly usable. Participants identified specific aspects of effectiveness and efficiency that could be improved. Similar problems were reported by intervention and control participants regardless of communication mode (app-based vs. in-person). However, almost half the requests received via ReSound Assist were for problems that required advice from the provider or physical modifications to the hearing aids rather than fine-tuning, highlighting the continued importance of in-person hearing health care. There was no significant difference in hearing aid outcomes between intervention and control participants.Conclusions: Apps enabling remote patient-provider communication are a viable method for hearing aid users to seek and receive help with hearing aid problems that can be addressed through fine-tuning. Fine-tuning may be undertaken at the time of the initial hearing aid fitting, or, more commonly, after the patient has had the opportunity to wear the hearing aids in daily life. For this reason, several follow-up appointments may be needed to meet a patient's individual preferences.Hearing loss, a disorder of the ear characterized by a reduction in auditory sensitivity, is the most prevalent sensory impairment10 As a result, they may delay or forgo seeking help for their hearing aid problems. Second, patients can struggle to accurately describe listening problems retrospectively.11 If there is a lengthy delay between their experience of a problem and a visit to their provider, key details about the problem may be forgotten. Third, hearing aids are typically fine-tuned in the clinic, with the patient expected to rapidly assess whether the new, fine-tuned settings have adequately addressed the problem. This may lead to an unsatisfactory result when the patient trials the new settings in daily life, particularly if the original problem was experienced in an acoustic environment that differs markedly from a quiet clinic.12 Fourth, a recent longitudinal study of a large hearing health care provider found that unplanned fine-tuning appointments made up the largest proportion of appointment types, with almost a third of their patients attending four or more fine-tuning appointments after a hearing aid fitting.13 Together, these challenges suggest that postfitting care is a logical target for improving hearing health care access, effectiveness, and efficiency. Hearing aid manufacturers have recently begun to leverage cloud-based m-health technologies, such as smartphone applications (apps) that enable remote communication between patients and providers, in an effort to achieve these goals.15The potential need for multiple face-to-face follow-up appointments poses a number of challenges to hearing health care provision. First, patients who have mobility problems, are time-poor, or do not live near an audiology clinic can find it difficult to make repeated in-person visits to a provider.16 A recent study found that the usability of several m-health apps for chronic condition self-management was suboptimal across each of these dimensions, with excessive navigation through multiple screens, complex language, and ambiguous instructions identified as barriers to use.17 While m-health technologies are intended to improve health care access and efficiency, the authors point out that poor app usability can actually introduce an additional obstacle to achieving this goal. Balancing health care efficiency with patient outcomes is another important consideration in the development of m-health technologies. If an existing element of service delivery is to be augmented or replaced with an app, it is critical to ensure that patient outcomes are at least equivalent to those achieved through standard face-to-face care.Before m-health innovations are implemented into routine clinical practice, they must be rigorously evaluated to ensure they are both usable by, and beneficial for, the target patient population. The concept of usability encompasses three major components: (1) effectiveness, the accuracy and completeness with which the technology can be used to accomplish its goal; (2) efficiency, the resources expended by the user relative to the technology's effectiveness; and (3) satisfaction, the degree to which users are comfortable with, and accepting of, the technology.An app enabling remote communication between patients and providers was recently introduced by hearing aid manufacturer GN Hearing. Since the app is the first of its kind, very little is known about its acceptability to patients and its effect on hearing rehabilitation outcomes. An exploratory study was therefore conducted to gather preliminary information about the feasibility of incorporating the app into clinical practice. The aims of the study were to (1) assess the usability of the remote communication feature of the app; and (2) determine whether hearing aid fitting outcomes are influenced by the mode of patient-provider communication.Thirty adults  took part in the study. The inclusion criteria were as follows: (1) ≤85 years of age; (2) a four-frequency average hearing loss  between 25 and 75 dB HL; (3) smartphone ownership, to ensure data were collected on a sample that parallels likely real-world users of a hearing aid app; and (4) ≥1 year of bilateral hearing aid experience. The exclusion criteria were as follows: (1) presence of active ear disease; (2) non-English speaking; and (3) additional disabilities, such as severe cognitive impairment, that would preclude participation in the study. The median age of the participants was 67 years (range = 22–83 years). The median four-frequency average hearing loss was 45 dB HL (range = 29–75 dB HL).The hearing aids used in the study were ReSound LiNX 3D™ 962 hearing aids , receiver-in-ear devices with 4 programs, 17 channels, an environmental classifier, and binaural adaptive noise management algorithms. The smartphone app was the ReSound Smart 3D hearing aid app, which communicates with the user's hearing aids via a direct Bluetooth connection between the hearing aids and the user's smartphone. The app feature under test, ReSound Assist, enables hearing aid users to remotely request adjustments to their settings and to receive and upload the new settings from their provider. To use ReSound Assist, users must first have an internet connection. The user is then prompted to answer a series of questions to identify the nature of the problem, the environment(s) in which the problem is occurring, and the perceived severity of the problem. The request is sent to the provider via the cloud and the user receives an automated message indicating the approximate timeframe within which a response can be expected. In response to the request, the provider makes changes to the hearing aid settings within the fitting software and sends the new settings to the user via the cloud. The user is prompted in the app to download the new settings and upload them to the hearing aids.18 In its original form, the questionnaire contains 21 items that assess acceptance of and ability to use telehealth services and equipment. In the modified version used in this study, the phrase the telehealth system was replaced with the Assist feature in the ReSound Smart 3D app. Three items probing ease of real-time communication with the provider  were not relevant to ReSound Assist and were therefore removed. Possible scores range from 1 to 10, with lower ratings indicating greater usability.Usability of ReSound Assist was assessed only in the intervention group with a modified version of the Telehealth Usability Questionnaire.Usability was further assessed in the intervention group during a semi-structured exit interview. The first six questions, which required participants to provide a rating on a 5-point Likert scale, probed ease of use, satisfaction with the questions and answer choices provided by the app, satisfaction with the new settings sent by the provider, preference for ReSound Assist versus the type of postfitting face-to-face consultation they have attended with their own hearing health care provider, and preference for a similar feature with their own hearing aids. The other two questions were open-ended and asked participants to describe the problem(s) they reported via ReSound Assist and their overall experience with the feature.19Hearing aid benefit was assessed with the Abbreviated Profile of Hearing Aid Benefit, a 24-item self-report inventory in which participants rate the degree of difficulty they experience in a variety of quiet, noisy, and reverberant environments.20 Participants were asked to rate their satisfaction with device performance, effect on self-image, and negative aspects of hearing aid management, with higher ratings representing greater perceived satisfaction.Hearing aid satisfaction was assessed with the 15-item Satisfaction with Amplification in Daily Life scale.21 Testing was conducted in a circular array of 16 loudspeakers. Speech (subject-verb-object sentences containing three to eight morphemes) was presented from the loudspeaker at 0° azimuth; a recording of café noise was presented from the other 15 loudspeakers. The level of the speech was varied adaptively according to the participant's response  and the level of the noise was fixed. Speech was presented adaptively until a minimum of 16 sentences had been presented and a test-retest standard error of 0.8 dB was reached, or a maximum of 32 sentences had been administered.22The signal-to-noise ratio at which 50% speech recognition in noise is achieved was measured with the Beautifully Efficient Speech Test.Hours of use were logged by the hearing aids and read out in the hearing aid fitting software at the end of the study.Participants were assigned to one of two groups (intervention or control) matched for gender, age, and hearing loss severity. All participants attended an initial assessment at the laboratory during which otoscopy and pure tone air- and bone-conduction audiometry were completed and demographic data were recorded. At the second appointment, ∼2 weeks later, all participants were fitted bilaterally with the hearing aids and given the ReSound Smart 3D app. During the following 6-week field trial, intervention participants had access to ReSound Assist. Control participants did not have access to ReSound Assist; instead, they attended a face-to-face follow-up appointment 2 weeks postfitting. At the end of the field trial, all participants completed the outcome measures; intervention participants additionally completed the measures of ReSound Assist usability. The timing of the study appointments and the use of a 6-week field trial parallel real-world clinical practice in audiology, in which patients attend an initial assessment, are fitted with hearing aids ∼2 weeks later, and are followed up ∼6 weeks postfitting.23The treatment of participants was approved by the Australian Hearing Human Research Ethics Committee (AHHREC2018-18) and conformed in all respects to the Australian government's National Statement on Ethical Conduct in Human Research.17 data available for this participant, nor could he answer the closed-ended interview questions.Twelve of the 15 intervention participants used the ReSound Assist feature at least once during the field trial. Of the participants who used ReSound Assist, 11 were successful, meaning they were able to access the feature, answer the prompt questions, send a request, and upload the new settings to their hearing aids. The one unsuccessful participant attempted to use ReSound Assist several times but received a “service unavailable” message each time. The problem could not be reproduced in the laboratory. Since the usability measures could only be completed by participants who accessed ReSound Assist, there is no Telehealth Usability QuestionnaireThe mean overall score among the 11 participants who accessed ReSound Assist was 1.9 (standard deviation = 0.83), suggesting that they believed ReSound Assist was simple to use, they could use it to explain their needs effectively, and that it was an acceptable way to receive hearing health care services.Responses to the closed-ended exit interview questions are shown in Responses to the open-ended questions about participants' experiences using ReSound Assist were classified according to the three components of usability: effectiveness, efficiency, and satisfaction. There were 14 comments about effectiveness ; 6 about efficiency , and 6 about satisfaction . Representative comments about each component are shown in The problems reported via ReSound Assist are shown in Three participants did not use ReSound Assist. All reported they did not experience any problems with their hearing aids that would warrant contacting their provider.t-tests, namely a lack of influential outliers, normality of distribution, and homogeneity of variances.24t-test comparing the intervention and control groups. One participant in the control group did not complete speech discrimination testing because he lost one of the hearing aids during the trial. Hours of use could not be downloaded from the hearing aids of one participant in the intervention group. There were no significant differences  between the intervention and control groups in terms of speech discrimination threshold, hearing aid benefit, hearing aid satisfaction, or hours of daily hearing aid usage.Outcome measure data were assessed to ensure they met the necessary assumptions for performing independent samples 25 In the present study, the majority of ReSound Assist users successfully used the feature at least once during the trial and rated their satisfaction with ReSound Assist and its usability very positively.m-Health apps that enable remote patient-provider communication are a potential way to increase the accessibility of hearing health care and to facilitate real-time reporting of hearing aid problems. Usability has been identified in previous studies as an important prerequisite to successful integration of m-health apps into routine clinical practice.17 who advocated for participatory design as a way to improve the usability of apps for chronic condition self-management, the feedback given by the intervention participants provides valuable guidance for further improving the feature's usability. Although 11 of the 12 participants who used ReSound Assist were able to successfully use the feature, they did comment negatively on aspects of the app's effectiveness and efficiency. Specifically, the participants reported that the multiple-choice questions asked by the app—intended to ensure patients fully define the nature, severity, and frequency of their problem—were not always applicable to the problem they were experiencing, thus lessening perceived effectiveness. Several participants reported that as a result, they had to describe their problem in the text box in addition to answering all the questions, thus reducing perceived efficiency. Interestingly, this was most frequently the case when the participant wished to report a problem that could not be addressed through fine-tuning, such as difficulties maintaining a Bluetooth connection or streaming audio input. Together, user feedback and the finding that approximately half of the problems reported via ReSound Assist could not be solved through fine-tuning highlight the possibility of expanding the app's capabilities to increase usability. For example, the app could be programmed to send back automatically generated advice for a range of common problems, such as those related to Bluetooth and audio streaming.In line with Sarkar et al.,One participant used ReSound Assist to report that her hearing aids were uncomfortable to wear. Such problems almost always require the provider to make physical alterations to the hearing aid, such as changing the ear tip to a different size. This reinforces the important role of face-to-face consultations in hearing health care. However, if an app can help to triage patients such that only those truly requiring face-to-face care attend in-person follow-up appointments, this would still contribute toward alleviating the time and resource burden on individual providers.26 who found that remote versus in-person fine-tuning did not have a significant effect on speech understanding in noise or self-reported aided benefit in a sample of 14 adults. However, our results should be considered in the context of several limitations. First, the sample size of this exploratory study was small because its stated goal was to gather preliminary information about a recently introduced app with novel capabilities. It is possible that significant differences between the intervention and control groups may have been detected on one or more of the outcome measures with a larger sample size. On the basis of the present study's findings, a larger trial is warranted. Second, participants were followed for only the first 6 weeks after the hearing aid fitting since outcomes are typically measured at this time point in real-world clinical practice. However, this also means we cannot be certain of the longer-term impact of app-based patient-provider communication. Third, all study participants were experienced hearing aid users with established listening preferences and well-developed hearing aid management skills; those new to hearing aids may present with qualitatively different problems that may or may not lend themselves to resolution via an app. Future work in this area could focus on longer term usage experiences beyond 6 weeks and the ways in which m-health technologies could serve first-time hearing aid users as they acclimatize to amplified sound and acquire the skills necessary to become successful hearing aid users.There were no significant differences in hearing aid fitting outcomes between the intervention and control groups. This finding suggests that replacing the standard postfitting appointment with an app enabling remote patient-provider communication does not have a detrimental effect on outcomes, at least in the short-term. The current findings are also in agreement with Groth et al.,Our study found that (1) ReSound Assist, the remote communication feature in a commercially available hearing aid app, was highly usable based on a validated usability questionnaire and self-report; and (2) replacement of a face-to-face postfitting follow-up appointment with an app did not have a detrimental effect on hearing aid outcomes, at least in the short term. These findings suggest that while there is still scope for improvement, apps enabling patients to communicate remotely with their hearing health care provider are a viable method for experienced hearing aid users to seek and receive help with their hearing aid problems.


Hearing loss affects hundreds of millions of people all over the world, leading to several types of disabilities, ranging from purely physical to psychological and/or social aspects. A proper analysis to ascertain the main risk factors is essential in order to diagnose early and treat adequately. An exploratory analysis based on a heterogeneous sample of 1418 workers is presented in order to identify the main trigger factors for hearing loss. On the one hand, we recorded several medical and environmental parameters, and on the other, we created a model based on Bayesian networks in order to be able to infer the probability of hearing loss considering different scenarios. This paper focuses on three parameters: gender, age, and a family history of hearing problems. The results obtained allow us to infer or predict the best or worst auditory level for an individual under several different scenarios. The least relevant factor is the existence of a family history of deafness, followed by the gender factor, which slopes considerably toward better hearing for females, and most prominent of all, the age factor, given the large differences identified between the various age groups when the gender and family history of deafness variables remain constant. Hypoacusia is a prevalent condition in the population that affects some 360 million people worldwide, resulting in various levels of disability ranging from physical to social and psychological aspects . In partFernando Pablo  identifiAlthough the most common trigger for this disease is noise , in termWhile one could assume that the ears of young people are more resistant due to their more elastic basilar membrane, there are no conclusive data to support this hypothesis. It is believed that the likelihood of an injury rises in middle-aged individuals, and a great deal of controversy surrounds the correlation that might exist with the hearing loss caused by age itself (presbycusis) . FernandAlthough it is not predominant in either gender, various studies indicate that women are more resistant to noise than men  and thusFinally, there are studies that consider the individual susceptibility to noise, which may be hereditary (with family history being relevant), and the risk factors associated with hypoacusia, such as ototoxic treatments, meningitis, diabetes mellitus, and high blood pressure, among others ,10.Bayesian networks have been extensively used in the field of healthcare ,31,32,33This study analyzes the likelihood of developing hypoacusia, taking into account multiple variables. Bayesian networks (BN) are used. This model is based on demographic and personal factors, as well as occupational factors in different companies and non-work factors. The hypothesis is that the auditory health of people depends on the combination of all the aforementioned factors.Lastly, it is important to note that the purpose of this study was to answer the basic questions of how and why hypoacusia develops in workers: What factors most influence hearing health in individuals? What effects do demographic factors or the physical characteristics inherent to the individual have, and to what extent? To answer these questions, our research specifically focuses on studying the key demographic variables (age and gender) in combination with the factor on family hearing of deafness and their influence on the development of hypoacusia.Taking into account the data  of a period of two years from the Servicio de Prevención Ajeno Ingemédica S.L. (Limited Society), we gathered a pool of employees in different sectors of activity. These individuals, of various ages and nationalities, work in companies of Spain.The University of Burgos through its bioethics committee approved the study, and the ethical approval code is IR28/2020.We first proceeded to take noise measurements in the workplaces of the individuals in our study. We also conducted audiometric tests, which were complemented by the surveys published and authorized by the Ministry of Health and Consumption . All of As concerns the noise measurements, which were taken with sound level meters and dosimeters by qualified industrial hygiene specialists using proper measurement techniques, we were able to determine the sound levels in the different work environments in the companies where the workers in the sample carry out their activity. We also wrote personalized reports and evaluated the noise conditions at the companies, pursuant R.D. 286/2006, on protecting workers against the risks related to noise exposure .In the sample, two steps were taken to assess the hearing ability of the workers. First, each individual was subjected to a pure-tone audiometry via air conduction, which yielded the target medical data on their hearing acuity. Second, the survey given to the participants included several questions on their habits as well as on the subjective perception that the respondents have of their hearing acuity.As required by the applicable law on the Prevention of Occupational Risks ,46, the The sample pool consisted of 1418 individuals, for whom we collected demographic data such as age, gender, nationality, etc.; occupational factors such as type of sector or activity, the noise level, the noise exposure, the use or non-use of hearing protection, occupational exposure to noise in previous jobs and exposure to ototoxic agents, time-exposure limits; and lastly, data on non-work factors, such as off-hours noise exposure , a family history of hearing loss, use of drugs that affect hearing, and the history of auditory diseases or otologic events [Our conceptual model aims to explain the development of hypoacusia due to different variables, personal and demographic, occupational and non-occupational.To achieve this objective, we consider as key study variables the Speech Average Loss (SAL) index, the Early Loss Index (ELI), and the Overall Loss Percentage Index, which can most objectively determine the hearing acuity of an individual. We will analyze how these factors are affected by the other variables.Personal and demographic variables: nationality, weight and height, blood pressure, gender, and age.Occupational variables: previous jobs , noise level at workplace (measurement), daily hours of noise exposure, years at current job, occupational exposure to ototoxic agents, sector, workstation, and system for protecting against noise or use of personal protection.Non-occupational variables: off-hours exposure to noise, a family history of hearing problems, the presence of general diseases with the potential to affect hearing, a history of otologic events, and the use of ototoxic drugs.Hypoacusia evaluation variables: objective such as SAL index/ELI index/% Overall loss; or subjective such as hearing perception, quality of communications, Television volume, hearing ability in noisy environment, and sensitivity to loud noise.The variables involved in this model are:The variables chosen for this study are as follows: the Percentage of Binaural Loss Index as an objective variable, the effects on which were considered for the age, gender, and a family history of hearing problems for the individuals in the sample.The percentage of binaural loss (%Bl) is used for evaluating hearing acuity based on audiometric tests ,44 that Hearing loss is evaluated by measuring the preliminary thresholds for 500 Hz, 1000 Hz, 2000 Hz, and 3000 Hz tones (see Equation (1)). In one ear, the loss percentage is the individual percentages associated with each tone. To know the general loss percentage in both ears, the loss in the better ear (expressed as a percentage of hearing loss) is multiplied by 5, and it is multiplied by 1 for the worse ear. Then, the losses are added and divided by 6, as shown in Equation (2) The variable was discretized on the following intervals see .The gender variable refers to the sex and is therefore an independent, qualitative, and nominal variable. The sample pool consists of 1233 men and 185 women, which represents 86.95% and 13.05% of the sample, respectively.The distribution of the sample pool based on the age of the individuals is shown in This variable was discretized into quintiles for statistical processing, yielding the following groups based on age ranges see .This variable is divided into just two groups, depending on whether or not the worker had a family history of deafness or other significant otorhinolaryngological conditions see .4 − 1 = 15. However, considering the DAG, only 4 parameters are needed, which will simplify the learning process.Bayesian networks (BNs)  are probAs we have seen, in order to train a Bayesian network, two steps are needed. First, the DAG has to be trained , and secondly, the conditioned probabilities of the factorization obtained have to be adjusted to yield the final JPD. Both processes can be done automatically considering the data available . This reN/10 elements each. The data subsets will be used once as a test set, and the remaining data will be used to train the model [Note that, for each group of the target variable, a natural classifier is obtained defining a threshold for the probability given by the Bayesian network above (below) which the corresponding group occurs (or not). As a result, for each group, this classifier should be properly evaluated to both know the accuracy of the obtained model and avoid possible overfitting to the training sample, which leads to lower than expectable accuracy for new samples. In order to do this, a 10-fold cross-validation  is propohe model . Note thhe model ) Curve  to analyze their influence on the hearing health of the sample considered. Then, the results of the sensitivity analysis of the primitive variables are described in the subsections that follow.Below is the subgraph resulting from the proposed Bayesian network, showing the relationship between the primitive variables see .This study considers the joint influence of gender and age as factors that affect the development of hypoacusia see . It mustThus, it may be concluded that hearing loss increases with age, which is an effect that is more pronounced in men.The aim of this study is to determine the combined influence of gender and family history of hearing problems variables in the development of hypoacusia. We see that in both women and men, the probabilities of belonging to the group with the best hearing  is higher for individuals who do not report a family history of hearing problems than for those who do see . Once moThis study shows that people with no family history of hearing problems are more likely to belong in the group with the best hearing, for every age group . We can As far as the family history of hearing problems factor is concerned, we see that for people of the same gender and age, the likelihood of being in the Group 1 (best hearing) is higher for individuals who do not report a family history of hearing problems than for those who do. The difference in these probabilities is around one percentage point. For example, in the case of women ranging in age between 35 and 40, the likelihood of being in Group 1 is 97.92% when no family history of hearing problems is reported, versus 96.78% when such a history is present.As for the gender factor, we see that hearing in the women’s group is always better than in the men’s group when the age and family history of hearing problems factors are the same. The differences in the probability of belonging in the group with the best hearing are around 3 percentage points for the youngest individuals in the sample, and they rise to 17 percentage points for the older individuals. For example, we see that for women 49 years of age and older that do not report a family history of hearing problems, the probability is 90.56%, while for men of the same age who also report no family history of hearing problems, this probability is 73.58%.Focusing now on age, we see than in every case, regardless of whether or not a family history of hearing problems is reported, hearing acuity drops as the age of the individuals rises. In the case of women, the differences between the probabilities of being in Group 1 is 8 percentage points between the youngest and oldest individuals, which is a difference that rises to 23 percentage points in the case of men. For example, for men who report a family history of hearing problems, the probability is 95.03% for those under the age of 29 and 72.29% for those over the age of 49.In view of the results, we can conclude that the variables analyzed affect the development of hypoacusia such that the likelihood of presenting this condition increases with age, especially for men and if a family history of significant hearing problems is reported see .Consequently, the influence of the three variables analyzed varies in intensity, such that the element with the least effect, meaning the factor that exhibits the lowest percent variation when the other two factors are unchanged, is the existence of a family history of deafness, followed by gender, which slopes considerably toward better hearing for females, and most prominent of all, age, which is the most crucial of all given the large differences identified between the various age groups when the variables involving gender and family history of deafness or significant hearing problems remain constant.The first result of our research was the compilation of an extensive database, useful for multiple studies, that allows us to infer or predict the best or worst hearing acuity for an individual given several different scenarios. By creating a Bayesian network based on the data obtained from a sample of 1418 workers and consistent with the main factors responsible for hypoacusia, classified by demographic/personal origin and occupational and non-occupational variables, we were able to more accurately weigh and ascertain those variables that are most influential in the development of hypoacusia. One of the main findings of this study lies in the use and operation with the aforementioned Bayesian network methodology to conduct a combined and predictive analysis of how the factors of gender, age, and family history of hearing problems affect the probability that an individual will exhibit good or poor hearing acuity.The hearing acuity was assessed via medical audiometric tests that were processed using the criterion of the Percentage of Binaural Loss Index, which is an intuitive and widely used method, of critical importance to the legal process of quantifying disability due to deafness of hypoacusia. For our sample pool, we determined that the average binaural loss was 1%. Taking into consideration the magnitude of the sample, which consisted of 1418 workers in various economic sectors and different jobs, we found their auditory health to be generally good, as there were only 6 people (0.28%) who showed hearing loss of more than 30% versus 86.11% of people who did not show any hearing loss at all.Our study of the factors that influence an individual’s hearing acuity first analyzed the three selected factors—gender, age, and family history of hearing problems—separately. We noted that women exhibit better hearing acuity than men. As for age, the younger respondents (below the age of 29) are more likely to have good hearing, which is a probability that decreases inversely with age. Lastly, as for the family history of hearing problems, those individuals who do not report such a history have a slightly higher likelihood of having better hearing than those who do indicate some type of family history.Then, we analyzed the combined influence of the gender and age factors, noting that hearing in women is always better than in men when their respective age groups are compared. We also concluded that women, regardless of their age, are more likely to be in Group 1 (best hearing) and that this probability always exceeds the initial probability of 89.04%.As concerns the analysis of the influence that the gender and family history of hearing problems variables have on the development of hypoacusia, we see that in both women and men, the probability of having good hearing is higher for those who do not report a family history of hearing problems than for those who do.When we both studied the influence of the age and family history factors, we saw that for every age range, those with the highest likelihood of having good hearing are those who do not report a family history of hearing problems.A study of all three factors—gender, age, and family history—combined confirms the above findings. As for the factor involving a family history of hearing problems, we see that for individuals of the same age and gender, the probabilities of being in the group with the best hearing are higher for those who do not report a family history of hearing problems than for those who do. As concerns the gender factor, we see that hearing acuity for women is always better than for men given the same age and family history of hearing problems. If we focus on age, we see that in every case, regardless of whether or not a family history of hearing problems is reported, hearing acuity decreases as the age of the individual increases.In view of these results, we may conclude that the variables analyzed affect the development of hypoacusia, which is more likely to develop with age, especially in males, and more so if the individual reports a family history of deafness or considerable hearing problems.As for the gender of the individuals, our study confirms the theories that ascribe a superior hearing acuity to women compared with men, such as those by Muñiz , FlodgreIn terms of the age factor, our work substantiates those studies that find that hearing worsens with age, that the ear deteriorates with age, and that independent of the type of noise exposure experienced, hearing loss will result, as concluded by Fernando Pablo . It alsoAs concerns the family history of hearing problems and its effect on developing hypoacusia, our study supports the findings of Sanz , who undIt is important to emphasize that the three variables analyzed have different levels of influence on a person’s hearing, such that the least relevant variable is the existence of a family history of deafness, followed by the gender variable, which varies considerably in favor of better hearing for females, and most prominent of all, the age variable, given the large differences identified between the various groups, while the gender and family history of deafness variables remain constant.


This study aimed to describe and compare the performance of older adults with normal hearing and hearing impairments in mismatch negativity (MMN), correlate MMN with cognitive tasks and central auditory processing (CAP), and identify normal values for MMN in older adults.This study had 54 participants. The Montreal Cognitive Assessment (MoCA) was used to assess cognition and the random gap detection test (RGDT), dichotic digit test (DDT), and speech to noise (SN) test were used to evaluate CAP. MMN was elicited with the verbal stimulus /da/ (frequent) and /ta/ (rare), and the latency, amplitude, duration, and area were analyzed.When comparing the normal-hearing group to those with hearing loss, there was no significant difference in MMN. When correlating MMN with MoCA, RGDT, DDT, and the SN test, there was a weak correlation between the MMN amplitude and the RGDT and DDT. When comparing the MMN of participants with normal and altered cognitive aspects and those with normal and altered DDT, the MMN duration was found to be affected by the DDT. The mean latency value of the MMN in the normal-hearing group was 199.8 ms, the amplitude was -2.2 µV, area was 116.1 µV/ms, and duration was 81.2 ms.Mild hearing loss did not influence MMN. There was no correlation between MMN and cognitive aspects, and there were weak correlations with CAP. Alterations in CAP led to longer durations in MMN. Normal values for MMN in adults aged between 60 and 77 years were generated. Considering the rapid aging of the global population, geriatric research has become increasingly necessary, as there has never been such a large number of people at such an advanced age . Among tAudiologists are already aware of the importance of using hearing tests that evaluate both peripheral and central hearing and the benefit of this union for a more accurate diagnosis . UndoubtCAPD can occur because of presbycusis, but also by the process of natural aging. During aging, there is a decrease in the number of neurons responsible for synapses that adequately transmit sound stimuli . It is nThe evaluation of the central portion is performed using behavioral tests that evaluate central auditory processing (CAP) and electrophysiological properties, such as long latency evoked auditory potentials (LLEAPs). LLEAPs are advantageous because, in addition to hearing assessment, it allows one to assess attention and memory ,6. HowevFrom this perspective, tests that evaluate cognition can work in tandem to guide the rehabilitation process. Cognitive decline can occur continuously and regularly for intensive processing tasks such as processing speed, working memory, and long-term memory ,8.Therefore, the justification for this study is centered on expanding assistance to older adults, providing a more accurate diagnosis and, consequently, greater possibilities for rehabilitation. It is also intended to establish the relationship between MMN and behavioral and cognitive tests in older adults.Thus, this study aimed to describe and compare MMN in older adults with normal hearing and those that are hearing-impaired, correlate MMN with cognitive and CAP tasks, and identify normal values for MMN in older adults.This was a cross-sectional, descriptive, and quantitative study approved by the local Research Ethics Committee on Human Beings (#3326307). All individuals invited to participate in the research were instructed about their free and spontaneous participation and signed a Free and Informed Consent Form, which contained all the procedures to be performed.Older adults of both sexes from social group participants in the region and those who sought audiological evaluation from a public speech therapy service were invited. Individuals aged 60 years or older were considered older adults .The eligibility criteria were as follows: age ≥60 years; auditory thresholds within the normal range in both ears , or mildAfter collecting the eligibility data, the behavioral tests of the dichotic digit test (DDT), random gap detection test (RGDT), and speech in noise (SN) test were performed inside an acoustically treated booth, with the aid of a two-channel audiometer  and earphones . The test was transmitted by a computer that remained attached to the audiometer.The DDT was performed to evaluate the auditory ability of figure-background for verbal sounds . Two digThe SN test was performed to assess auditory closure using the Brazilian version by Pereira and Schochat . We presThe RGDT  was perfThe tests were selected to perform auditory processing screening. Therefore, the most relevant skills for older adults were considered. In addition, an evaluation that was neither extensive nor tiresome was recommended, as it could otherwise interfere with performance. Thus, the purpose of this CAP evaluation was to capture alterations present in older adults with complaints about the ability to perform figure-background and auditory closure when they are exposed to unfavorable environments. Temporal resolution is also considered a skill affected by age, which compromises speech understanding; the RGDT is considered the most sensitive test to detect alterations in this ability .In addition, the DDT and RGDT can be applied to older adults with hearing loss. The DDT, for example, has normality criteria for older adults with sensorineural hearing loss . The RGDAfter the CAP tests, participants were evaluated using the Montreal Cognitive Assessment  , which a®  electrolytic paste and micropores. Before placing the electrodes, the skin was cleaned with Nuprep® (Weaver and Company) exfoliating gel for better conduction of the electrical signal.Finally, all participants underwent MMN testing using two-channel Smart-EP equipment . To capture the potentials, silver electrodes were fixed at specific points according to the International Electrode System 10-20 as follows: active electrode in Fz, ground electrode in Fpz, and reference electrodes in the right and left mastoids, with the aid of MaxxiFixThe participants remained awake, sitting in a comfortable armchair, and the potentials were captured and visualized on a computer to which the equipment was attached.MMN was analyzed with the verbal stimulus of da/ta, a synthetic and unnatural speech stimulus, in which /da/ represents a frequent stimulus and /ta/ a rare stimulus , presentAuditory stimuli were transmitted via earphones in a binaural way and were guaranteed from 20 to 25 dBNS in all participants . They weThe stimuli were presented at a speed of 1.9 stimuli/s, with a rare stimulus probability of 20%. There were 750 stimuli presented in total, in an attempt to obtain at least 150 rare stimuli ,22,23. TWave analysis was performed by the researchers and two expert judges in the area to achieve a consensus. The presence or absence of MMN was analyzed, and if present, the variables analyzed were latency, amplitude, duration of the potential, and valley area.MMN was considered as a negative peak, obtained by the difference in curves (resulting wave) by subtracting the response curves to the frequent stimulus from the response curves to the rare stimulus, visualized in a latency after N1 ,26 and mFor the sample calculation , an analp≥0.05 were considered normal and those with p≤0.05 were non-normal.After collecting the data, all results were recorded in Microsoft Excel  and later analyzed using Statistica 9.0 software . The Shapiro-Wilk test was used to assess normality, in which variables with p≤0.05, with a 95% confidence interval.After this analysis, the majority of variables were non-normal. Therefore, non-parametric tests were used for further analysis. The Mann-Whitney U test was used for comparisons, and Spearman's correlation coefficient was used for correlations. Significant results were considered when Initially, 85 older adults participated, but only 54 had the necessary criteria for the study. p=0.086). The mean years of formal study in the group with normal hearing was 11.1 years (SD=5.9) and 9.8 years (SD=4.6) in those with hearing loss. There was no significant difference between the groups in terms of years of education (p=0.433).There were 33 older adults with normal hearing with a mean age of 65.8 years (SD=3.9) and 21 with hearing loss with a mean age of 68.4 years (SD=5.3). There was no significant difference in the mean ages of participants with or without hearing loss  in the right ear, the MMN amplitude increased (improved), which is also not expected because it is understood that the poorer the auditory processing, the poorer the discrimination of sounds in the electrophysiological evaluation would be and vice versa. In this case, the correlation was weak and did not occur in the left ear. There was no correlation between the SN test and MMN.Given the results, it was evident that MMN was not negatively affected by difficulties in behavioral skills assessed by the RGDT, DDT, and SN test. No studies that carried out an analysis of MMN with CAP tests in older adults were found, which made it difficult to compare and discuss the results in this population. The influence of CAP alteration on MMN has already been shown in children , but theWhen comparing normal and altered older adults in terms of cognitive and CAP aspects through screening using MoCA and DDT, it was observed that only MMN duration was affected by the alteration in DDT, becoming longer . MMN durAs older adults with altered DDT results show longer MMN durations, this may indicate that they need more time to discriminate the rare stimulus, considering that there is a great similarity between the rare and frequent stimuli, despite the detection time (latency) being similar to older adults with normal DDT results.However, cognition is unlikely to cause impairment in MMN , as theyThus, to generate normality values for MMN, older adults aged between 60 and 77 years with normal CAP and normal hearing or mild sensorineural hearing loss were considered, regardless of cognitive conditions and an average schooling of 11.08 years. Regarding the normal values found for the MMN variables , it was A limitation of this study is the absence of older adults with higher degrees of hearing loss for comparison. In the future, it is believed that MMN would not as a diagnostic instrument for alterations in CAP or cognition, but as a biomarker that can monitor the effects of therapy or auditory training in older adults.MMN was observed in normal-hearing older adults with mild sensorineural hearing loss. Mild hearing loss did not influence the latency, amplitude, area, or duration of this potential. When correlating MMN with CAP tests, there were some weak correlations with amplitude, but alterations in CAP did not negatively affect MMN. Individuals with altered DDT had a longer MMN duration. Cognitive aspects do not seem to influence MMN responses.It was possible to generate normality values for older adults aged between 60 and 77 years with normal hearing or hearing loss. The average latency value was 199.8 ms, the amplitude was -2.2 µV, the area was 116.1 µV/ms, and the potential duration was 81.2 ms.Brückmann M was responsible for the data collection, data tabulation, statistical analysis, and manuscript preparation. Pagliarin KC was responsible for the manuscript writing and revision. Garcia MV was responsible for the orientation and revision of the manuscript.


In the “No decline” -group, the ADL rose by 3.3 points . A multiple regression analysis revealed that preoperative cognitive impairment  2.862 ; p = 0.019) and duration of postoperative delirium ≥ 2 days (Exp(B) 3.534 (1.094–11.411); p = 0.035) was independently associated with ADL decline half a year after the operation and ICU. Of note, preoperative ADL per se was neither associated with baseline cognitive function nor a risk factor for functional decline. We conclude that the preoperative assessment of cognitive function, rather than functional assessments, should be part of risk stratification when planning complex cardiosurgical procedures.Cardiac surgery and subsequent treatment in the intensive care unit (ICU) has been shown to be associated with functional decline, especially in elderly patients. Due to the different assessment tools and assessment periods, it remains yet unclear what parameters determine unfavorable outcomes. This study sought to identify risk factors during the entire perioperative period and focused on the decline in activity of daily living (ADL) half a year after cardiac surgery. Follow-ups of 125 patients were available. It was found that in the majority of patients (60%), the mean ADL declined by 4.9 points (95% CI, −6.4 to −3.5;  Cardiac surgery and subsequent intensive care unit (ICU) treatment in patients at higher age have been shown to be associated with sustained cognitive impairment ,2, beingMost cardiac surgery patients “expect to return to normality“ . The risThese contradictory findings may be attributed to the variety of tools used to assess functional outcomes and the degrees thereof . For thiThis is an a priori planned secondary analysis from a single-center prospective cohort study which enrolled patients scheduled for cardiac surgery in the University Hospital Bonn, Germany, with approval from the medical ethics committee of the University of Bonn, Chair Prof. Dr. Racké , and registered in the German clinical trials registry (DRKS00021662). This study was conducted in accordance with the Declaration of Helsinki. During a 6-month period from July through December 2009, every consecutive patient scheduled for cardiac surgery was screened for eligibility, and followed up by telephone until June 2010. The exclusion criteria were age <50 years, inability for preoperative assessment of cognitive function , participation in another study, as well as urgent and emergency surgery. After obtaining written informed consent, the patients’ demographics and clinical parameters—including age, gender, length of school and job education, weight, height, and gender—were recorded. The assessment of their past medical history included current medication, visual and hearing impairment, and nicotine and alcohol consumption. Nicotine consumption was classified as “never”, “stopped before at least two months”, and “ongoing”. Alcohol consumption was graded as “never”, “occasionally” (≤7 drinks per week), “moderate” (7–14 drinks per week), and “heavy” (>5–6 drinks per day.) A thorough assessment of organ dysfunctions, including cardiac, pulmonary, neurological, gastrointestinal, hematological, malignant, and connective tissue diseases was carried out, and the Charlson comorbidity index as well as the logistic EuroScore—derived from age, sex, and the number and seriousness of pre-existing comorbidities—were calculated ,14.ADL was assessed according to the “Alzheimer’s Disease Cooperative Study Group” (ACDS-ADL) pre-operatively and six months thereafter. ACDS-ADL includes the evaluation of instrumental activities of daily living . ACDS-AD−1·h−1), use of milrinone, lowest hemoglobin concentration during cardiopulmonary bypass (CBP), length of hypothermia (classified as T < 35 °C), lowest temperature, duration of cardiopulmonary bypass, duration of aortic cross clamping, use of intraaortic ballon counterpulsation (IABP), hypoglycemia (serum glucose < 60 mg/dL), and hyperglycemia (serum glucose > 150 mg/dL) were recorded.The premedication consisted of midazolam  on the evening before and on the morning of surgery. The induction of anesthesia included propofol, sufentanil, and pancuronium bromide. Anesthesia was maintained with continuous sufentanil and inhalative isoflurane. Dosages were left to the attending anesthetist’s discretion. Mild hypothermia  was induced during cardio-pulmonary bypass. No antagonization of neuromuscular blockade was conducted. Transesophageal echocardiography was used to confirm the intraoperative deairing of the heart. All the patients were transferred sedated and mechanically ventilated to the ICU. The type of cardiac surgery, length of hypotension , length of catecholamine requirement  intravenously and ibuprofen as a suppository three times a day. Beginning with the first day after cardiac surgery, patients were rated at least once per day shift and (if not sleeping) once per night for their state of vigilance with the Richmond Agitation Sedation Scale (RASS)  and theip < 0.05 was considered statistically significant for all parameters. Patients’ demographic data were grouped into whether they had postoperative ADL lower than preoperative ADL (“ADL decline”), or whether there was no change or a higher ADL than before surgery (“No decline”). Patients’ characteristics, including age, height, weight, EuroScore, laboratory results, SAPS II on the day of admission to ICU, duration of mechanical ventilation, length of stay in the ICU, and length of stay in hospital were calculated as a median with interquartile range (IQR) and compared with the Mann–Whitney U test. Categorical variables such as gender, comorbidities, type of surgery, and presence of ApoE ε4-allel were calculated as relative frequencies with percentages and compared with Fisher’s exact test or a Chi square-test, if appropriate. A p ≤ 0.05 and an exclusion criteria of p ≥ 0.10. Statistical analyses was performed with IBM® SPSS® Statistics Version 26  and GraphPad Prism 5.0 .Factors associated with “ADL decline” in the univariate analysis , as well as age, gender, and preoperative ADL were entered into a binary logistic backward regression analysis with “ADL decline” as the independent variable. A stepwise backward selection logistic regression analysis was used with an inclusion criteria of n = 102), emergencies (n = 46), participation in another study (n = 5), and not German speaking (n = 9). Eighteen more patients declined or withdrew consent, leaving 221 patients for complete preoperative assessments. Out of these, three eventually did not receive surgery, and 12 more died in ICU or during the follow-up period. Twenty-eight patients did not have a spouse or close relative to complete the preoperative ADL questionnaires. For 37 patients, the postoperative ADL was not completed due to multiple reasons , 14 patients or their relatives declined to participate, and two patients were lost to follow-up, leaving 125 datasets for the analysis of decline in ADL. Of two patients, ADL could not documented before surgery, and two more patients’ relatives declined to complete the ADL questionnaire after surgery, but they all stated that the patients were “doing much worse” than before surgery. These four patients were grouped into “ADL decline”. They were excluded from the calculation of postoperative ADL, but were used otherwise to identify the risk factors of ADL decline.Four-hundred and one patients were screened, 162 of whom were not eligible for this study . Reasonsp = 0.049).Data from those patients of whom no follow-up information was obtained (N = 81) are available as online n = 75 of 125) with completed follow-up had a lower ADL 180 days after cardiac surgery and ICU. In those, the mean ADL declined by 4.9 points . In the “No decline” group, the ADL inclined by 3.3 points . Intraoperative patients’ parameters divided into “ADL-decline” and “No ADL-decline”. All the continuous data were compared with the Mann–Whitney U test and presented as medians with interquartile ranges (IQRs). Categorical variables are presented as the number and percentage of patients and were compared with two-sided Fisher’s exact test. ADL, activity of daily living. Vasopressors: sum of the highest dosage of epinephrine and norepinephrine.p = 0.007), duration of aortic crossclamping  in the univariate analysis, as compared to higher and lower MMSE levels. For no other parameter, including age and preoperative ADL, was a statistically significant difference found even after computing them as dichotomous variables. Three variables differed between those with and without ADL decline: lower score of preoperative cognition . The ADL remained stable in the “MMSE ≥ 27” group , whereas there was a significant ADL decline in the “MMSE ≤ 26” group to 36 [28–40] points . When comparing patients with preoperative MMSE ≤ 26 and MMSE ≥ 27, no significant difference was found in the preoperative ADL a. The mep = 0.001, Wilcoxon signed rank test) in the group who had “Delirium ≥2 days”. ADL remained stable in the groups with no or only one day of delirium. Note that, again, the preoperative ADL did not differ between groups .Postoperative delirium did have an impact on ADL when lasting two days or longer . Figure Factors associated with “ADL decline” in the univariate analysis , as well as age, gender, and preoperative ADL were entered into a binary logistic backward regression analysis with “ADL decline” as the independent variable. n = 123 patients’ data sets. R2 = 0.094 (Cox and Snell); R2 = 0.126 (Nagelkerke); χ2(4) = 12.089; p = 0.002. CI, confidence interval; MMSE, Mini-Mental State Examination.Age, sex, MMSE ≤ 26, preoperative ADL, duration of aortic clamping, and length of delirium ≥2 days were included in a binary logistic regression analysis with the outcome variable, ADL decline. This model included This study was conducted to investigate the functional status before and after cardiac surgery and intensive care treatment, and to explore potentially modifiable risk factors of adverse outcomes. The data presented in this study revealed that the majority of patients (60%) experienced substantial functional decline half a year after elective cardiac surgery and intensive care treatment. The risk factors for “ADL decline” were preoperatively impaired global cognition MMSE ≤ 26) and length of postoperative “delirium ≥2 days”. Preoperative functional status (ADL) per se was not a risk factor for “ADL decline”, and it was not associated with preoperative cognitive status. Factors reported by others to be associated with functional decline  were not confirmed in this study [ and lengPreoperative cognitive impairment has repeatedly been shown to be a risk factor of postoperative delirium and sustained cognitive impairment after cardiac surgery ,10,27,28Delirium has been previously identified as an independent predictor of postoperative cognitive impairment up to one year after cardiac surgery ,4, whilen = 566), delirium was risk factor for “clinically meaningful” functional decline 18 months after surgery [In a prospective study involving 300 elective cardiosurgical patients, delirium was not only associated with increased mortality, frequent hospital readmissions, and reduced quality of life, but also with functional impairment, such as reduced independency in ADL and mobility . In non-Interestingly, they also demonstrated that the duration of delirium did have an impact: one month after surgery, each additional day of delirium increased the risk of functional decline significantly . That reOnly a few studies have evaluated functional status preoperatively and followed patients up postoperatively for more than four to six weeks. The comparison of studies is difficult due to a variety of assessment tools used at different postoperative time points.In a study involving 62 patients after cardiac surgery and using a count of nine pre- and postoperative ADLs, seven of which were instrumental ADLs (IADL), pre-operative ADL impairment was associated with ADL decline 1 month postoperatively, but was not discriminative of functional outcomes six months after surgery ,31. The The temporal course of postoperative assessments should be paid attention to when comparing studies on functional long-term outcomes. In a study on 372 non-cardiosurgical patients, the maximum functional declines occurred 1 week postoperatively . The meaSome major limitations should be addressed: Firstly, we investigated only elective cardiosurgical patients of higher age. This led to a rather homogenous patient group. Therefore, age and creatinine were not found to be risk factors of functional decline, in contrast to other reports . The risFourth, the postoperative assessment of the MMSE was performed by a telephone version with a maximum of only 22 points. It skips those tasks that require a face-to-face situation, such as drawing the interlocking pentagons, etc. We found a significantly lower telephone MMSE in the “ADL-decline” cohort. Though the 22-item telephone MMSE was shown to strongly correlate with the full MMSE , we did Finally, we used only ADL to assess functional status. In non-surgical patient groups, functional status and cognition are closely associated . This maThe majority of patients had a substantial decline in ADL after cardiosurgical ICU. A lower preoperative cognitive score and ICU delirium ≥2 days were independent risk factors for ADL decline. Preoperative cognition and baseline functional status were statistically not associated. Hence, additional work should be directed towards tool development for the reliable detection of risk factors for post-operative functional decline. Ideally, these should include brief measures of cognition, functional status, and QoL, and it should be possible to perform them during follow-ups on the telephone. They would be relevant for the future development of interventions to prevent functional decline in older people undergoing cardiac surgery.