E. coli-produced A3A. The enzyme binds to single-stranded DNA with a Kd of 150 nM and forms dimeric and monomeric fractions. A3A, unlike APOBEC3G (A3G), deaminates DNA substrates nonprocessively. Using a panel of oligonucleotides that contained all possible trinucleotide contexts, we identified the preferred target sequence as TC (A/G). Based on a three-dimensional model of A3A, we identified a putative binding groove that contains residues with the potential to bind substrate DNA and to influence target sequence specificity. Taking advantage of the sequence similarity to the catalytic domain of A3G, we generated A3A/A3G chimeric proteins and analyzed their target site preference. We identified a recognition loop that altered A3A sequence specificity, broadening its target sequence preference. Mutation of amino acids in the predicted DNA binding groove prevented substrate binding, confirming the role of this groove in substrate binding. These findings shed light on how APOBEC3 proteins bind their substrate and determine which sites to deaminate.APOBEC3A (A3A), one of the seven-member APOBEC3 family of cytidine deaminases, lacks strong antiviral activity against lentiviruses but is a potent inhibitor of adeno-associated virus and endogenous retroelements. In this report, we characterize the biochemical properties of mammalian cell-produced and catalytically active  APOBEC3A (A3A) is one of the seven-member APOBEC3 family of cytidine deaminases encoded in the human genome Expression of A3A is largely restricted to myeloid cells such as monocyte-derived macrophages (MDM) and monocyte-derived dendritic cells (MDDC). The expression of A3A is upregulated in these cells in response to type I interferon treatment, which suggests a role for A3A in the antiviral response CA as the preferred trinucleotide motif for deamination C trinucleotide preferred by A3G. How the sequence differences between A3A and A3G account for this altered sequence specificity has not yet been determined.A3A, like all APOBEC3 family members, specifically deaminates single-stranded DNA (ssDNA). It consists of a single deaminase domain, a feature in common with APOBEC3C and APOBEC3H but different from APOBEC3B, APOBEC3D, A3F, and A3G which have two deaminase domains. When expressed in myeloid cells, A3A localizes in the cytoplasm and is not genotoxic E. coli and in mammalian cells. We found that the protein is a dimer that acts nonprocessively with a preference for a TC (A/G) trinucleotide. By generating chimeric proteins in which loops of A3A were exchanged with those of A3G, we identified a putative sequence recognition loop, which determines the deamination target site specificity. We also identified several residues in the putative ssDNA binding groove and a second putative recognition loop that were required for A3A interaction with ssDNA and identified two amino acids that are specific to A3A that appear to play a role in reducing the affinity of the protein for ssDNA.Here, we biochemically characterize the enzymatic activity of catalytically active A3A produced in E. coli  in E. coli . The rA3E. coli . It also58±70 nM . To dete58±70 nM . While t58±70 nM .Since the production of A3A in bacteria or conditions used during the SEC might have led to the observation of artifactual multimers A3G processively deaminates ssDNA. To determine whether A3A also deaminates processively, we established a deaminase assay using an oligonucleotide substrate containing a fluorescein tag flanked by two TCG trinucleotides . This asWe further tested processivity by determining the ability of rA3A to deaminate an oligonucleotide substrate containing deamination sites arrayed in tandem. Following this deamination reaction, the oligonucleotide substrate was subjected to one round of amplification, cloned into TOPO-TA vector and the resulting clones were sequenced . Eight oCA, NCT, NCC, and NCG). Each oligonucleotide was incubated with rA3A, and the products were separated on a gel and analyzed as in the in vitro deaminase assay. The analysis demonstrated that rA3A preferred a TC dinucleotide (C followed by A or G was the preferred trinucleotide motif (C (A/G). These results are in agreement with a previous study investigating the 5′ context constraints of the deamination site We used a panel of four oligonucleotides to determine the target site preference of A3A, each of which contained four tandem deamination sites. The four 5′-biotinylated oligonucleotides varied in the nucleotide 5′ of the target cytosine , and each oligo contained four different deamination sites differing at the nucleotide 3′ of the target cytosine  consensus deamination site of A3A differs from the CCC consensus site of A3G. The catalytic domains of A3A and A3G are very similar in amino acid sequence and thus, relatively few amino acids are likely to determine this sequence preference. In order to test this hypothesis, we compared the sequences and structures of A3A and A3G . In contrast, the RL1 chimera was active, but was more flexible with respect to the nucleotide 5′ to the deaminated C, deaminating AC, CC and GC with increased frequency  and recognition loop 2 (RL2) in A3A were replaced by the corresponding recognition loops of A3G. In addition, we generated A3A with a W104A mutation or a deletion of W104 and G105 (ΔWG104-5). To determine the catalytic activity of the mutated enzymes, we expressed them in transfected 293T cells, immunoprecipitated them, and tested the catalytic activity of the proteins in an cleotide . There wrequency . These din vitro deaminase assay . This finding is similar to the (T/C) CA consensus previously reported by Chen et al. C identified by others C. The amino acid sequence similarity of the catalytic domains of A3A and A3G allowed us to generate chimeric proteins to determine the domains of the protein that specify the target site preference. The analysis identified a recognition loop termed RL1 in the amino-terminal domain of A3A. Replacement of RL1 with the corresponding sequence of A3G did not exchange the target site preference to CCC but allowed for deamination irrespective of the 5′ and 3′ nucleotides. Unlike A3G, A3A deaminates ssDNA substrates by a nonprocessive mechanism, consistent with the findings of Love et al.A detailed analysis of deamination target site preference shows that the consensus deamination sequence for A3A is Tet al. The mechanism by which RL1 determines target site specificity of A3A is not clear. One possibility is that residues G25 and I26 in RL1 directly contact the DNA substrate; however, the NMR structure reported by Byeon et al. et al. Kohli 2+, it is surprising that insertion of these amino acids are tolerated yet deletion has no effect. In the evolution of these proteins, the insertion of these amino acid residues into A3A in new world monkeys and hominids must have occurred following the divergence of A3A and A3G. The deletion of the two amino acids caused a three-fold increase in affinity of the protein for ssDNA resulting in an affinity similar to that of A3G for its substrate. Mitra et al.et al., we did an additional kinetic analysis to definitively determine the deaminase activity of the W104A A3A. The results again confirmed our finding that the W104A, RL2 and E72Q mutants lacked detectable deaminase activity . The protein as produced in 6 cells per well and cultured for 20 h with or without 2000 units of Universal Type I IFN  or 2.0 µg/ml γ-IFN after which they were lysed in protease-supplemented lysis buffer .293T and HeLa cells were cultured in Dulbecco’s modified Eagle medium supplemented with 10% fetal bovine serum and penicillin and streptomycin. Primary monocytes, monocyte-derived macrophages (MDM), monocyte-derived dendritic cells (MDDC) and T cells were cultured in RPMI 1640 supplemented with 10% FBS and penicillin and streptomycin. Monocytes were purified from leukocyte enriched blood samples obtained from anonymous donors by the New York Blood Center using anti-CD14-conjugated magnetic beads (Miltenyi Biotec) and differentiated into MDM by culturing for 7 days with 50 ng/mL GM-CSF or into MDDC by culturing with 50 ng/mL GM-CSF and 100 ng/mL IL-4 (Invitrogen). MDM and MDDCs were plated in 12 well plates at 1.0×10E. coli. Point mutations were introduced into A3A by overlapping PCR. All plasmids were confirmed by nucleotide sequencing and expression of the encoded proteins was confirmed by immunoblot analysis.Mammalian expression vectors for FLAG-tagged, HA-tagged, and Myc-His tagged A3A were generated by PCR amplification of the coding sequence with oligonucleotide primers containing EcoR-I and Xho-I sites and ligated to pcDNA6 A/myc-his (Invitrogen). Amplicon lacking a Kozak sequence was cloned into pET42a+ to generate the pET42.A3A for expression of a GST-A3A fusion protein in E. coli BL21 (DE3) CodonPlus RIPL cells (Stratagene) were transformed with pET42a-A3A and single colonies were cultured overnight and used to seed 500 ml of Luria broth. The cultures were grown for 5 h at 37°C and induced for 2 h with 200 µM IPTG. The bacteria were pelleted, freeze thawed, resuspended in PBS, sonicated and lysed in buffer containing 1% Triton-X100. The lysate was treated for 1 h at rm. temp. with 25 units/ml of Benzonuclease (Novagen) and then clarified by centrifugation for 10 min at 6000×g. The recombinant protein was collected on 500 µl of glutathione agarose (Sigma) for 16 h at 4°C. The resin was washed with PBS and resuspended in buffer containing 50 mM Tris-HCl (pH 8.0), 100 mM NaCl, 5 mM CaCl2 (pH 8.0). The protein was cleaved from the beads with 10 U Factor Xa (Novagen) and used for size exclusion chromatography or concentrated on YM-10 (Millipore) and stored at −20°C in 50% glycerol. rA3A, without concentration, was analyzed by FPLC on a Superose-12 gel filtration column (GE) with protein standards. 1.0 ml fractions were collected and the protein concentration and deaminase activity was determined for each fraction.5) were transfected with 4.0 µg pcDNA6-A3A-myc-his using Lipofectamine 2000 (Invitrogen). After 48 h, the cells were lysed in lysis buffer . To immunoprecipitate A3A, the lysates were precleared with protein-G sepharose  and immunoprecipitated with anti-myc antibody (Covance) and protein-G sepharose for 2 h at 4°C. Unbound protein was removed by washing and the beads were resuspended in deaminase buffer .293T cells (5.0×10E. coli expressed A3A (1.0 µg), FPLC fractions (10 µl) or mammalian expressed A3A bound on sepharose beads (5 µl) was incubated with 10 pmoles of 5′-biotin-labeled oligonucleotide in deaminase buffer for 60 min (E. coli A3A), or 1–6 h  at 37°C. The A3A was inactivated for 3 min at 95°C and then treated for 30 min at 37°C with 1 unit UDG in buffer containing 20 mM Tris pH 8.0, 1 mM DTT, 1 mM EDTA. The product was hydrolyzed for 30 min in 140 mM NaOH at 37°C. The resulting oligonucleotide fragments were separated on a 15% TBE-urea PAGE gel and transferred to a nylon filter (Invitrogen). The membranes were UV crosslinked, blocked with 5% milk and incubated for 30 min. with 1.0 µg of DyLight 800 conjugated Streptavidin (Pierce). Signals were quantified on an Odyssey Imager (LI-COR). The percent deamination was defined as the amount of cleaved oligonucleotide divided by the sum of the cleaved and uncleaved oligonucleotides.28(TCA)T28-3′) (Integrated DNA Technologies). To determine the deamination site preference of rA3A, a set of biotinylated oligos containing all possible three-base combinations were used (5′-biotin-T14(ACA)T7(ACT)T9(ACG)T17(ACC)T31-3′, 5′-biotin-T14(TCA)T7(TCT)T9(TCG)T17(TCC)T31-3′, 5′-biotin-T14(CCA)T7(CCT)T9(CCG)T17(CCC)T31-3′, 5′-biotin-T14(GCA)T7(GCT)T9(GCG)T17(GCC)T31-3′). Trinucleotide deaminase specificity was determined using biotinylated oligos with each possible trinucleotide context: NCN sites (5′-biotin-T28(NCN)T28-3′).Most of the deaminase assays used a biotinylated oligonucleotide with a single TCA site (5′-biotin-TGGT AGA TTG AGG TAA GTA (TCA)18TGA ATA GGA GTG TTA AGG GGG-3′) was treated with 50 ng rA3A in deaminase assay buffer. The deaminated DNA was cloned into TOPO TA (Invitrogen) and sequenced.An oligonucleotide containing repeating rA3A preferred deamination sites (5′-biotin-GGG E. coli-produced rA3A from which the GST had been removed. Protein lysates (30 µg) were separated on a 4–12% SDS PAGE gradient gel and then transferred to a PVDF membrane. The membrane was blocked in 5% milk and incubated with 1∶1000 anti-A3A serum diluted, 1∶5000 anti-α-tubulin monoclonal antibody B-5-1-2 (Sigma) or 1∶1000 anti-Myc monoclonal antibody 9E10 (Covance). Bound antibody was detected by hybridizing to 1∶1000 anti-rabbit or anti-mouse biotin-conjugated secondary antibody followed by streptavidin conjugated DyLight 800 (Thermo Scientific) and visualized on an Odyssey Infrared Imaging System (LI-COR Biosciences).Anti-A3A antiserum was raised at Pocono Rabbit Farm & Laboratory (PRF&L) by repeated immunization of 2 rabbits with 8CG(T)6 DNA oligonucleotide at 4°C with 2 µg rA3A in 10 µl deaminase buffer for 1 h. The samples were separated by 6% native PAGE and visualized on a Typhoon Trio imager . DNA binding was quantified by measuring the intrinsic fluorescence of 225 nM rA3A with increasing amounts of oligodeoxynucleotide in 25 mM Tris pH 8.0 and 25 mM NaCl on a FluoroMax-4 spectrofluorimeter d was determined based on the ligand-binding curve.DNA binding by electrophoretic mobility shift assay was determined by incubating 0.5 pmol of 5′-fluorescein-conjugated (T)A3A NMR structure 2M65,  and A3G Anti-A3A antiserum was prepared by Pocono Rabbit Farm and Laboratories (PRF&L) under the protocol PRF2A approved by PRF&L Institutional Animal Care and Use Committee (IACUC). PRF&L is accredited by the Association for Assessment and Accreditation of Laboratory Animal Care (AAALAC) and by the National Institutes of Health (NIH) Office of Laboratory Animal Welfare (OLAW), assurance number A3886-01 expiration January 31, 2017.Figure S1rA3A monomer and dimer fraction are catalytically active. Deaminase activity of 1.0 µg A3A protein extract or 10 µl of each size exclusion chromatography fraction was determined by incubation with an oligonucleotide containing a TCA consensus target sequence. The results are representative of two independent repetitions using different batches of rA3A.(TIF)Click here for additional data file.Figure S2Comparative A3A and A3G structure. A) Alignment of A3A and the carboxy terminal catalytic domain of A3G primary sequence against A3G secondary structure. The sequences were aligned using ClustalW2 . Identical amino acids are in white on a red background. A3G secondary structure was extracted from its crystal structure. The α-helices are represented above their corresponding primary sequence by a drawn helix, while arrows represent β-sheets. Each residue mutated in A3A is indicated with a triangle containing the matched color from the 3D model of (TIF)Click here for additional data file.Figure S3The rabbit anti-A3A antibody does not cross-react with other members of the APOBEC3 family. 293T were transfected with an empty pcDNA6 vector (EV) or vectors encoding HA-tagged A3A, APOBEC3B, APOBEC3C, A3F and A3G. Lysates were separated by SDS-PAGE, and blotted with mouse anti-HA antibody, to control for protein expression, or a rabbit antiserum raised against rA3A.(TIF)Click here for additional data file.Figure S4W104A is catalytically inactive. Wild-type and mutated A3A were expressed in transfected 293T cells, immunoprecipitated from cell lysates and then tested for deaminase activity against an oligonucleotide containing a TCG target sequence. The activity was measured at the indicated time points.(TIF)Click here for additional data file.


Grooming is a well-recognized, multipurpose, behavior in arthropods and vertebrates. In this paper, we review the literature to highlight the physical function, neurophysiological mechanisms, and role that grooming plays in insect defense against pathogenic infection. The intricate relationships between the physical, neurological and immunological mechanisms of grooming are discussed to illustrate the importance of this behavior when examining the ecology of insect-pathogen interactions. In vertebrates, grooming has been described in terms of mutual expression of social acceptance and indicative of familial, as well as dominance, relationships between the different members of a group. Yet grooming is not always associated with social consequences as evidenced by the fact that the majority of animal species studied devote some time to grooming activities . The intAs for hygiene behavior, special behavior directed toward the care of body surfaces is known from a wide range of animal species ,4. EarliThere are two broad categorizations used to describe grooming of the self or others. Autogrooming (self-grooming) is a classification that includes any act by the subject related to maintenance/care of the body surface and is considered an innate behavior represented across a plethora of vertebrate and invertebrate taxa ,24. AlloEuphydryas phaeton larvae regurgitate on attacking braconid parastoids, which react with prolonged grooming [Heliothis virescens larvae use a head strike to apply an oral exudate to attacking Cardiochiles nigriceps females, which, in turn, groom [The inevitable ambiguity when attempting to classify a grooming behavior such as the simple scratching sweep that is often incorporated into a more complex sequence of defense-related behaviors. This is because of a high level of plasticity in grooming-related behaviors and often-subjective observations of the behavior itself. Thus exhibition of a behavioral reaction to a simple stimulus as evoking a scratching reflex make insects an excellent model for studying the neural circuitry underlying specific behaviors ,47,48. Egrooming  while Hen, groom ,51. Groon, groom , oviposin, groom ,54 and mn, groom . At a ban, groom . Groominn, groom . This reGrooming in animals is a complex, multipurpose behavior as reflected in the “microstructure” of events used to phenotype such behaviors . The cleVarious functions have been proposed to explain insect grooming behavior: cleaning dust particles from sensory organs , smearinMammals and birds display displacement activities that have been classified as locomotory behaviors, cleaning behaviors  and manipulation of objects, which are often disrupted by a variety of stressors ,72,73 siPhormia regina subjected to an irritant vapor, evert the proboscis, regurgitate a droplet onto its tip (the labellum), and proceed to wipe the labellum against the substrate [Mechanical or chemical stimulation causes movements aimed at eliminating foreign substances from the contaminated body surface ,91,92,93ubstrate . These dubstrate ,99.Visuaubstrate , althougubstrate ,91.Periplaneta americana cockroaches [Sphodromantis lineola that has mechanosensory sensilla in a femoral brush yet continue to perform eye cleaning movements after surgical removal of the brush [Aimed scratching, a stereotypic response to acute stimulation, has been used as a model for describing functional neuromorphology ,92 and lkroaches ,107. SOGhe brush . In conthe brush . Our obsThere is little doubt that multiple neural feedback mechanisms tune grooming behavior according to current circumstances. In the German cockroach for example, the marginal sensilla located on the antennal basal segments 20–24 respond to the bending of flagellomeres and presumably play a role in determining the duration of flagellum grooming  while chet al. [Insect behavior is often the result of a reaction to environmental signals hiding in the general background noise present in insect habitats . This ocet al.  suggesteet al. . The simet al. . et al. [et al. [Insect olfaction seems to help protect insects from disease ,122,123.et al. , the vol [et al.  reported [et al. ,127,128.Caenorhabditis has been shown to detect specific chemical stimuli from bacterial pathogens [The literature on animal behavior indicates that recognition of pathogens is a common trait across taxonomic categories. The nematode athogens , and disathogens ,131,132.athogens . It is aathogens ,138,139.athogens ,140. et al. [Formica podzolica even display a response to their infected aphid mutualist partners [Insect perception of pathogens has long been thought to begin after contact ,141,142.et al.  reportedet al. ,146,147.partners . Drosophila possess olfactory receptors that detect 1-octen-3-ol, a typical fungal odor [The sensitivity of insects towards chemosensitive odors and tastes has been discussed in the context of food, sex or social interactions ,151,152 gal odor ,157, andgal odor ,159.Metarhizium anisopliae conidia more than less-virulent conidia [Termite hygiene behaviors are likely triggered by chemical information, because most termites are blind and therefore represent a good model system to test the hypothesis of chemoreceptive avoidance behavior. Several studies have reported that insects are repelled by the odor of strongly virulent entomopathogenic fungi ,161,162. conidia ,161. It  conidia . Future  conidia . There is still a long way to go to recognize behavior as an integral part of the strategies used by insects to cope with pathogens ,140,167 Insect defenses against pathogens have been studied from the point of view of an overall immune response ,142. VerInsects employ several strategies to fight back against microbial infection at cell, individual and ecological levels. Behavioral resistance will be one of the most initial defense in the infection stage.Hygienic behavior has been shown to play a key role in disease prevention in insects ,144,179.Autogrooming can prevent infection from various microorganisms, especially in species like flies that live in an environment littered with bacteria, fungi and other microorganisms developing on decaying material ,188. ConDrosophila spend a considerable amount of time grooming and that grooming systematically occurs after egg-laying [Beauveria bassiana conidia deposited on adult Drosophila are actively removed by grooming. There are reports that insect contact with pathogens can result in up/down regulation of gene expression, drive immune reaction and alter behavior [Drosophila mutants show increased susceptibility to B. bassiana while infection leads to the expression of the antifungal peptide genes Drosomycin and Metchnikowin [The trigger(s) that initiate insect behavioral reaction to pathogens is currently not well described. Increased grooming was noticed in the presence of parasitic nematodes for both earwigs and Japanese beetle larvae ,190, howg-laying ,191. Ourbehavior ,175,192.hnikowin ,194. TheHorizontal disease transmission can be significantly more serious in eusocial insects because colony members are closely related and frequently interact, often under conditions of high population densities ,196,197.Varroa mites [Allogrooming is a well-known social behavior exhibited by numerous animal species that serves both hygienic and social functions . Reducedoa mites  after whoa mites ,219,220.Maintenance of the cuticle, that physical barrier between an animal and the environment, can be considered the first line of defense against disease. The grooming behavior displayed by vertebrates and insects serve multiple functions, such as care and maintenance of the body surface and sensory organs. In insects mechano- and chemosensory sensitivity play an important role in the discovery of pathogenic organisms toward initiating grooming behaviors. Antimicrobial secretions spread by grooming provide insects with an additional role for this behavior. Sensory recognition can also trigger mobilization of immune response to compliment a suite of behavioral mechanisms, such as avoidance, self-medication and grooming . GroominGrooming behavior has long been observed and reported in many insects . Future


We describe the novel solution adopted in positioning middle ear implant in a child with bilateral congenital aural atresia and craniofacial dysmorphism that have posed a significant challenge for the safe and correct management of deafness. A five-year-old child, affected by a rare congenital disease , suffered from conductive hearing loss. Conventional skin-drive bone-conduction device, attached with a steel spring headband, has been applied but auditory restoration was not optimal. The decision made was to position Vibrant Soundbridge, a middle ear implant, with an original surgical application due to hypoplasia of the tympanic cavity. Intubation procedure was complicated due to child craniofacial deformities. Postoperative hearing rehabilitation involved a multidisciplinary team, showing improved social skills and language development. Congenital aural atresia is a general term to describe a spectrum of ear deformities characterized by aplasia or hypoplasia of the external auditory canal. Commonly it is associated with microtia and occasionally with anomalies of the inner ear . This maThe treatment of congenital aural atresia included first restoration of auditory function and then esthetical reconstruction of the pinna, usually performed not before the age of six , 4.Hearing rehabilitation should begin as soon as possible, to not compromise the development of the language and the social skills. Conventional air-conduction hearing aids are common and easy means to improve patient's deafness. However these devices cannot give an acceptable benefit, if air-bone gaps are as great as up to 60 dB or the external auditory canal is absent or hypoplastic . BesidesThe patient is a 5-year-old child, born at term in the 41st gestational week, from consanguineous parents (first cousins). The pregnancy was complicated by polyhydramnios and fetal ascites. At birth the measurements were as follows: 49 cm length, 2.750 g weight, and occipital-frontal head circumference (OFC) of 35 cm. His past medical history is remarkable for an admission in the Neonatal Intensive Care Unit during the first days of life for respiratory crisis requiring a tracheostomy and a procedure of mandibular advancement by distraction osteogenesis at the age of 2 months for severe micrognathia and retrognathia.His craniofacial features were distinctive with microcephaly, short palpebral fissures, telecanthus, epicanthus, and bilateral microtia associated with an external auditory canal atresia; limb anomalies included camptodactyly and syndactyly of the fingers and interdigital webbing  , 10.At the clinical evaluation at the age of five years, speech development was markedly delayed, despite the application of traditional bone-conduction hearing aids from the age of twenty-two months.The cognitive phenotype showed a psychomotor retardation. Speech production, with the use of hearing aids, was limited to vocalization, babbling reduplicated, and lexical vocabulary of less than ten words. The communication modalities were mostly gestural without clear and evident relational disorders.To optimize the surgical outcomes, multidisciplinary evaluation of the patient was performed preoperatively.Brain MRI revealed neuronal migration abnormalities with hypoplasia of the corpus callosum. The posterior horns of the lateral ventricles were dilated without significant reduction of both hemispheres. Cerebellar abnormalities were not observed .Temporal bone high-resolution computed tomography (CT) showed bilateral external auditory canal atresia, hypoplasia of the tympanic cavity, absent pneumatisation of the mastoid, and radiological normal cochlear morphology. No clear discontinuity and malformation of the ossicular chain have been revealed  .A preoperative pure-tone audiometric test showed a bilateral conductive hearing loss . We have detected a good functional gain with hearing aids although the patient did not have a good compliance and the device was not used correctly. This has influenced not only communication skill but also some aspect of quality of life such as peer-acceptance and self-esteem because of his physical appearance, like this was reported by his family.In agreement with the parents, the boy was submitted to Vibrant Soundbridge (VSB) implantation –11. The Vibrant Soundbridge (VSB) is a middle ear implant composed of two parts, the external audio processor (AP) and the implantable Vibrating Ossicular Prosthesis (VORP), consisting of the internal receiving coil, a modulator, a cable, and the floating mass transducer (FMT), applied to one of the vibratory structures of the middle ear , 13.The child underwent surgery under general anesthesia, with the use of a facial nerve monitoring system. Maxillofacial dysmorphism posed technical difficulties to the anesthesiologists for the safe management of the airway. Intubation was carried out by two anesthetists, side by side; while the first introduced the laryngoscope into the oral cavity (lidocaine 4% spray was added to minimize the instrument response), without loading the tongue, the second one introduced the pediatric fiberscope (2.8 mm diameter) on which the armed cuffed tracheal tube was loaded and displayed and exceeded the glottis. The procedure was very rapidly completed at the first attempt, maintaining the patient in spontaneous breathing, and the armed orotracheal tube was correctly positioned. During surgery any other anesthetic complication was not observed .The Vibrant Soundbridge was implanted on the left side, using a posterior approach . A hairlFinally the FMT was placed to the long process of incus with superior orientations .Care has been taken that the axis of the FMT was put parallel to the orientation of the stapes, so that the device vibrated simulating the natural movement of the ossicular chain. This type of technical solution is also compatible with the new model of Vibrant Soundbridge (VORP 503 with vibroplasty couplers). Intraoperative test was performed and the device was working properly.The VSB was activated eight weeks after surgery and no postoperative complications were observed as well as facial nerve injury or inner ear damage. A good improvement in perception scores was noted after one year using speech perception test conducted with no visual contribution in free field .An open questionnaire regarding the use of the VSB and the change in social life before and after surgery after one year was compiled by the parents. The device was well accepted and used properly by the young patient probably because VSB is less visible and more comfortable.Bone-conduction devices (BCDs) and middle ear implants offer new treatment options in children with congenital aural atresia when the conventional hearing aids are not successful .A careful multidisciplinary assessment, which includes audiological and radiological evaluation, clinical history, and anesthetic risk, helps to identify the best surgical solution.In this case, the child suffered from a rare disease, Van Maldergem Syndrome, and craniofacial dysmorphism posed a significant challenge for both the anesthesiologist and the surgeon.All hearing devices, available at that time, have been evaluated.A bone-anchored hearing aid (BAHA implantation) was proposed as first option. This is a percutaneous bone-anchored device that consists of an external sound processor that converts sound energy into vibration through a percutaneous abutment to the skull. The main indications are a minimum of five years of age at the time of implantation and a cortical bone thickness >3 mm. This technique is a reversible surgical procedure that avoids any risk of additional hearing loss in the patients. However parents were informed of the possible postoperative risks of skin complication, fixture loss, and osseointegration failure, which have a higher incidence in children, in particular in syndromic one as reported in literature . BonebriLately the Vibrant Soundbridge extended its indications to patients younger than eighteen years, providing another surgical option for bilateral congenital conductive or mixed hearing loss .This hearing device, unlike BAHA and Bonebridge, provides stimulation to the inner ear in a different way through an electromagnetomechanic cylinder (FMT) placed to the ossicular chain or to the oval or round window. The external processor picks sound signals up and transmits them to the internal receiver/demodulator as electrical signal. The demodulator transmits the information to the FMT that provides direct stimulation of the cochlea.The position of the floating mass transducer depends on the middle ear anatomy. A high-resolution computer tomography (HRCT) should be routinely used preoperatively to assess the bony structures of the temporal bone and tympanic cavity . In thisModern technology has brought more surgical options. Bone-conduction devices (BCDs) and middle ear implant offer an alternative choice for patients suffering from congenital aural atresia. In particular in children with additional disabilities a careful multidisciplinary assessment is important, considering risks of all possible treatments to provide benefits in social and relational skill that are important for their quality of life.


N = 8), hearing-individuals who were experts in CS (N = 14) and hearing-individuals who were completely naïve of CS (N = 15). Results confirmed that, like hearing-people, deaf people can merge auditory and lip-reading information into a single unified percept. Without manual cues, McGurk stimuli induced the same percentage of fusion responses in both groups. Results also suggest that manual cues can modify the AV integration and that their impact differs between hearing and deaf people.Speech perception for both hearing and deaf people involves an integrative process between auditory and lip-reading information. In order to disambiguate information from lips, manual cues from Cued Speech may be added. Cued Speech (CS) is a system of manual aids developed to help deaf people to clearly and completely understand speech visually Cornett, . Within  The McGurk effect suggests that visual articulatory cues about place of articulation are integrated into the auditory percept which is then modified.In face-to-face communication, speech perception is a multi-modal process involving mainly auditory and visual (lip-reading) modalities . This technology improves a child's ability to access auditory information. Studies have shown that deaf individuals (both adults and children) whom of which were fitted with CI's were able to integrate auditory and visual information, with better performance in the AV condition than in the audio condition Erber, . HoweverAside from lip-reading, Cued Speech could help deaf people overcome the uncertainty of auditory signals delivered by the CI. Originally, the Cued Speech (CS) system was designed to help deaf people (without a CI) perceive speech through disambiguating the visual modality Cornett, . The CS While the advantages of exposure to CS are well-recognized, the processing of the CS signal still remains unclear. Attina et al.  were theAlegria and Lechat  studied The goal of the present research was to examine how manual cue information is integrated in AV speech perception by deaf and hearing participants. We wondered whether (1) CS receptors combine auditory, lips and manual information to produce a unitary percept; (2) on which information  they primarily rely; and (3) how this integration is modulated by auditory status. To address these issues we designed the first experiment using audio-visual McGurk stimuli produced with manual cues. The manual cue was either congruent with auditory information, lip information or with the expected fusion. We examined whether or not these experimental conditions would impact the pattern of responses differently for deaf and hearing subjects.Thirty-seven adults participated in the study. They were split into three groups according to their auditory status and degree of CS expertise. The first group consisted of eight deaf CS users (mean age: 18 years), hereafter referred to as the CS-deaf group. Three of them had cochlear implants and five used binaural hearing aids. Seven had been exposed to CS from the age of two to three years and the remaining one from the age of 14 years . Scores groups and participants are indicated in Appendix, Table A female French speaker was videotaped while uttering CV syllables consisting of one of the /p, k, t/ consonants articulated with /a/ Figure .Two uni-modal and four multi-signal congruent conditions were created  presented with or without manual cues (see Table The experiment took place in a quiet room. Videos were displayed on a 17.3 inch monitor on a black background at eye level and at 70 cm from the participant's head. The audio track was presented at 65 dB SPL (deaf participants used their hearing-aids during the experiment). On each trial, participants saw a speaker's video , we used non-parametric tests. In the congruent condition, we wanted to compare participants according to two criteria: auditory status (hearing vs. deaf) and CS abilities (CS users vs. non-CS users). Mann-Whitney tests were used to compare hearing (CS and non-CS together) with deaf groups and to compare CS users (deaf and hearing together) with the control group.As the groups were small . As it appeared that the standard deviation for the deaf group (18.2) was much higher than that of the hearing group, we analyzed individual scores of the deaf participants. Participant 2 was the only one to have a score under 83%; he obtained only 17% of correct responses. As confirmed by TERMO scores . However, the CS-deaf group had more difficulty than the two hearing groups in identifying stimuli /ta/  and /ka/ . Compared to the Audio-Only condition, the addition of cues improved the percentages of correct answers for the CS-deaf group, nonetheless the hearing groups still had more correct responses for /pa/ , /ta/  and /ka/ As illustrated in Table U = 77; p = 0.068), /ta/  and /ka/ . The addition of cues, in comparison with the Lip-reading-Only condition, increased the percentages of correct answers for CS users (deaf and hearing). CS users had better responses than control participants for /pa/ , /ta/ , and /ka/ . Percentages of correct responses for each group are shown in Table In the Lip-reading-Only condition, both deaf and hearing participants had similar percentages of correct responses for /pa/  and /ka/ . Deaf participants did not obtain 100% of correct responses for stimuli /ta/ and /ka/, because both the audio and visual information were difficult to identify  were presented, participants had the same percentage of correct responses for /pa/.Participant responses were classified into four categories: audio (when the response was /pa/), lip-reading (when the response was /ka/), fusion (when the response was /ta/) and other. In the baseline condition, we used Mann-Whitney tests to compare hearing (CS and non-CS together) with deaf groups. In each group, the Wilcoxon test was used to compare response patterns between baseline and other experimental conditions.p = 0.39) and auditory (p = 0.18) responses.As illustrated in Table p = 0.03) in favor of other responses congruent with cue information (60% of other responses: 38% of /da/ and 19% of /Ʒa/). In the CS-hearing group, the addition of cue n°1 reduced the percentage of fusion responses (p = 0.001) and increased auditory responses from 17% to 60% (p = 0.003). In the Control hearing group, the addition of the cue had no effect on the response pattern.Response patterns for each group in the McGurk-audio condition are shown in Table p = 0.02) and increased the percentage of lip-reading responses (p = 0.03), in comparison with the baseline condition. In addition, some participants responded with the alternative, /za/, which was congruent with cue information. In the CS-hearing group, the addition of cue n°2 also decreased fusion responses (p = 0.002) and increased lip-reading responses (p = 0.003). In the Control hearing group, the addition of cue had no effect on the response pattern.As illustrated in Table In all groups, the addition of the cue coding /m, t, f/ had no effect on response patterns , percentages of fusion responses were high and similar for both hearing and deaf groups , the addition of manual cues that were incongruent with the expected fusion response impacted the pattern of responses. For both deaf- and hearing-CS users, the proportion of fusion responses decreased. The CS system therefore has an effect on AV integration processes. In the case of congruency between manual cues and expected fusion, the CS system supports illusory perception. However, for all groups the percentage of fusion did not increase. One explanation might be that the proportion of fusion responses in the baseline condition was already fairly high in deaf and hearing groups  increased only audio responses for /pa/ in the CS-hearing group but not in the CS-deaf group. In this latter group, fusion responses decreased in favor of other responses, congruent with the manual cue coding /p, d, Ʒ/ . Thus, despite their good performance in the Audio-Only condition (85%), CS-deaf users seemed more confident with visual information . They were unable ignore lip-read information and relied more heavily on such information than on auditory.The addition of manual cues congruent with lip-read information increased lip-reading responses in both groups. These results suggest that deaf- and hearing-CS users are capable of ignoring auditory information when such information is contradicted by lip-reading or manual cues. As the CS system is not necessarily used with auditory information, ignoring auditory information could be easier.Deaf-CS users' multimodal speech perceptions differ from that of hearing CS-users. Our results have shown that the addition of manual cues congruent with auditory information impacts the speech perception of deaf and hearing-individuals differently. Perception for deaf individuals relies more on visual information ; whereas perception in hearing-CS users relies more on auditory information. This suggests that the processing of CS information is modulated by auditory status. We have envisioned two speech perception models in order to explain these results. As it is illustrated in Figure Therefore, in a new study , we investigated whether auditory status or auditory abilities impact audio-lip-read-manual integration in speech perception by testing a larger sample of deaf individuals whom of which were fitted with cochlear implants. Our first collection of data suggests an effect of auditory ability. Deaf individuals with good auditory ability had the same pattern response as their hearing-counterparts. Thus, for hearing- and deaf individuals with good auditory speech perception abilities, speech perception may first involve an integration between auditory and lip-read information. The merged percept then could be impacted by manual information when such information is delivered Figure . For deaA number of other studies have revealed an impact of CI proficiency on AV speech integration. For example, Landry et al. , compareMany AV integration studies on hearing-individuals have attempted to determine how and when integration takes place. More specifically, the issue of whether integration is early (before phonetic categorization) or late (after phonetic categorization) has been a topic of empirical and theoretical research. A number of speech perception and AV integration models have been proposed. Among such designs, the “Fuzzy logical model of perception”  is an interesting adaptation of FLMP  are processed in parallel and constitute the uni-modal, visual signal  or later (as in the second hypothesis). Furthermore, we have learned that deaf participants are capable of ignoring auditory cues, whereas they cannot ignore labial or manual information. Thus, for future studies, we aim to analyze more precisely the effect of auditory efficiency on speech perception, using data to confront our hypotheses.In natural speech (without CS), humans speak and spontaneously produce gestures to support what they are saying. Analysis of speech and symbolic gesture production in adults suggest that both “are coded as a unique signal by a unique communication system” , naturally but irrelevant information (like in audio-aerotactile integration), or non-natural but relevant information (such as CS cues).Findings from our work also suggest that the integration of different types of information  related to a common source  is a flexible process that depends on the informational content from the different sources of information, as well as on the auditory status and hearing proficiency of the participants.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Sir, We thank Kariuki and Newton for their letter which raises several interesting points. We value their contributions to this discussion.Failure of cerebral autoregulation may be an important step in the cerebral malaria disease process. Ideally our review would have not only included comparisons of autoregulatory function in retinal and cerebral vessels, but also other important subjects such as the nature of the blood-tissue barriers, distribution of endothelial receptors, and vessel ultrastructure in retina and brain. Comparing and contrasting the retina with other areas of the CNS in terms of these and other features could well provide valuable insights, not just into cerebral malaria, but for a whole range of neurovascular diseases. We hope our paper will help to stimulate individual reviews on these topics.Plasmodium falciparum histidine-rich protein 2 (pfHRP2) as a biomarker in severe malaria has recently been reviewed , and to standardize imaging methodology in malaria research.Far from precluding the use of other disease markers, retinal imaging represents an opportunity to assess novel biomarkers, both for their clinical use and to investigate relationships between multiple aspects of cerebral pathogenesis. More work is needed to compare retina–brain biological characteristics, describe empirical associations between retina, brain, and prospective biomarkers (including


Congenital sensorineural deafness (CSD) is the most common type of deafness in dogs and it occurs in numerous canine breeds including the English bull terrier. This study estimates prevalence, heritability and genetic correlations of CSD and coat pigmentation phenotypes in the English bull terrier in England.Hearing status was assessed by brainstem auditory evoked response in 1060 English bull terrier puppies tested at 30–78 (mean 43.60) days of age as complete litters. Gender, coat and iris colour and parental hearing status were recorded.The prevalence of CSD in all 1060 puppies was 10.19 % with 8.21 % unilaterally deaf and 1.98 % bilaterally deaf. The coat was predominately coloured in 49.15 % puppies and white with or without a patch in 50.85 % puppies. The majority (96.29 %) of deaf puppies had a white coat (with or without a patch); 19.29 % of the puppies with a white coat (with or without a patch) were deaf.P < 0.01). Heritability of coat pigmentation phenotype  was 0.49 (standard error 0.077). Genetic correlation of CSD with coat pigmentation phenotype was estimated at −0.36 to −0.37 , but was not significantly larger than zero (P > 0.05). Analysis of CSD in all white and white patched puppies only estimated the heritability of CSD as 0.25 and was significantly greater than zero (P < 0.01), and the heritability of coat colour  as 0.20 (standard error 0.096). The genetic correlation was estimated at −0.53 to −0.54  but was just above the statistical threshold determining significant difference to zero (P = 0.06).Heritability and genetic correlations were estimated using residual maximum likelihood. Heritability of hearing status as a trichotomous trait  was estimated at 0.15 to 0.16 and was significantly different to zero (These results indicate that CSD occurs predominantly in white English bull terriers and there is genetic variation in CSD beyond that associated with coat colour.The online version of this article (doi:10.1186/s12917-016-0777-6) contains supplementary material, which is available to authorized users. Congenital sensorineural deafness (CSD) is the most common type of deafness in dogs and it has been reported in more than 90 canine breeds including the English bull terrier , 2. CSD The cochleo-saccular type can occur unilaterally or bilaterally and is characterized by initial degeneration of the stria vascularis, loss of the elevated potassium concentration in the endolymph, degeneration of the hair cells within the organ of Corti, collapse of the Reissner’s membrane, degeneration and collapse of other cochlear structures including the spiral ganglion cells whose axons constitute the auditory branch of the eighth cranial nerve . The vesi), piebald (sp), and extreme white (sw). More recent studies have identified the microphthalmia-associated transcription factor gene (MITF) as being a candidate gene for, or closely linked to, the S locus  = −0.335; 1 [unilaterally deaf] = 1.252; 2 [bilaterally deaf] = 2.208, to reflect the different categorical proportions of CSD in the reduced data.CSD has been shown to be associated with extensive white coat colour , associa evident . Therefon = 6, 6, 9, 24, 34, 48, 30, 56, 103, 118, 99, 86, 131, 98, 113, 62, 37 puppies). Hearing status was bilaterally normal in 952 (89.81 %) puppies, 87 (8.21 %) were unilaterally deaf and 21 (1.98 %) were bilaterally deaf. Of the 87 puppies with unilateral CSD, 33 (37.93 %) were deaf in the left ear and 54 (62.07 %) were deaf in the right ear. There were 547 (51.60 %) males and 513 (48.40 %) females. Puppy hearing status stratified by coat colour, gender and hearing status of sires and dams is summarised in Table n = 1; right blue n = 1). These two puppies with blue irises were 38 and 40 days old at time of BAER, respectively; one was unilaterally deaf and one had normal hearing status. Coat colour in the two puppies with blue irises was all white and white with a patch on the head, respectively. None of the sires and dams with known hearing status was unilaterally or bilaterally deaf.Inclusion criteria were met for 1060 pure bred English Bull terrier puppies from 209 unique litters . Univariate analysis of coat pigmentation phenotype  estimated the heritability at 0.488 (0.077). When hearing status and coat pigmentation phenotype were analysed in a bivariate model, the estimates of heritability were of similar magnitude to those estimated using univariate models . The genetic correlation between hearing status and coat pigmentation phenotype was −0.372 (0.185) with hearing status on the observed scale and −0.358 (0.186) on the liability scale (i.e. CSD associated with completely white coat). However on neither scale was the genetic correlation significantly larger than zero . The residual correlation between hearing status and coat pigmentation phenotype was similar, although slightly smaller in magnitude, and was significantly larger than zero .The estimate of heritability of hearing status was 0.151 (0.059) on the observed scale and 0.159 (0.061) on the liability scale. Estimates were significantly larger than zero (n = 539) determined heritability estimates of 0.245 (standard error 0.108) and 0.254 (standard error 0.102) on the observed and liability scale respectively. Both estimates were significantly greater than zero . Univariate analysis of coat pigmentation phenotype  estimated the heritability at 0.196 (standard error 0.096), implying additive genetic variation in the presence and absence of patches of pigment in white dogs. Bivariate analysis of hearing status and coat pigmentation phenotype  yielded slightly higher heritability estimates than from the univariate analysis . However, estimates were within one standard error of those estimated in univariate analyses. The genetic correlation between hearing status and coat pigmentation phenotype  was −0.544 (standard error 0.240) with hearing status on the observed scale and −0.528 (standard error 0.239) on the liability scale (i.e. CSD associated with completely white coat). In both cases the genetic correlation was very close to the threshold indicating estimates were significantly larger than zero . Residual correlations were smaller in magnitude and not significantly larger than zero; 0.087 (standard error 0.081) on the observed scale, and 0.093 (standard error 0.083) on the liability scale.Univariate analysis of hearing status  using data from all white and white patched dogs only  reported in a previous study including 665 English bull terriers [Similarly to previous studies in other canine breeds with CSD , 23, preThe prevalence of unilateral and bilateral CSD in coloured English bull terrier puppies was 27 and 19 times lower respectively than that in the other two predominantly white combined categories (‘white’ and ‘patched’). The significance of the coloured coat pigmentation phenotype as a fixed effect in the univariate analysis of hearing status, with coloured English bull terriers less likely to be deaf than either all white or white patched English bull terriers, is in line with the dual role of melanocytes in cochlear function and extent of coat pigmentation. Therefore, breeding only coloured English bull terriers would help to minimise the breed-wide occurrence of CSD. However, in this study, 80.71 % of the puppies with a white coat (with or without a patch) also had bilaterally normal hearing status, demonstrating that a white coat does not definitively imply occurrence of CSD in English bull terriers, and implying some other influence (genetic or otherwise) in the manifestation of CSD.MITF), where the dominant allele S produces solid colour, and the recessive allele sw results in an extreme white coat phenotype, with occasional small areas of pigmentation (observed and categorised as ‘patches’ in this study). The extreme white allele, sw is known to produce the extreme white coat in the English bull terrier [w/sw dogs outlined above. Therefore, the genotype sw/sw was presumed in puppies with the ‘white’ and ‘patched’ phenotypes and the analysis of this cohort alone was undertaken to determine any additive genetic variation in predisposition to CSD beyond that conferred by the sw allele.The categories of presence and extent of coat pigmentation utilised in this analysis reflect allelic variations at the white spotting locus  in this study was sizable (−0.35 to −0.37), implying a genetic association between white coat colour and CSD which reflects the discrepancy in prevalence of CSD in coloured and predominantly white dogs (0.77 % vs 19.29 %) and is likely to be largely due to the effect of the S allele in coloured dogs. However, the genetic correlation was not significantly different to zero, which may be due to the large effect of a single gene. When the analyses were repeated using only dogs with the presumed genotype sw/sw (‘white’ and ‘patched’), this study determined that there was still significant additive genetic variation and so a sizable estimate of heritability of CSD in completely or predominantly white dogs. This means there is variation in genetic predisposition to CSD in the English Bull Terrier beyond that conferred by the alleles at the white spotting locus in MITF. The presence of pigmentation in predominantly white dogs (i.e. patching) was also found to be moderately heritable, implying the existence of genetic modifiers overlaying the major effect of the extreme white (sw) allele. The genetic correlation between hearing status and presence/ absence of a patch in white dogs was moderate and implies a genetic association between CSD and completely white coat , although falling just short of the threshold determining significance (from zero), most probably due to a small sample size (by quantitative genetic standards).The genetic correlation between hearing status and coat pigmentation phenotype determined using all dogs (w/sw), and this can be the focus of selection to improve canine welfare. The estimated genetic correlations imply probable genetic commonality between deafness and white coat, even among white patched dogs, although estimates were not significantly different to zero .The overall prevalence of CSD in the 1060 English bull terrier included in this study was 10.19 %, similar to that reported previously in this breed. This study has successfully demonstrated the existence of underlying additive genetic variation in the risk of CSD in predominantly white English Bull Terriers (presumed to have the genotype sMITF, microphthalmia-associated transcription factor geneBAER, brainstem auditory evoked response; CSD, congenital sensorineural deafness;


CSAG, 1998) and the Cleft Care UK  studies.To compare oral health and hearing outcomes from the Clinical Standards Advisory Group . Forty‐three per cent of children received at least one set of grommets – a 17.6% reduction compared to CSAG. Abnormal middle ear status was apparent in 50.7% of children. There was no change in hearing levels, but more children with hearing loss were managed with hearing aids.Oral health was assessed in 264 of 268 children (98.5%). The mean dmft was 2.3, 48% were caries free, and 44.7% had untreated caries. There was no evidence this had changed since the CCUK than in CSAG, although there was reduced use of grommets and increased use of hearing aids. The service specifications and recommendations should be scrutinized and implemented.Outcomes for dental caries and hearing were no better in  Children born with cleft lip and palate are at risk from oral health issues because teeth adjacent to the cleft may be misshapen, of poor quality or missing altogether, additional loss of teeth as a result of preventable dental caries may further compromise dentition. Children with a cleft have a higher incidence of tooth decay All of these factors point to a need for dental prevention. There are programmes in Scotland and Wales which have shown it is possible to reduce caries in high‐risk groups of children Middle ear disease and hearing problems are common in infants and children with cleft palate The aim of this report is to describe the functional status of CCUK children in terms of their oral health and ear and hearing status and to compare these outcomes with those reported in the CSAG study.The data were derived from two cross‐sectional studies that took place 15 years apart – the CSAG and CCUK studies. In both studies, we recruited children born with non‐syndromic unilateral cleft lip and palate (UCLP) over a defined period. The total sample size was 268 and 239 in the CCUK and CSAG study, respectively. Details of the recruitment and selection of children into these studies can be found elsewhere These data were collected with a proforma which was based on the original CSAG data collection sheet. Data on dental caries were collected using the British Association for the Study of Community Dentistry (BASCD) criteria Pure tone audiometry was conducted in the hospital audiology clinics according to British Society of Audiology [BSA standards] in situ or cholesteatoma.The appearance of the tympanic membrane on otoscopy was noted and coded as normal or abnormal, based on Flynn et al. Tympanometry was used to determine middle ear function, and tympanograms were coded according to Jerger's classification Summary statistics are presented as means and standard deviations for continuous variables and percentages for categorical variables. Comparisons of outcomes between CSAG and CCUK were done where data exist in both surveys using confidence intervals and hypothesis tests based on a normal approximation because the sample size was sufficiently large (>400).In all, 264 children of 268 (98.5%) had some form of oral health assessment. The median age was 5.5 years , and 178 (67.4%) were boys. Table p = 0.6). A small percentage (5.3%) reported that they were receiving dental treatment in a hospital setting. The mean dmft was lower when there was a paediatric dentist working within the cleft team; however, there was no statistical evidence of a difference .Table A total of 227 of 268 (84.7%) children had some form of audiological assessment. The median age was 5.6 , and 151 (66.5%) were boys.p < 0.001). There was also weak evidence of a decrease in the number of multiple insertions of grommets in the CCUK cohort compared to the CSAG study . The median age of insertion was 2.7 years , 3.6 years  and 2.3 years  for the first, second and third treatments. Of those children with grommets, 23 of 91 (25.3%) had them inserted at the same time as their palate closure. In addition, one child had an operation for cholesteatoma, and one had a nasal operation.Table Twenty‐four children  had been fitted with hearing aids, with most children receiving two hearing aids at the first fitting . Air conduction aids (AC) were more commonly fitted than bone conduction (BC) aids . Seven children were fitted with hearing aids on more than one occasion. Of the 24 children fitted with hearing aids, 17 had also received one or more set of grommets. Sixteen of the 24 children fitted with hearing aids were still wearing them at the age 5 assessment and had mean hearing levels (better hearing ear) of 28 dB (SD 14 dB).in situ, tympanic membrane retraction or cholesteatoma. Table From the otoscopy results, there were 115 of 227  children with abnormal middle ear status in one or both ears, defined as either middle ear effusion, perforation, grommet or T‐tube Tympanometry results were available from at least one ear of 196 children and 379 ears of 454 (Table p = 0.8). In the worst hearing ear, 44% of children had a mild or greater hearing loss; 14% had a moderate or greater loss. Overall 56% had normal hearing, 22% had a unilateral hearing loss, and 22% had a bilateral hearing loss. The hearing losses were primarily conductive with only one bilateral sensorineural case and two cases of bilateral mixed hearing losses . In addition, five unilateral cases did not have enough test information to determine the type of hearing loss.Hearing threshold data were available from at least one ear of 201 children  had a paediatric dentist attached, and although there have been some improvements in the number of five‐year‐old children with a cleft remaining caries free, the results are still disappointing. It is worth documenting the intentions of centralization in the original CSAG study. Unlike most other aspects of the CCUK study, the recommendations for dental care have been interpreted differently by different units around the country. The minimum standards for the management of oral health in children born with cleft lip and palate recommended that dental health education should be the responsibility of a named member of the team. The cleft team should ensure that dental health education, fluoride supplementation and dental attendance are maintained throughout childhood. To ensure this is coordinated, children with repaired clefts should have priority access to a consultant in paediatric dentistry where necessary. If this consultant is not a team member, access should be available for treatment planning at an early enough stage to be able to influence outcome. Unfortunately, at the time of the CCUK study, only five of the 11 regional cleft units had managed to persuade commissioners that a consultant in paediatric dentistry needed to be part of the MDT. All of these were employed on a part time basis, and only in three regions did the consultant in paediatric dentistry have a regular presence at the MDT clinics. At the time when these children were born and first dental prevention should have been done, the figures were even less. Therefore, many of the children in this study would not have been seen previously by a paediatric dentist. Non‐dental members of the team screening for oral health would have only been able to detect overt dental disease and would not have been able to carry out a caries risk assessment to identify children in the higher risk categories. The fact that the average dmft had shown no change compared to the CSAG study level There is evidence that the teeth around the site of the cleft have a higher prevalence of enamel discolouration The lack of regular screening and use of simple preventive procedures such as fluoride varnish applications will also be reported in more detail in a subsequent publication. In the CLAPA report on users’ perspectives of cleft care only 18% of families had met a paediatric dentist With regard to hearing, there was evidence  of a decrease in the number of multiple insertions of grommets in the CCUK cohort compared to the CSAG study. Furthermore, grommet surgery episodes were reduced and the number of multiple insertions decreased. In an Australian study of cleft care in situ. The proportion with hearing loss has not changed since the CSAG study, possibly because approaches to management have altered with hearing aids now being used . This is important as it is how hearing loss is managed rather than the hearing loss itself which determines the impact that hearing difficulties may have on listening, language and other aspects of development. Hearing aids are now being offered as a treatment option with around 10% being treated with these and often before or after grommet surgery. The latter is a predictor of hearing aid treatment implying that hearing aids are being offered as an alternative option to multiple sets grommets.Most children had normal average hearing levels in one or both ears but about 20% had a bilateral hearing loss which was primarily conductive. It is not possible from these cross‐sectional data to determine the persistence of the hearing losses, although a quarter of cases were being managed by hearing aids or had grommets Fifty‐one per cent of children had abnormal middle ear status in one or both ears. The equivalent data were not available from CSAG for comparison so it is not possible to determine whether there has been any improvement. It would be expected that the introduction of regular audiological assessments post‐CSAG would lead to a reduction in cases of middle ear disease as a result of earlier detection. Flynn et al. The decrease in grommet use may be related to the changes in cleft care delivery or the introduction of the NICE guidelines ENT and audiology care is the joint responsibility of the central and local teams within the Cleft network. There is variation in the way assessments, and interventions are conducted both within and across networks. This may be due to practicalities and logistics of delivering the service rather than a result of clinical need. Local audiology teams may also be unaware of the care standards for cleft palate which do not have the same high profile as, for example the audiology care standards for Down Syndrome Overall the centralization of cleft services in the UK has had little impact on oral health of children born with UCLP. The most pressing issue is to implement fully the recommendations made following CSAG with regard to provision of dental care and service. Outcomes for hearing were no better in CCUK than in CSAG, although there was reduced use of grommets and increased use of hearing aids. These two aspects of cleft care in the UK would benefit from further scrutiny of service specifications and support.Two key outcomes in children with a cleft are oral health and ability to hear. The latter function will also impact on speech development, and together, they may affect well‐being and development. In the 1998 Clinical Standards Advisory Group study, oral health outcomes were poor and it was hoped that the centralization of cleft services in the UK (a reduction of cleft centres from 57 to 11) would improve this. The implementation of paediatric dental services and ENT/audiology into centralized multidisciplinary care has been slow and incomplete and has yet to have significant impact on oral health and hearing.


Presbycusis has a direct influence on autonomy of the elderly but hearing aids lack of affordability. Moreover a recent review demonstrate that electroacoustic characteristics of OTC hearing aids were generally not suitable for the elderly people. In our study, we assessed the clinical value of a new over-the-counter (OTC) hearing aid device (TEO First®) in the elderly.This prospective monocentric open label study included patients over 60 years of age with a mild to moderate presbycusis. Patients were assessed with acceptable noise level test (ANL), pure tone (PTA) and speech (SA) audiometry in silent and noisy environment, with and without TEO First®. A Glasgow Hearing Aid Benefit Profile, acceptability and satisfaction surveys were completed after one month of using the device.p < 0.01; PTA: -9.04 dB, p < 0.01) or in noise . After one month of use of the device, quality of life has improved with regards to the following parameters: decrease of perceived hearing difficulties during conversation without background noise (-9.6 % p = 0.018), in conversation with several people (-16.2 % p = 0.0076), decrease of negative emotions while watching TV (-18.5 % p = 0.011), during conversation without background noise (-16.5 % p = 0.0024), during conversation in noisy background (-17.1 % p = 0.027) and during conversation with several people (-20 % p = 0.014). The acceptability of the device was low to moderate.Thirty one patients were included. There was an improvement of hearing with TEO First® in silence (SA: +39.2 %, TEO First® is an effective OTC hearing aid that improves the patient’s quality of life.NCT01815788Current Controlled Trials  Hearing loss affects 8 to 10 % of the European population . PresbycFrailty could be defined as a reversible state associated with subtle physical, psychological, and social impairments that could lead to loss of autonomy. The evaluation of hearing capabilities is a part of frailty assessment. Indeed, hearing loss widely contributes to loss of autonomy in elderly people, and thus affects their quality of life –5. NeverA few data are available concerning over-the-counter (OTC) hearing aids. Recently, Mc Pherson and colleagues have updated previous studies concerning the electroacoustic characteristics of OTC hearing aids . As in p© society, Meyreuil, France has developed a new OTC hearing aid named TEO First®. This assistive listening device is based on a new sound processing process. This device is a low cost technology (US$250) compared to classical prosthetic devices (between US$1600 and US$2100). The request submitted by Tinteo - Personal Sound© society to the Center for Healthcare Innovation and Uses (CIU-santé) was to assess the value of the TEO First® device in a population of mild to moderate presbycusis patients. We decided to focus our study on elderly patients because of the high prevalence of presbycusis in this population, the potential positive impact of this prosthetic device on their quality of life and because they are the main consumers of these products.In this context, Tinteo - Personal SoundThe primary objective of our study was to assess the quantitative earing benefit provided by the use concerning TEO First®. Audiometric evaluation was completed by an assessment concerning the acceptability of this device, its influence on patient’s quality of life and its impact on the project to switch for permanent hearing aid.This prospective monocentric open label study carried out by the University Hospital of Nice (reference 12-pp-17). The study took place from July 15, 2013, to September 18, 2014. All audiometric assessments were performed by the same audiologist at the IUFC (Institut Universitaire de la Face et du Cou) at the Nice University Hospital (VAT number FR 72 260 600 705). The study was approved by the South Mediterranean V Ethical Review Board , as well as by the French Agency for the Safety of Health Products . The study was also declared on ClinicalTrials.gov with the number NCT01815788. Patients who agreed to participate gave their written informed consent.Inclusion criteria were: age over 60 years old with a mild to moderate presbycusis , wish for a hearing improvement, commitment to use the device daily and sufficient cognitive capacity to use the device. Non-inclusion criteria were: profound hearing loss that cannot be rehabilitated with a prosthetic device, previous use of hearing aid device, previous rejection of hearing aid because of discomfort, aestheticism or local intolerance , acute pathology, and legally protected patient. Patients who agreed to participate had to be covered by social insurance. Patients who withdrew consent were excluded from the study. They could also be excluded by the investigator and the study coordinator .Recruitment was made at the hearing and geriatric clinics of the University Hospital of Nice, and in nursing homes. Fifty patients were screened and thirty one were included Fig. . Screene© company. The device is composed of earphones (speakers or headphones 3.5 mm) linked to the electronic system . It is sold with software, USB link (for software update), charger, and transport box. The battery is a 350 mAh Li-ion polymer technology battery with a battery life of 10 h and a charging duration of 1.5 h (1000 charging cycles). The amplification range of the device  is built on a digital signal processing (DSP) which was initially used for processing sound in the music industry. In this way, the signal is processed in real time, in stereo, on a high fidelity frequency range from 20 Hz to 20 KHz. Sound recording is made by 4 analog Micro-Electro-Mechanical Systems (MEMS) microphones giving a stereophonic effect and improving the signal to noise ratio. The signal is processed via proprietary algorithms. It is composed of: a) a multiband dynamic compression that amplifies soft sounds without amplifying loud sounds; b) filters that allow an improvement of selected frequencies based on presbycusis hearing loss; c) a limiter that avoids transmission of the loudest sounds to users; d) a sound spectral analyses that absorbs disturbing sounds, especially those due to device utilization. The device includes two sound processing modes optimized for calm and noisy environments. It is “pre-fitted” for the average hear-loss of a 65 year old man  and the average hear-loss of a 75 year old man (noisy environment). The user can adapt the volume  and adjust the balance between ears (11 positions are possible). The earphones were standard ones with a foam cover provided to improve fitting. The microphones were located on the device. The patients were advised to clip the device to the belt with the provided clip.TEO First® is an OTC hearing aid developed by Tinteo - Personal SoundBefore the first visit, the patients received the informed consent form. They had seven days to make a decision whether to participate in the study. At the beginning of the inclusion visit, the informed consent form was signed in the presence of a physician or the audiologist. After a functional evaluation  ; InstrumThe study was ended by a final visit (Day 40) when the physician and the study coordinator received back the surveys and checked the device. All the devices were offered at no cost to the patients at the end of the study. The patients were not informed of this offer until the end of the study.The population of the study was characterized by age, sex, level of education, lifestyle, cognitive function (MMSE), autonomy (IADL-E) and ANL. The qualitative benefit to use TEO First® was assessed by the Glasgow Hearing Aid Benefit Profile (GHABP) . InitialAll the data (audiometric tests and survey) were collated on Excel®.First of all, a descriptive analysis was conducted by a Geriatric Department, Nice University Hospital biostatistician. Results were presented with the number of subjects (N), mean ± standard deviation (SD) for quantitative variables and percentage for qualitative variables. Quantitative data were compared using Student t-test for paired data or Wilcoxon test if t-test conditions were not respected. Qualitative data were compared with Chi square test or Fisher test if Chi square test conditions were not respected. The significance level of all tests was set to 5 %.Statistical analyses were performed using SPSS® 11.0 .p = 0.071).Thirty one patients were included with 17 women (54.8 %) and a mean age of 78.9 ± 9.7 years  and in noisy environment  , in conversation with several people (-16.2 % p = 0.0076), decrease of negative emotions while watching TV (-18.5 % p = 0.011), during conversation without background noise (-16.5 % p = 0.0024), during conversation in noisy background (-17.1 % p = 0.027) and during conversation with several people (-20 % p = 0.014). Finally, the average daily time of use of the device was 60 min [1st quartile 30 min -3rd quartile 240 min].There was an improvement of hearing with TEO First® device in speech and pure tone audiometry, both in silent environment . The acceptability of the device was presented in Table N = 25).Acceptability results were presented with the average ± standard deviation, number of responses . The one month trial period was sufficient for the patients to form an opinion concerning the device  . The secOTC hearing aids could partially remove the first obstacle allowing an easier access to hearing aid devices. Indeed, this category of devices is clearly targeting a low cost market segment compared to digital prosthetic hearing aids. Moreover, OTC hearing aids could also partially solve the problem of lake of information by facilitating access to hearing professionals and therefore improving information as well as screening of deafness.The satisfaction of the patients with those devices could lead to proposing a digital prosthetic hearing aid to improve hearing rehabilitation. Indeed, to ensure optimum performance of the device, it was necessary to involve the expertise of an audiologist who performed hearing evaluation and adjusted the settings of the device. Nevertheless, our study shows that the wish to use hearing aids continuously was not changed by the use of this OTC hearing aid. Yet, OTC hearing aids could be sufficient hearing rehabilitation devices for certain populations of patients, for example, for financially constrained patients and for those who do not need individual adjustment of digital prosthetic hearing aids. For example, if the patient has difficulties manipulating the device, or in case of cognitive impairment.TEO First® is an effective OCT hearing aid that improves the patients’ quality of life. However, our results are short term results and further studies are needed to confirm our findings. Its low cost reduces the financial burden of digital prosthetic hearing aids on the patients. Its use could be a promising way to educate the population and to increase the interest of professional caregivers in hearing loss.Its use is not expected to replace either the expertise of an ENT professional in the diagnosis or that of an audiologist in the hearing rehabilitation. The device is best positioned as a complementary offer filling the current gap in the field of hearing rehabilitation.ANL, acceptable noise level; ENT, ear nose and throat; GHABP, Glasgow Hearing Aid Benefit Profil; IADL-E, Instrumental Activities of Daily Living for Elderly; MMSE, Mini Mental State Examination; OTC, over the counter; PTA, pure tone analyses; SA, speech analyses