This article reports a study exploring what older people believe would enable them to adjust to and gain maximum benefit from wearing a hearing aid. A mixed methods approach was employed during 2006 involving interviews with key stakeholders, a survey across three Scottish health board areas and focus groups. Nine key stakeholders from six national and local organisations were interviewed about the needs of older people being fitted with hearing aids. In total, 240 older people belonging to three different types of hearing impaired older people were surveyed: long-term users of hearing aids, new hearing aid users, and those on a waiting list from urban and rural areas (response rate = 24%). A series of eight follow-up focus groups with 31 audiology patients was held. Health professionals appeared to neglect appropriate provision of information and overly rely on technological interventions. Of 154 older people already fitted with hearing aids, only 52% of hearing aid users reported receiving enough practical help post fitting and only 41% reported receiving enough support. Approximately 40% reported not feeling confident in the use of their aids or their controls. Older people wanted more information than they received both before and after hearing aid fitting. Information provision and attention to the psychosocial aspects of care are key to enabling older people to adjust and optimise hearing aid benefit. Audiological rehabilitation is incomplete if it only includes hearing aid fitting.Evidence concerning efficacy of educational or counselling interventions is mixed.Significant problems exist in regard to availability, uptake and adherence to audiological rehabilitation programmes.Older people want and require information and support before and after they are fitted for a hearing aid.A range of audiological rehabilitation interventions is required to meet the needs of older people, which includes group-based emotional support and counselling.The ability to communicate is an important component of healthy ageing and well-being , and as There is consensus that providing technology alone does not meet the needs of older persons . Other sThe unclear evidence is highlighted by two systematic reviews of aural rehabilitation programmes. One focused on individual auditory training  the otheA mixed methods four-phase sequential research design was employed in 2006. Phase 1 involved semi-structured key informant interviews with professionals providing services to older people. In Phase 2, a survey of older people either on the waiting list for a hearing aid or already fitted with a hearing aid was conducted. In Phase three, we held focus groups with older audiology out-patients, and in Phase 4 a confirmatory round of focus groups was conducted. The study received ethical approval from the University and National Health Service (NHS) Research Ethics Committees and all data stored in accordance with Data Protection Act 1998. All participants at each phase of the research gave their informed consent to participate.Semi-structured interviews were conducted with representatives from six different organisations serving older hearing disabled people. The purposive sample was selected on the basis of location of organisation  and sector . All people approached for interview agreed to participate. Interviews addressed stakeholders’ perceptions of the strengths and weaknesses of services currently offered older people, what rehabilitation services older people needed to adjust to life with a hearing aid as well as the benefits and possible outcomes of effective rehabilitation. Interviews were audio-recorded and field notes were taken. Transcripts and field notes were analysed thematically. The findings from the interviews informed the development of the survey instruments.f = 0.2 in one-way 3-group analysis of variance (ANOVA) at 5% significance and 99% power. In retrospect, 99% power was too high and resulted in a much larger sample size than necessary; a sample size of 246 would have been sufficient to detect f = 0.2 at 80% power and 5% significance. Inclusion criteria included being at least 60 years of age, having any type of hearing loss, having no cognitive impairment, not having a terminal or life threatening illness, and speaking English. A total of 1000 postal questionnaires were distributed. A reminder letter and duplicate questionnaires were sent after 1 month to non-respondents.A random sample was selected from patient databases of audiology departments in three health boards serving urban, remote and rural areas of Scotland. Three different groups of older patients were sampled. This included long-term users of hearing aids (fitted with hearing aids for more than 6 months); first time hearing aid users (fitted with hearing aid for less than 6 months); and older people on a waiting list for hearing aid fitting. Randomisation was achieved through systematic sampling with a random start. Using G*Power 3.1 , items related to their hearing abilities  hearing aid usage  and a 5-point Likert question regarding satisfaction with audiology services. Dichotomous yes/no items were developed to capture which types of information or supports aided the adjustment to wearing a hearing aid, and about the timing of supports . A chi-square test was used to test different response rates across groups to the yes/no questions regarding supports and information needs. The text-based qualitative data were exported into N-Vivo  for analysis. Responses were coded into themes independently by two researchers and later compared for consistency before agreeing on final coding.The first round of focus groups consisted of eight groups. These initial focus groups were completed to deepen understanding of the issues identified from the survey and to further identify content for the development of a rehabilitation programme for older people. Survey respondents interested in participating in a focus group were invited to return an expression of interest form separately from their completed questionnaire. Two focus groups were scheduled in each health board area and an additional two were scheduled in the remote/rural health board. All participants who indicated willingness were invited to attend the focus groups. The semi-structured focus group guide included questions regarding participants’ own hearing loss journey, helpful supports and adjustments to life with a hearing aid, and additional supports needed. In addition, results of the survey were presented and participants discussed and explored the meaning of the results. Following the analysis of the first round of focus groups, a second set of focus groups was used to confirm the findings and further explore a proposed group-based approach to audiological rehabilitation.Responses to questions were generated and captured on a flipchart. Sessions were also audio-recorded and transcribed for content analysis using N-Vivo. The written transcripts were compared with the recordings and the flipcharts to promote accuracy and analysed independently by two researchers. Nine people were interviewed across six organisations working with and on behalf of deaf and hard of hearing communities. The six women and three men included an NHS audiologist, two social workers and an allied health professional working in a specialist local authority social work deaf service, two human service workers from voluntary organisations serving deaf and hard of hearing people, two people from deaf and hard of hearing advocacy organisations, and an executive from a large organisation. n = 95) and new users 18% (n = 43). An additional 7% of the sample were hearing aid users, although they did not specify the length of time they had been using a hearing aid (n = 16). There were no statistically significant differences between the three groups in terms of age .A total of 240 completed questionnaires were returned, representing a 24% response rate. As can be seen in n = 86), the mean length of time being on the waiting list was 8.5 months (SD 5.5) with a range from 6 weeks to 2 years. However 31 people did not know how long they had been on the waiting list. There was a significant difference in the mean length of time on the waiting list reported by participants from the three health board areas  with the mean in months for the three health board areas being 6.5 (SD 4.6), 8.1 (SD 4.6) and 11.4 (SD 7.0) months.For those on the waiting list (n = 79) of the respondents already fitted felt that they received enough instruction in the use of their hearing aid pre-fitting, increasing to 64% feeling that they received enough instruction after issue (n = 99). Only 52% (n = 80) felt they received enough practical help, and the percentage dropped to 41% (n = 64) when asked about getting enough support to use the hearing aid after fitting. Over one-third (36%) of hearing aid users reported not feeling confident using their hearing aids or using the controls on the aid (n = 56). These results were consistent across long-term and new users.The 154 participants who had already been fitted with a hearing aid were asked if they had received enough instruction, practical help and support during the process of receiving a hearing aid. Fifty-one per cent (All respondents were asked whether it would be/would have been helpful to learn more about the various types of information or supports identified by the key informants. n = 34) of all respondents had a family member or close friend with them during the process of being tested for or getting a hearing aid. Only 13% (n = 32) reported feeling that a family member or close friend should have been more involved. No waiting list participants had or wanted family involvement.Two questions asked about family involvement. Only 14%  = 5.48, p = 0.07]. 2 = 5.24, P = 0.02].Forty-two per cent of respondents indicated they would be happy to learn about hearing loss and hearing aids in small groups, 49% indicated they would not and 9% did not respond. Comparing responses across the three groups suggested some variations in feelings about group support, though the variations were not statistically significant,  I was invited there and they weren’t very helpful because they were just promoting one thing and said that it would cost somewhere between £700 and £7000, I said well what do I get for that? A car to carry it in? He said no but they are sophisticated and we’ve done a lot of research on this and so on and so forth well maybe, maybe I don’t know but it would be helpful if I could get an unbiased opinion on hearing aids. Focus Group 2Respondents spoke of how private dispensers would pressure them into buying a hearing aid and without complete information they felt unsure about their options.You would have thought he was selling double glazing. You sit in there and he says the sad thing is both your ears are quite bad. I had already had a hearing test at [NHS Hospital], you’ve got a loss in both your ears but today if you were to buy them today we’d knock six hundred off and if you take the two of them at one thousand four hundred and it’s a bargain. I did hear that, I did hear the one thousand four hundred. Focus Group 3Disappointment when hearing was not ‘normal’ againParticipants described having unrealistic expectations concerning the difference a hearing aid would make. Some thought that their hearing would be ‘normal’ again and were very disappointed when they received their hearing aid.Participants articulated numerous needs post fitting. In addition, many of the current hearing aid users continued to experience difficulties or lacked basic information about wearing, maintaining and getting the most out of the aid. The needs they identified were categorised as informational needs and support needs.The need for information post fitting included the following: information on environmental aids, how to care for and maintain the aid, coping with new sounds, other sources of information and support, managing the controls, when to wear the hearing aid and communication tips. Those who had been fitted with hearing aids reported a lack of information to help them adjust to wearing them. Both new and experienced users reported the dearth of information.You know I can’t help but compare this with the support from the diabetes. It’s just unbelievable that so little is given for audiology where with diabetes you are inundated with information…They look after you and it seems to me that with hearing aids you just have to look after yourself. It’s unbelievable that information is not available. Focus Group 3A consistent need identified by focus group participants was information about environmental aids. Even experienced hearing aid users were unaware of the range of environmental aids available or how to access them. The most commonly discussed assistive devices were loop systems, telephones, doorbells, televisions, alarm clocks and safety devices (e.g. smoke detectors). Even some of the participants who knew about loop systems had never tried to use them.The second most discussed informational need was related to hearing aid cleaning. This included knowing how to clean the aid and tubing, dealing with condensation, worries about getting the aid wet in the rain and caring for or changing batteries. Although some participants reported getting an ‘owner’s manual’ with their aid that included some of this information, most reported not remembering receiving such information. Participants described feeling overwhelmed when being fitted with a hearing aid, and getting home not remembering what the audiologist had told them.Another important informational need was advice on when they should wear the hearing aid. Some participants were afraid that wearing it too much would ‘weaken’ their hearing. Participants asked if it was okay to wear the aid at night. Others were confused about the accommodation and adjustment period immediately after getting the hearing aid. Stories exemplifying the shock and discomfort of using a new aid in high noise situations (e.g. stadiums) were plentiful, and participants believed they were avoidable had people received appropriate information.Support needs included psychological, practical and problem-solving needs. Items included follow-up, help with adjustment period, managing problems with the aid, coping with cosmetic concerns, managing batteries, problems with inserting the aid, support to persevere with the aid, coming to terms with hearing loss and the need to wear a hearing aid, and finally assertiveness and confidence.Respondents described many difficulties with their aids. Problems included the sound of the wind blowing in the microphone, a piercing whistling sound when inserted, difficulty reassembling the aid after cleaning, uncomfortable ear pieces, ear infections, difficulties using assistive devices, electronic security devices interfering with the aid and difficulty changing batteries. Participants were unaware that most problems could be resolved.Participants expressed the need for more follow-up services from the audiology department.Some participants had cosmetic concerns and were very self-conscious about wearing their aids. Participants suggested support needs in the adjustment process of wearing the devices.Most questionnaire respondents reported that family members were not involved and most did not wish for family involvement. For some focus group participants families had been the source of their referral to audiological services, putting pressure on them to see their doctor. Others reported that family members treated their hearing loss as a joke or it was the cause of family tensions. Participants identified reasons why family members should be involved and these included help with remembering and/or understanding what information was provided by the audiologist, understanding the problems that the hearing loss has caused, and needing different communication strategies (e.g. facing each other when speaking). The participants also identified barriers to family involvement. Barriers included the participants’ concerns regarding paternalistic treatment by their spouse or children. Other barriers originated from the communication partner . There was a consensus that a person with hearing loss should be given the opportunity to bring a family member along, and that written information should be provided for family members.The impetus for this study was to explore what older people thought would enable them to gain most benefit from hearing aids, including the possibility of group-based audiological rehabilitation. In interpreting our findings we acknowledge the relatively low response rate. The low response rate may have been exacerbated by unexpected patient record database challenges at research sites. For example, the patient database at one site was not current and many patients were listed in the wrong category, had wrong addresses, had died, or not informed they were on a waiting list. The low response rate requires that the results and subsequent discussion be read with caution. Respondents may represent those most dissatisfied with the service they received, have fewer functional limitations, and belong to a more vocal and articulate subpopulation. There are inherent limitations in using self-selection as a sampling strategy for focus groups and the likely positive predisposition towards group work. Still understanding the perspectives of those who have an expressed preference for auditory rehabilitation may point to key facilitators. The methodological limitations have to be offset against the innovative use of a sequential research design, which incorporated multiple methods. This methodological approach allowed for the identification of important aspects of audiological rehabilitation grounded in the views of older people, experts practising in the field and in professional literature. Such an approach could be beneficial in developing rehabilitation for other health conditions.A key finding is that the informational needs of older people were not being met. Most of the older people in our study wanted more informational support than they received both before and after hearing aid fitting. These findings on unmet informational support needs are echoed in the professional literature which calls for more than technological interventions – providing information is commonly identified e.g. . Howeverclearly meet a pressing concern, they would more likely attend and benefit. Further research is needed to identify effective means of providing support as part of a rehabilitation programme. Online support and information, peer mentoring, better designed information packages, and well-timed individual support and service user-led community based programmes are possible means of providing the support.Respondents were unequivocal that more support through the formal network was needed (i.e. follow-up from NHS). Peer support is cited in the literature as an important component to adjusting to a hearing aid e.g. . HoweverThe audiological literature discusses the importance of involving communication partners in rehabilitation e.g. . InteresCurrent best practice guidelines call for rehabilitation beyond hearing aid fitting alone. However given current resources, many audiology departments struggle to meet demand for hearing aid fitting alone – let alone comprehensive rehabilitation services. A group-based approach may be a feasible way to provide follow-up services in stretched services. A group service could be structured so that the majority of service users are provided with information and support maximising the benefits of hearing aid fitting and preventing problems. Only those needing extra support or follow-up could be referred on for more intensive follow-up services. This is consistent with the findings of This study endorses calls for enhanced auditory rehabilitation, and the findings are relevant to and consistent with messages from the international literature. Our work highlights that the perceived lack of pre- and post-fitting information and post-fitting support are unacceptable. Older people raised concerns about their ability to make informed choices between private and NHS providers in the absence of objective information and highlighted the distress associated with NHS waiting list uncertainty. We conclude that information provision and attention to psychosocial aspects of care are key to enabling older people to adjust and optimise hearing aid benefit, and that group rehabilitation approaches may offer an acceptable alternative for some older people. Older service users can and should be involved in shaping such services.


This review examines psychometric performance of three widely used generic preference-based measures, that is, EuroQol 5 dimensions (EQ-5D), Health Utility Index 3 (HUI3) and Short-form 6 dimensions (SF-6D) in patients with hearing impairments.A systematic search was undertaken to identify studies of patients with hearing impairments where health state utility values were measured and reported. Data were extracted and analysed to assess the reliability, validity  and responsiveness of the measures across hearing impairments.Fourteen studies (18 papers) were included in the review. HUI3 was the most commonly used utility measures in hearing impairment. In all six studies, the HUI3 detected difference between groups defined by the severity of impairment, and four out of five studies detected statistically significant changes as a result of intervention. The only study available suggested that EQ-5D only had weak ability to discriminate difference between severity groups, and in four out of five studies, EQ-5D failed to detected changes. Only one study involved the SF-6D; thus, the information is too limited to conclude on its performance. Also evidence for the reliability of these measures was not found.Overall, the validity and responsiveness of the HUI3 in hearing impairment was good. The responsiveness of EQ-5D was relatively poor and weak validity was suggested by limited evidence. The evidence on SF-6D was too limited to make any judgment. More head-to-head comparisons of these and other preference measures of health are required. Economic evaluations using a cost-utility framework have been increasingly used to support decision-making in the allocation of health resources and priority setting –3. Cost-One common way to obtain health state utility values is to use one of the generic preference-based measures (GPBMs) of health-related quality of life. Examples of the most commonly used GPBMs include the EuroQol 5 dimension (EQ-5D) , Short-fEmpirical evidence has confirmed that health state utility values obtained from these three GPBMs are different from each other –14. In ohttp://www.healthmeasurement.org/NHMS.html) attempted to build a versatile ‘toolbox’ for this purpose, and EQ-5D, Short-form 36 version 2 (from which SF-6D can be derived) and HUI were included in the toolbox .More evidence on the performance of EQ-5D and other GPBMs is required for a wider range of conditions and/or treatments to demonstrate whether these measures are appropriate for these conditions in order to judge when alternative measures should be considered. The assessment of the validity and responsiveness of GPBMs is fraught with conceptual and empirical problems owing to the lack of a gold standard measure. However, by taking into account of a range of evidence on specific conditions in a systematic and transparent way, it is possible to judge the performance of the instruments . This isHearing impairment is one of the most common chronic health problems in Western society, in part due to the growth of the elderly population, affecting 15 % of the adult population . HearingThe objective of the literature review was to identify published papers reporting evidence of the performance of EQ-5D, HUI3 and SF-6D in patients with hearing impairments.A broad search was conducted to identify studies reporting EQ-5D, SF-6D and HUI3 to examine the health-related quality of life of patients with a hearing impairment. BIOSIS, CINAHL, EMBASE, MEDLINE, PsychINFO and Web of Science electronic databases were searched. The database available from the EuroQol Group Website was also searched but comparable databases for HUI3 and SF-6D are not available. The search focused on key words search, including ‘hearing impairment/disorder’, ‘euroqol/EQ-5D’, ‘hui3’ and ‘sf6d’, all with alternative spellings. The search strategy is presented in Appendix Study characteristics—country, type of hearing impairment, disease or treatment stage, any treatment given, study design;Participant characteristics—number of participants, age, gender, ethnicity, missing data;Instruments used—EQ-5D/SF-6D/HUI3, other generic measures of health-rated quality of life, condition-specific health-related quality of life measures and clinical measures of disease severity, patient’s own health state valuations , Time trade-off (TTO) and Standard Gamble (SG));Health state utility values—mean of utility index, scoring algorithm;Construct and convergent validity—methods of assessment and results;Responsiveness—methods of assessment and results.Reliability—methods of assessment and results.Considering the aim of the study and reviewing forms used for similar studies in other disease areas , 25, a tFor the review, of the most importance was the relevance of the study in terms of the patient population and inclusion of evidence to answer our research question. Nevertheless, the quality of studies was assessed by examining study design, recruitment process, sample size and the extent of missing data reported. The intention of the assessment of quality was not to exclude relevant studies. Rather, it gives some indications of quality to assist with the interpretation of the findings. It should be noted that some studies may be of high quality for their research question, but provide limited information for the assessment of validity, reliability and responsiveness. For example, a case–control study may be well designed and conducted, but offer information limited to the presence or absence of hearing problems, and not detailed information on the severity of the condition.Validity is defined as how well an instrument measures what it was intended to measure , 26. Idet test) and regression were used for assessment. The patient population could be stratified on the basis of a clinical indicator or a health-related quality of life measure (generic- or condition-specific). A less stringent test of construct validity is to define groups using a case–control analysis where scores of patient group and non-patient groups or general population are compared.A common test to identify construct validity is the ‘known group’ method . This isAnother type of construct validity is known as convergent validity . This isResponsiveness is the ability to measure change. A pre/post-intervention study which reports EQ-5D, SF-6D or the HUI3 and another valid measure of health change would allow the responsiveness of a measure due to change in health status to be identified. As with the tests of validity, it is important to consider whether the measures of health change that used for comparison are valid themselves. In addition, it is important to consider whether other health changes not directly related to the condition could have impacted upon health-related utility .The reliability of a measure is defined as its ability to reproduce results when measurements are repeated on an unchanged population . ReliabiData were presented in a series of summary tables as well as brief text, providing information on characteristics and quality assessment of included studies, the measures included, methods and result for validity assessment, methods and results for responsiveness assessment. At the end, a table providing an overview of performance of EQ-5D, HUI3 and SF-6D was presented recording the findings as a ‘√’ if the evidence supported the statement, or ‘x’ if the evidence did not support the statement, or ‘?’ if the evidences were mixed and conclusion could not be made, or ‘N/R’ if no information was reported. If the pattern and direction of EQ-5D were consistent with other measures in terms of difference between groups or change over time, this was considered as supporting evidence. Correlation coefficients were grouped as small (<0.3), moderate (0.03–0.5) and strong (>0.5), and a significant predictor of regression was recorded as ‘√’.Bibliographic searching was completed in July 2010. The search strategy identified 119 articles. After reviewing titles and abstracts, 70 papers were excluded. Forty-nine papers were reviewed in full, and a further 31 were excluded and 18 papers were included in the final review , and the remaining studies included adults in their studies with most focussing on older adults over 60 years. The studies involving children used parents or caregivers as proxies to assess health-related quality of life of children.Table A total of 11 papers also reported Visual Analogue Scale (VAS) results including: EQ-VAS, a general health VAS, a hearing-specific VAS and a general quality of life VAS. In total, 7 papers reported the EQ-VAS and used imaginable best and worst imaginable health as anchors. Among them, 4 publications related to a single study reported the results of a hearing-specific VAS , 34, 35 Time trade-off (TTO) values were obtained without the use of generic measures in 2 studies , 37. TheA total of 9 studies employed self-reported hearing-specific health-related quality of life measures. This included 3 studies using the Hearing Handicap Inventory for the Elderly, 2 using the Hearing Handicap and Disability Index, and 1 using the Nijmegen cochlear implant questionnaire, the Speech Spatial and Qualities of hearing scale for parents, Amsterdam Inventory and Audiological Disability Preference Index which is a hearing-specific preference-based measure derived from Amsterdam Inventory. Six studies reported clinical indicators to indicate severity of hearing impairment, including pure-tone average for the best or worst ear without hearing aid and speech identification tests.The review found little evidence on the reliability assessments of EQ-5D, HUI3 and SF-6D in hearing impairment. No papers reported conducting test–retest experiments. Although not specifically for test–retest reliability purposes, one study  reportedOut of the 18 papers include in the review, 7 papers provided information to enable an assessment of the EQ-5D, HUI3 or SF-6D, although most studies were not designed to examine the validity of these measures. The results are summarised in Table p < 0.001) and 12 months after intervention (p < 0.1) using t test. Similarly, HUI3 discriminated 2 groups of patients with cochlear implant and with normal hearing aids where the hearing loss severity of these 2 groups was different according to their pure-tone average. In a study comparing HUI3 and QWB in hearing loss, both scores declined with the degree of hearing loss for children who did not have a cochlear implant with a much greater extent for HUI3 than QWB [Seven studies presented data to allow an assessment of ‘known group’ differences where the groups were defined by severity of hearing loss. Using ANOVA, the study by Grutters et al.  demonstrthan QWB . A furththan QWB . Howeverp < 0.01) in a large cross-sectional study. HUI3 scores apart from this, no other papers reported correlations between health-related quality of life measures with clinical indicators of hearing loss. Barton et al. [Three studies presented data for an assessment of convergence of EQ-5D and HUI3. HUI3 showed poor correlation with two speech perception tests; however, a hearing-specific quality of life measure also showed similar results . Grutersn et al.  reportedTwelve papers involved a total of 8 studies that provided adequate information to allow an assessment of responsiveness of EQ-5D and/or HUI3 (see Table p < 0.05), whereas non-significant for other dimensions. The results suggest that the EQ-5D was responsive in capturing larger improvements in hearing as in the study by Lee et al. but was not able to capture the smaller levels of improvement shown in the study by Grunter et al.Comparison of mean change scores of different GPBMs using statistical tests were reported by Gruter et al.  and Lee Eight papers reported the responsiveness of EQ-5D without the other 2 generic measures by comparing them with EQ-VAS, hearing VAS or other hearing-specific measures, which involved a total of 4 separate studies. In these studies, no statistically significant changes before and after the hearing intervention were detected by the EQ-5D , 38, 39 p < 0.1). Only the change scores of hearing and speech dimension of HUI3 were significant and the hearing dimension had the biggest change score while scores of other dimensions were stable over time. Moderate correlations (around 0.48) between change scores of VAS, TTO and HUI3 were found [Three papers reported responsiveness of HUI3 without the other 2 generic measures, comparing with VAS/TTO and hearing-specific measures , 37, 43.The 18 papers (14 studies) included in this review provide useful information to assess the validity and responsiveness of GPBMs for use in hearing impairment. A summary of the overall performance of the 3 GPBMs is provided in Table Overall, the HUI3 was the most commonly used measure in the studies. In all 6 cases, the HUI3 detected difference between groups defined by their severity of hearing impairment and 4 out of 5 cases detected statistically significant changes as a result of intervention. Differences picked up by the HUI3 were driven by the hearing dimensions, and also, in some cases, the speech dimension and the emotion dimension. On the other hand, the findings of the review suggested relatively poor responsiveness of EQ-5D in this condition as in 4 out of 5 cases EQ-5D failed to detected change. The only study that allowed an assessment of known groups using the EQ-5D suggested it only had weak ability to discriminate difference between severity groups. Only one study involved the SF-6D, thus the information is too limited to conclude on its performance. Converting published mean SF-36 scores into SF-6D would not help since psychometric testing requires individual level data.Two studies reported validity of EQ-5D where the results were mixed when the groups were defined by severity of hearing impairment . In termThere were 2 exceptions to the poor performance of EQ-5D: one study demonstrated a statistically significant improvement in EQ-5D index scores after cochlear implantation and in another study, the EQ-5D differentiated between severe hearing loss but not in different levels of milder hearing loss. Although EQ-5D utility indices remained stable over time, 1 study showed that the proportion of respondents who reported problems for dimensions of EQ-5D increased or decreased. Another study treated responses of EQ-5D dimension as continuous variables to compare mean responses before and after intervention, which was judged to be problematic for analysis. There were 2 studies where the HUI3 reflected differences, but much smaller differences were found in the EQ-5D utilities.It is perhaps unsurprising that HUI3 performs well as it explicitly includes a hearing dimension. The lack of a direct reference to an impairment or symptom in EQ-5D does not mean that, by definition, its effects will not be captured; however, this review suggests that EQ-5D may perform poorly in this particular type of condition. A five-level version of the EQ-5D has recently been developed and this may overcome the problem if it is simply one of the sensitivity. However, it may be related to a lack of relevant dimensions to pick up the impact of hearing loss. Evidence is required using the 5-level version to confirm this hypothesis. Another approach to the problem might be to use a condition-specific preference-based measure for hearing like the one developed by Yang et al. for asthma  or RowenIt cannot always be assumed that a generic measure should reflect the change of health states which a condition-specific measure detects. Disease- or condition-specific measures are tailored to the condition of interest and are therefore more focussed on the condition of interest and may be more sensitive to change. However, they may not capture the broader impacts of the condition on health-related quality of life. In addition, the general population (or indeed the patients) may not regard the change as sufficiently important when valuing health. Interestingly, in this study, not only GPBMs, but also the hearing-specific measures showed poor correlations with clinical indicators. This emphasises the importance of including patient-reported outcome measures in the evaluations of health care interventions. In addition, preference-based measures can reflect how changes in health states are valued, in relation to other aspects of health.This is the first-time information on the validity and responsiveness of GPBMs that have been comprehensively reported and analysed in hearing impairment. This paper reports important findings for the use of GPBMs of health to compare the impact of hearing loss on health-related utility. The results indicate that HUI3 is an appropriate measure for use in hearing impairment given its good performance of validity and responsiveness. EQ-5D was not responsive to modest changes in hearing impairment, and the limited evidence suggested it has weak validity in this condition. Very little evidence was found for SF-6D.


Beauveria bassiana  Vuillemin  were grown on cooked rice using diphasic liquid-solid fermentation in plastic bags to produce and harvest spore powder. The cultures were dried and significant differences were found for isolates and time of harvest. The spores were harvested manually and mechanically and after the cultures were dried for nine days, when moisture content was near 10%. After harvesting, spores were submitted to quality control to assess concentration, germination, purity, moisture content, particle size and pathogenicity to the coffee berry borer, Hypothenemus hampei (Ferrari) (Coleoptera: Curculionidae). Spore productivity on cooked rice was less than 1×1010 spores/g using both manually and mechanically harvesting methodologies. Germination at 24 hours was over 75% and pathogenicity against H. hampei was over 92.5%. This methodology is suitable for laboratory and field studies, but not for industrial production when a high concentration of spores are required for formulation and field applications.Two isolates of fungal entomopathogen  Hypothenemus hampei (Ferrari) (Coleoptera: Curculionidae) poses a serious threat to coffee production throughout the world due to its destruction of the coffee seed. Among the various biocontrol methods used to control this insect, the fungal entomopathogen Beauvena bassiana  Vuillemin  is highly promising. The fungus has been shown to cause high mortality in various countries where the coffee berry borer is present  was reported to have 5.8 × 1010 spores per gram of substrate. This implies that the conversion of substrate to spores was high, and that at least some formulations already in the market should be able to increase yield while remaining economically viable to produce.Jenkins  reviewedThe development of mycoinsecticides to be sprayed with controlled droplet application technology must consider the production and formulation system. The spores produced for oil formulation must be lipophilic, this means that they should be produced using surface liquid media, on solid substrates or a combination of these methodologies that are called diphasic liquid—solid fermentation . The spoB. bassiana spores using the diphasic liquid—solid fermentation technique developed for the LUBILOSA  project to produce Metarhizium flavovinde  B. bassiana 9002 was isolated from the coffee berry borer H. hampei (Coleoptera: Curculionidae) collected in Ancuya (Nariño) in a coffee plantation and (2) B. bassiana 9205 was isolated from the sugar cane borer, Diatraea saccharalis (Fabricius) , collected in Palmira  in a sugar cane plantation. Both isolates were selected as the most virulent coffee berry borer strains in the CENICAFÉ B. bassiana collection.Two isolates of B. bassiana cultured on rice using LUBILOSA's diphasic liquid—solid fermentation methodology , 35 (500 m), and 60 (250 m). The spore powder, passing through all three sieves, was used for subsequent research such as spore storage in oil, spore oil formulation and feasibility of spraying using controlled droplet application technology.Five trials were carried out, each one with a batch of 30 kg of hodology  using plThe experiment was set up as a completely randomized design with a factorial arrangement (2 × 4). The treatments were two isolates and four different times of harvest, 15, 25, 35 and 45 days after the inoculation and incubation. Each treatment combination was replicated five times and each replicate consisted of one bag of 200 g. The data were analyzed using one-way analysis of variance ANOVA: The spores were harvested at four different time intervals, 15, 25, 35 and 45 days after the inoculation, to evaluate if harvest time had any effect upon spore yield and to obtain an estimate of the optimal harvesting period. To harvest the spores as powder it was necessary to dry the fungus to reduce moisture content and allow the spores to separate from the rice substrata. The spores harvested following this procedure can be preserved for a long time without loss of germinative power or pathogenicity .www.wstyler.com/) that uses horizontal circular motion and vertical taping motion to stratify and screen the particles. The manual harvest consisted of back and forth movements of the sieve. The samples were then put through 3 sieves as described above. The spore powder that was collected after sieving was weighed and kept in separate sterile vials for further assessments, such as moisture content and quality assessment (see below) and stored for later use inside a sealed silica gel vacuum desiccator and kept in a cool room under the conditions described above.Treatments were selected at random to be dried at each harvest time. To dry the cultures the plastic bags were opened in a room with a temperature of 15 ± 4°C and an average relative humidity of 55 ± 7 % and allowed to air dry. Harvesting was done both mechanically and manually for 20 minutes. The mechanical harvest involved the use of a shaker Ro-Tap Sieve Shaker . However, the statistical analysis (ANOVA) ( (ANOVA)  of indepB. bassiana culture and rice during air drying process before the spores were harvested. The B. bassiana culture and rice in to each treatment were dried for nine days at which point the moisture content was stable .B. bassiana 9205 was slightly more productive than B. bassiana 9002 and the highest production of both isolates was obtainedby manually harvesting the spores 15 days after inoculation.Spore powder production showed considerable variation. Production of both isolates was higher using the manual method compared with the mechanical method. The overall spore production by isolate shows that B. bassiana spore powder. The spore concentration was highly variable for harvest methods and for isolates. The spore concentration was higher for the mechanical method. This result was the opposite for the spore powder weight where a higher yield was obtained using the manual method.B. bassiana spores remained on the rice. Following sieving these cultures were washed out with water plus 1% of emulsifiable oil to extract the spores for counting and to calculate the total concentration for each treatment.Spore concentration was higher when harvested earlier compared with later times. It was observed that after harvesting the rice cultures B. bassiana 9205 is more productive than B. bassiana 9002. Production of B. bassiana 9205 was higher 15 days after inoculation and thereafter declined gradually to 45 days, which resembles a typical growth microbial curve. In contrast, B. bassiana 9002 did not show this pattern of spore production.B. bassiana 9205 was higher than B. bassiana 9002  and was over 92 % for both isolates and for all different times of spores harvested.hodology . The morH. hampei treated with the spores harvested in this experiment was not significantly different between isolates and days of harvest . Isolate B. bassiana 9002 at harvest times of 15, 25 and 45 days did not show a significant difference in mean mortality time, but between 15 days and the spores harvested 35 days after inoculation there was a significant difference . Isolate B. bassiana 9205 harvested at 15 and 25 days showed significant differences in mean mortality time compared with the spores harvested at 35 and 45 days. For both isolates, spores harvested at 15 days were more pathogenic to H. hampei than spores harvested after 35 days. The spores harvested at days 35 and 45 showed no significant differences between them .The mean mortality time MMT in  in days Penicillium spp. and Cladosporium spp.The presence of contaminant microorganisms was low, less than 2 % of colony-forming unit for both isolates and was present only in the spores harvested on day 25. Only the presence of contaminant fungi was detected. These were identified as B. bassiana spore powder harvested at different times showed a tendency to be lower for isolate 9002 and was higher for the spores harvest after 15 days. At this time 9205 had moisture content of 13 ± 3.1 % compared to 11.4 ± 0.5 % for isolate 9002. After harvest at 25 and 35 days the moisture content was similar for both isolates. At 45 days the moisture content dropped dramatically and was 6.3 ± 0.1 % for 9205 and 5.9 ± 0.9 % for 9002.The moisture content of The spores harvested were taken from the bottom of a set of sieves of size 18 (1 mm), 35 (500 m) and 60 (250 m); therefore, the spore powder that was obtained had particle sizes of less than 250 m.Moisture loss was a result of the metabolic activity of the fungus, transpiration and diffusion while the cultures were developing. Moisture was also lost when the cultures were dried for nine days in a cool room with 55 ± 7 % average relative humidity. The information obtained from drying suggests that the cultures can be dried in five days following the same process as in this study, which would save time and resources.The lowest moisture content achieved from harvested spore powder was around 10% for the best harvest period (15 days). This moisture content, obtained under controlled conditions and after nine days of air drying was still too high to store the spores and preserve their viability. Ideally, a moisture content of 5% would have been preferable . One wayB. bassiana cultures on rice is a mixture of starch and spores. The high weight of powder harvested from B. bassiana 9002, which had low spore concentration, means that there is a difference between B. bassiana isolates in the ratio of starch to fungal spores and this needs to be considered in mass production.Moisture content can influence the weight of the spores harvested. Although the spores with the highest weight also have high moisture content, this did not mean that they have high spore concentrations due to the presence of starch from the rice. Starch could block the nozzles of application equipment. These characteristics need to be evaluated if fungal production is to be scaled up to avoid application problems in the field situations. The powder harvested from The harvest methods used showed differences in the amount of powder extracted from the cultures and the concentration of spores per gram of powder. The possible reason for this result was that the mechanical method used the same frequency during the time the cultures were being sieved, while in the manual method the rhythm of shaking changed more often because the operator became tired. Also manual shaking could be stronger than the mechanical method allowing more rice starch to pass through the sieve mesh thereby adding more weight to the spore powder.It is not clear what happens with the spores, in terms of numbers, when the inoculation to harvest period is increased. It may be that they germinate and become mycelia, thereby, causing the loss of biomass. Alternatively cultures may begin to degrade because there are not enough resources to continue growing. To avoid a loss of spore production the harvest needs to be done early. Further experiments around 10–20 day intervals should be carried out to determine the optimum harvest period.B. bassiana spore production system is going to be based on rice, then a better method of harvesting the spores will be required to make the process more efficient because B. bassiana spores are strongly retained on the dry rice. Also, spore production may vary due to the different characteristics in strains, such as different patterns of spore production among various isolates.The results of this study show that if a 10 spores/g using the production methods evaluated in this study) require looking for better methods of B. bassiana mass production and spore harvesting if the fungus is going to be used as a mycoinsecticide (10 spores/g remain one of the major constraints in the production of reliable mycoinsecticidal products (B. bassiana products based on rice, it will be necessary to improve the extraction method to remove the spores that are retained on the rice, which were twice the spores produced.The mechanical and manual harvesting methodologies used had low efficiency to extract the spores from the rice grain and this result combined with the low spore productivity (less than 1 × 10ecticide . Althougecticide . Low yieproducts . If induproducts . In the B. bassiana showed that high quality spores can be obtained according to the standard of purity established by CENICAFÉ (However, the production method for CENICAFÉ  and thatCENICAFÉ .Additionally, the germination and pathogenicity of the spores, which are the most important quality control parameters, showed high values resulting in rapid mortality of coffee berry borer. The viability of the spores assessed for germination test at 24 hours was more accurate than when assayed after 48 hours. This implies that the assay of germination must be carried out within 24 hours as was also found by Bateman . Proper H. hampei compared to the other times of harvest.The pathogenicity test showed mortality levels over 92.5% for both isolates and harvest times. The use of high quality standards for spores increases the likelihood of success when applied in the field. The mean mortality time was shorter for the spores harvested early than for the spores harvested later. A possible reason was that early harvested spores could have a higher proportion of viable spores and therefore they more promptly infected the beetles and caused more rapid mortality than spores harvested later. However, there is no evidence to support this hypothesis. The mean mortality for both isolates harvested times at 15 days were shorter and therefore both isolates caused high mortality in The high spore quality, high spore germination, and high pathogenicity obtained using the methods used could be due to proper drying and harvesting of spores under controlled low temperature and relative humidity, which are factors recognized to cause a fast degradation of spore viability .B. bassiana powder spore production on an industrial scale because of its low efficiency and massive rice substrate requirement. This is illustrated in The diphasic liquid—solid fermentation methodology is not suitable for To carry out this production also requires laboratory facilities for cooking and sterilizing the rice, inoculum media, packing material and labor, a place to keep the culture while it develops, space and labor for spore harvesting, plus the hazardous risk to the workers exposed to airborne spores.B. bassiana spore production needs to be highly efficient and productive to make a successful, inexpensive mycopesticide based solely on B. bassiana spores. Current diphasic liquid solid fermentation technologies are incapable of yielding mycoinsecticide concentrations higher than 1×1010 (n 1×1010 . In addin 1×1010 . They aln 1×1010 .B. bassiana spores, but the quantities produced are only suitable for small-scale laboratory and field trials. All the constraints analyzed above do not imply that the use of B. bassiana against the coffee berry borer should be stopped. In addition to this fungus being the most important natural enemy of the coffee berry borer (B. bassiana and have shown that it is a promising strategy and a key component of the integrated pest management of the coffee berry borer even though they are in their initial stages (The methodology evaluated in this study allows for the production of high quality ry borer , field sl stages . The usel stages  that can


Lawsonia intracellularis is an obligate intracellular bacterium and the causative agent of proliferative enteropathy (PE). The disease is endemic in pigs, emerging in horses and has also been reported in a variety of other animal species, including nonhuman primates. Comparing the whole genome sequences of a homologous porcine L. intracellularis isolate cultivated for 10 and 60 passages in vitro, we identified a 18-kb prophage-associated genomic island in the passage 10 (pathogenic variant) that was lost in the passage 60 (non-pathogenic variant). This chromosomal island comprises 15 genes downstream from the prophage DLP12 integrase gene. The prevalence of this genetic element was evaluated in 12 other L. intracellularis isolates and in 53 infected animals and was found to be conserved in all porcine isolates cultivated for up to 20 passages and was lost in isolates cultivated for more than 40 passages. Furthermore, the prophage region was also present in 26 fecal samples derived from pigs clinically affected with both acute and chronic forms of the disease. Nevertheless, equine L. intracellularis isolates evaluated did not harbor this genomic island regardless of the passage in vitro. Additionally, fecal samples from 21 clinically affected horses and four wild rabbits trapped in horse farms experiencing PE outbreaks did not show this prophage-associated island. Although the presence of this prophage-associated island was not essential for a virulent L. intracellularis phenotype, this genetic element was porcine isolate-specific and potentially contributed to the ecological specialization of this organism for the swine host. Lawsonia intracellularis is a gram-negative obligate intracellular bacterium and the etiologic agent of proliferative enteropathy (PE). The disease is characterized by thickening of the intestinal epithelium due to enterocyte proliferation which is directly associated with the presence of intracytoplasmic bacteria [bacteria . PE is ebacteria -4.L. intracellularis has limited molecular studies comparing bacterial isolates, so far, there are approximately 15 isolates worldwide. The whole genome of a porcine L. intracellularis isolate (PHE/MN1-00) has been sequenced and annotated (accession: PRJNA183) using Sanger-based sequencing and a total of 1 719 014 base pairs distributed into one small chromosome (1.46 Mb) and three plasmids. The presence of few potential virulence factor-encoding genes identifying by comparative sequence analysis and many hypothetical proteins suggest that this organism has adopted mechanisms of survival and pathogenesis that are unique among bacterial pathogens [PE was first reported in 1931 , but theL. intracellularis at low passages (4 to 20) in cell culture [L. intracellularis associated with its adaptation to in vitro conditions due to mutational events at the DNA level has been speculated [L. intracellularis without requiring bacterial isolation.Non-pathogenic isolates obtained through multiple passages in cell culture have not been successful at inducing typical PE lesions or reversing virulence in experimentally-infected pigs . Convers culture -12. Vann culture . The loseculated . Howevereculated -16. A moL. intracellularis variants. The prevalence of a prophage-associated genomic island which was present in the pathogenic but not in the non-pathogenic variant was evaluated in porcine and equine isolates, as well as in fecal samples positive for the presence of L. intracellularis DNA derived from infected animals.The present study used high-throughput DNA sequencing technology to compare and characterize genomic variations between homologous pathogenic (passage 10) and non-pathogenic (passage 60) L. intracellularis isolate PHE/MN1-00 previously obtained from a pig with the hemorrhagic form of PE was used [75 cell culture flasks containing one-day-old McCoy cells (30% confluence) were infected with bacterial suspensions containing approximately 104 L. intracellularis organisms.The porcine was used . A previwas used . Murine was used . Pure cuL. intracellularis at passages 10 and 60 were prepared and used for DNA sequencing. Inoculated cultures were placed in an anaerobic chamber which was evacuated to 500 mmHg and refilled with hydrogen gas. Infected cultures were then incubated for seven days in a Tri-gas incubator with 83.2% nitrogen gas, 8.8% carbon dioxide, 8% oxygen gas and a temperature of 37°C, as previously described [L. intracellularis[After a recovery period, pure cultures of ellularis. All proBacterial cultures were prepared for extraction and sequencing using the supernatants of infected cell cultures in order to minimize the presence of eukaryotic DNA and enhance the purity of the bacterial suspension for DNA extraction. Briefly, cell culture supernatants were passed t through 0.8 μm sterile filters to remove potential detached McCoy cells present in the cell monolayer supernatant. Filtered bacterial suspensions were then pelleted by centrifugation at 8000 for 20 min. The pellets were used for DNA extraction using DNeasy Blood & Tissue Kit® , according to the manufacturer’s instructions.The sequencing procedures were conducted through the core facility of the Biomedical Genomics Center at the University of Minnesota. Following quantification using the PicoGreen Assay of the DNA generated in the library preparation, the samples were loaded on the Illumina® Genome Analyzer GA IIx platform with paired reads of 76 bp. Base calling and quality filtering were performed following the manufacturer’s instructions .The sequence contigs were generated using Velvet assembly software  followedL. intracellularis isolate PHE/MN1-00 but not in the non-pathogenic variant (passage 60) was evaluated in 12 other isolates from our collection at low and high passages , along with samples from 21 naturally infected horses from eight states  and four wild rabbits captured in a California horse breeding farm experiencing clinical cases of L. intracellularis infections.The presence of the prophage-associated genomic island identified by whole-genome sequencing in the pathogenic variant passage 10) of the porcine 0 of the Specific primers targeting all 15 genes included in the prophage-associated genomic island and the two flanking genes present immediately before and after the prophage region were designed Table . DNA froL. intracellularis available at the National Center for Biotechnology Information (NCBI accession: PRJNA61575) using Sanger-based sequencing. Although there is no information available regarding the number of passages in vitro used in this first sequencing project, our results showed identical DNA contents using the passage 10. This strongly indicates that the first genome project used low passage-cultivated bacteria.The present study resequenced the isolate PHE/MN1-00 which was used to generate the reference genome of L. intracellularis cultivated at 10 and 60 passages in vitro, respectively. For the passage 10, the average coverage of 42X was assembled with mean contig length of 11 845 bp (minimum: 2175 and maximum: 112 744) and 14.1% of unused data which represented eukaryotic-derived DNA. The data from the passage 60 (NCBI accession: PRJNA61575) generated an average coverage of 66X assembled with mean contig length of 10 674 bp (minimum: 1189 and maximum: 119 534) and 11.3% of eukaryotic -derived DNA.The whole genome sequencing generated 83 999 466 and 128 258 573 millions of bp for L. intracellularis variants reveals a major deletion of 18,086 base pairs (bp) in the passage 60 which includes 15 genes starting from the prophage DLP12 integrase gene (LI0173). General features of the genome comparison are summarized in Table The comparative analysis between homologous pathogenic (passage 10) and non-pathogenic (passage 60) ene LI017. GeneralL. intracellularis isolate PHE/MN1-00 at passage 60. This deletion is located at the position 218 578 to 236 664 and comprises 15 genes starting from the prophage DLP12 integrase gene  which do not harbor this genomic island regardless of the number of passages in vitro. Although the pathogenicity of the equine isolate at low passage (E40504) has been demonstrated in previous studies ,22, the L. intracellularis DNA in the feces were evaluated, derived from seven states of the United States . Twenty-two samples were derived from pigs affected with the chronic form of PE and four from pigs affected with the acute form of the disease, known as proliferative hemorrhagic enteropathy (PHE). Regardless of the clinical presentation of the disease or the state of origin, all the porcine-derived samples consistently exhibited the prophage-associated island characterized by the presence of all 15 genes within the chromosomal region.A total of 26 porcine samples that previously tested positive for the presence of L. intracellularis by fecal PCR from eight states  were evaluated. None of the genomic island genes were present in any equine-derived samples, confirming the observations from the two equine isolates previously described in this study. The absence of the prophage island also was observed in samples obtained from four wild rabbits captured in a horse breeding farm experiencing clinical cases of PE.Twenty-one horse samples that were positive for L. intracellularis isolate cultivated for 10 and 60 passages in vitro, we identified the loss of a prophage-associated genomic island in the passage 60. This chromosomal deletion comprises a total of 15 genes (18 086 bp) starting in the defective prophage DLP12 (a defective lambdoid prophage at the 12th minute of the chromosome) previously described in E. coli[E. coli K-12 contains 22 genes included in a region of 21 302 bp [L. intracellularis or underwent a partial deletion once integrated into the L. intracellularis genome. While DLP12 genes in E. coli encoding a two-component lysis cassette (holing-endolysin) are responsible for inducing lysis of the host bacterial cell, this cassette was not found in the prophage DLP12-associated island of L. intracellularis. As a result, this defective prophage integrated into L. intracellularis may have lost a function essential for lytic growth and can no longer liberate infectious particles.Comparing the whole genome sequences of a porcine n E. coli. The ful1 302 bp . From anE during the stress response [E. coli[L. intracellularis to produce biofilm. However, empiric observations of recurrent clinical infections in certain swine production systems may support future investigations regarding biofilm production, based on the potential persistence of L. intracellularis in swine installations and/or fomites. Previous studies did not identify expression of the 15 genes included in the prophage-associated island by L. intracellularis in the host cytoplasm in vitro or in vivo [E. coli, the expression of the DLP12 genes in L. intracellularis is likely to occur during the stationary phase of the extracellular life cycle.Although the impact of the prophage DLP12 in cell physiology and virulence remains unclear, studies have associated the presence of this integrated prophage with resistance to environmental stress and biofilm formation ,25. Rhodresponse . A recen in vivo ,28. TherE. coli K-12 (<1 per 100 000 cells) may explain the gradual loss of this genetic element during L. intracellularis cultivation in cell monolayer [L. intracellularis in vitro the infection is passed weekly [E. coli lost the ability to excise and form phage particles on SOS response challenge [The authors identified the persistence of the prophage DLP12-associated element for at least 20 passages in vitro in two porcine isolates and its loss after 40 passages in cell monolayer , it is possible that this gene may be expressed extracellularly and contribute to a higher antimicrobial tolerance during the extracellular stage. However, this hypothesis needs to be specifically addressed in a future study.A gene encoding ribosomal protection protein associated with tetracycline resistance was found in this prophage-associated island. Although the wide use of antimicrobials in the swine industry over the years has been speculated to select resistant and/or virulent bacterial strains ,32, the d Europe . Regardld Europe . Though L. intracellularis isolates available worldwide, our results showed the presence of the entire prophage region in ten porcine isolates at low passage in vitro indicating the consistent adaptation and specificity of this genomic island to porcine-derived isolates, regardless of the clinical form (acute or chronic) of the disease. The absence of this genomic island in the equine isolate at low passage reveals an important genomic variation related to species-specificity of L. intracellularis isolates. The availability of only one hamster isolate that has been cultivated over 100 times in vitro restricts a more confident conclusion regarding the prevalence of the prophage in this species. Nevertheless, this is the first study describing a significant genomic variation among L. intracellularis isolates, since to date L. intracellularis has been considered a monotypic organism [Despite the limited number of organism .L. intracellularis. Despite the fact that the loss of this genetic element was coincident with the loss of virulent phenotype in one porcine isolate (PHE/MN1-00) [L. intracellularis infections. However, our results show that this genomic region is indeed associated with host-adapted L. intracellularis variants.In addition to the porcine isolates, the presence of the prophage DLP12-associated genomic island was confirmed in fecal samples from PE-affected pigs and its absence confirmed in horses and rabbits infected with /MN1-00) , the conL. intracellularis in pigs and horses [L. intracellularis at low passages, pigs and foals infected with their species-specific isolates shed the bacterium in the feces for longer periods of time and exhibited stronger serologic immune responses compared with foals infected with the porcine isolate and pigs infected with the equine isolate. While the porcine isolate in the referred study harbors the prophage, the equine isolate does not have this genetic element. This evidence of host adaptation in pigs and horses seems to extend to experimental infection models using hamsters and rabbits [L. intracellularis variants evolved to be adapted to more than one host species. The evolutionary ecology responsible for driving host-adapted variants remains to be determined. Although our study failed to specifically associate the prophage DLP12 genomic region with virulent phenotype, we hypothesize that this genetic element contributes to the adaptation of L. intracellularis in the porcine host. Based on evidence showing the role of this defective prophage in helping E. coli cope with adverse environment and form biofilms, this genetic element may drive an ecological specialization in pig-adapted L. intracellularis variants. In a future perspective, the whole genome sequencing of horse isolates could allow a more comprehensive conclusion regarding the genetic traits related to the host-adapted L. intracellularis variants. Recently, the analysis of whole genome sequences of Staphylococcus aureus ST398 strains derived from livestock and humans showed the presence of the prophage φ3 in human but not animal-derived isolates [Supporting the genotypic variation among the species origin of the bacterial isolate described here, a previous study phenotypically demonstrated the host adaptation of d horses . In a cr rabbits . Sampier rabbits . These risolates . The autL. intracellularis isolates. The identification of this genetic element may be applied as a molecular marker to determine the species origin of the bacterial isolates and to trace the evolutionary history related to the host species in L. intracellularis infections. Finally, this first study showing significant genomic variation in L. intracellularis isolates associated with the previously reported host-adapted phenotype may support the characterization of novel L. intracellularis subspecies or species-specific genotypes.In summary, the present study showed a prophage-associated genomic island present specifically in pathogenic porcine The authors declare they have no competing interests.Conceived and designed the experiments: FAV, MRK, CJG. Performed the experiments and analyzed the data: FAV, MRK, CJG. Wrote the paper: FAV, MRK. Coordinated and helped to draft the manuscript: CJG. All authors read and approved the final manuscript.


Aerosol Measurement: Principles, Techniques, and Applications, 3rd ed.Pramod Kulkarni, Paul A. Baron, Klaus Willeke, eds.Hoboken, NJ:John Wiley & Sons, 2011. 900 pp. ISBN: 978-0-470-38741-2, $195Analysis of Chemical Warfare Degradation ProductsKarolin K. Kroening, Renee N. Easter, Douglas D. Richardson, Stuart A. Willison, Joseph A. CarusoHoboken, NJ:John Wiley & Sons, 2011. 160 pp. ISBN: 978-0-470-74587-8, $95Applications of Toxicogenomics in Safety Evaluation and Risk AssessmentDarrell R. Boverhof, B. Bhaskar Gollapudi, eds.Hoboken, NJ: John Wiley & Sons, 2011. 396 pp. ISBN: 978-0-470-44982-0, $115Bringing Ecologists and Economists TogetherT. Söderqvist, A. Sundbaum, C. Folke, K.-G. Mäler, eds.New York:Springer, 2011. 281 pp. ISBN: 978-90-481-9475-9, $129Chemical Biomarkers in Aquatic EcosystemsThomas S. Bianchi, Elizabeth A. CanuelPrinceton, NJ:Princeton University Press, 2011. 392 pp. ISBN: 978-1-4008-3910-0, $95Climate and the OceansGeoffrey K. VallisPrinceton, NJ:Princeton University Press, 2011. 232 pp. ISBN: 978-0-691-14467-2, $80Climate Change JusticeEric A. Posner, David WeisbachPrinceton, NJ:Princeton University Press, 2010. 240 pp. ISBN: 978-1-4008-3440-2, $27.95Emergency Response Management of Offshore Oil Spills: Guidelines for Emergency RespondersNicholas P. Cheremisinoff, Anton DavletshinHoboken, NJ:John Wiley & Sons, 2010. 529 pp. ISBN: 978-0-470-92712-0, $175Encyclopedia of Bioterrorism Defense, 2nd ed.Rebecca Katz, Raymond A. Zilinskas, eds.Hoboken, NJ:John Wiley & Sons, 2011. 688 pp. ISBN: 978-0-470-50893-0, $449.95Energy for a Sustainable World: From the Oil Age to a Sun-Powered FutureVincenzo Balzani, Nicola ArmaroliHoboken, NJ:John Wiley & Sons, 2011. 390 pp. ISBN: 978-3-527-32540-5, $45Everyday Environmentalism: Law, Nature, and Individual BehaviorJason J. CzarnezkiWashington, DC:Island Press, 2011. 150 pp. ISBN: 978-1-58576-152-4, $29.95Indoor Air PollutionRobert Maynard, Paul Harrison, Isabella Myers, eds.Hackensack, NJ:World Scientific, 2011. 400 pp. ISBN: 978-1-84816-493-2, $130The Economics of Enough: How to Run the Economy as If the Future MattersDiane CoylePrinceton, NJ:Princeton University Press, 2011. 336 pp. ISBN: 978-0-691-14518-1, $24.95The Rising SeaOrrin Pilkey, Rob YoungWashington, DC:Island Press, 2011. 224 pp. ISBN: 978-1-61091-004-0, $22.95


COL1A1 and COL1A2 and is associated with hearing loss in approximately half of the cases. The hearing impairment usually starts between the second and fourth decade of life as a conductive hearing loss, frequently evolving to mixed hearing loss thereafter. A minority of patients develop pure sensorineural hearing loss. The interindividual variability in the audiological characteristics of the hearing loss is unexplained.Osteogenesis Imperfecta (OI) is a heritable connective tissue disorder mainly caused by mutations in the genes COL1A1 or COL1A2 and originating from 89 different families. Due to the adult onset of hearing loss in OI, correlations between the presence and/or characteristics of the hearing loss and the underlying mutation were investigated in a subsample of 114 OI patients from 64 different families who were older than 40 years of age or had developed hearing loss before the age of 40.With the purpose of evaluating inter- and intrafamilial variability, hearing was thorougly examined in 184 OI patients , aged 3-89 years, with a mutation in either COL1A1 or COL1A2 genes and the occurrence, type or severity of hearing loss. Relatives originating from the same family differed in audiological features, which may partially be attributed to their dissimilar age.Hearing loss was diagnosed in 48.4% of the total sample of OI ears with increasing prevalence in the older age groups. The predominant type was a mixed hearing loss (27.5%). A minority presented a pure conductive (8.4%) or pure sensorineural (12.5%) loss. In the subsample of 114 OI subjects, no association was found between the nature of the mutation in Our study confirms that hearing loss in OI shows a strong intrafamilial variability. Additional modifications in other genes are assumed to be responsible for the expression of hearing loss in OI. COL1A1 or COL1A2 gene. More uncommon, autosomal recessive forms caused by mutations in other genes have recently been discovered, but have not been associated with hearing loss. The genes COL1A1 and COL1A2 are both responsible for the formation of type I collagen, the major structural protein of bone, sclerae, ligaments, and tendons. Different mutation types may lead to various OI phenotypes. Nonsense, frameshift, and some splice site mutations result in a reduced synthesis of structurally normal type I collagen, also referred to as haploinsufficiency or a quantitative defect, and usually cause milder phenotypes (OI type I). In the more severe OI types (II-IV), mutations affect the structure of either the proα1(I) or proα2(I) chain and lead to the production of qualitatively abnormal collagen molecules. Glycine substitutions in the triple helical domain are the most common, but some splice site mutations leading to in-frame exon skips may also induce structurally impaired type I collagen. This group of mutations has a negative dominant effect. The overall clinical outcome depends on the type of impairment of type I collagen synthesis , the mutated gene, the substituting amino acid, and the location of the mutation in the triple helical domain  [COL1A1 or COL1A2 gene.Genomic deoxyribonucleic acid (DNA) was extracted from ethylenediaminetetra-acetic (EDTA) blood samples obtained by standard procedures in all subjects. The methods applied for mutation screening differed somewhat between the Center for Medical Genetics Ghent (Belgian and Dutch patients) and the ROI . In the Dutch and Belgian probands, mutation screening of the COL1A1 null allele tests were retrieved in the concerned medical center and compared to the currently obtained results from molecular-genetic analysis.The outcomes of any previous biochemical analysis on skin fibroblasts or All data were entered into SPSS for statistical analysis . Quantitative parameters were evaluated for normal distribution by means of the Kolmogorov-Smirnov test. Associations between dichotomous variables were verified using Chi-square or Fisher's exact test, if appropriate. Differences between median values of two or more independent, quantitative, non-normally distributed variables were evaluated with the Mann-Whitney and Kruskal-Wallis tests, respectively. A 5% significance level was used throughout all analyses.Sixty-eight out of the 89 probands reported a positive family history for OI and from 39 of them, one to maximally six affected relatives participated in the study. A sporadic form of OI was noted in 21 probands.The majority of the 184 patients were diagnosed as OI type I (83.7%). The remaining patients exhibited OI types III (2.2%) and IV (14.1%). Mean age of the patients at audiometric evaluation was 30.5 years .Subjective hearing loss was reported by 50.0% of the 184 participants. Hearing amplification was used by 21.2% of the total sample of patients, of whom 87.2% wore hearing aids, 10.3% was equipped with a cochlear implant, and 2.5% had a bone-anchored hearing aid.The total sample of 184 participants implied 89 probands. Out of these probands, 66.3% reported a positive family history for hearing loss, which referred to either hearing loss in relatives affected with OI (64.0%) or presbyacusis in unaffected relatives of advanced age (2.3%). In none of them, any other genetic cause for familial hearing loss was suspected.Audiometric evaluation revealed that 52.7% of the examined OI patients exhibited a unilateral (8.7%) or bilateral (44.0%) hearing loss, resulting into a 48.4% prevalence hearing impairment in the total number of 368 OI ears. Figure The overall median age at onset of the hearing loss as reported by the patients was 20 years (range: 5-60 years). Pure sensorineural hearing loss was characterized by a significantly later median onset  compared to conductive or mixed hearing loss  .In 14.8% of the patients with bilateral hearing loss, audiograms from left and right ears were asymmetric. In the patients with unilateral hearing impairment, pure conductive (n = 4), mixed (n = 4), and pure sensorineural hearing losses (n = 8) were observed.On the basis of a thorough history, a potential risk for noise-induced hearing loss was noted in a total number of 22 OI patients (12.0%), of whom five demonstrated bilaterally normal hearing. Two patients reporting noise exposure exhibited pure sensorineural hearing loss bilaterally. The remaining 15 patients had conductive or mixed hearing loss.A total number of nine patients (4.9%) had sustained a skull fracture, one of whom exhibited unilaterally conductive, and three bilaterally mixed hearing loss. The remaining five patients had bilaterally normal hearing. None of the patients with skull fractures attributed development or deterioration of their hearing loss to the trauma.COL1A1 (77.5%) and 20 COL1A2 (22.5%) mutations. In the probands with a COL1A1 mutation we found nonsense (n = 12), frameshift (n = 29), and splice site (n = 21) mutations, as well as glycine substitutions (n = 7). Splice site mutations (n = 2) and glycine substitutions (n = 18) were observed in the probands with a mutation in the COL1A2 gene. The retrieved results of previous biochemical and COL1A1 null allele tests carried out on the probands' fibroblasts, confirmed a structural defect of type I collagen for one splice site mutation, and haploinsufficiency of type I collagen for 11 other splice site mutations. The quantitative either qualitative effects of the splice site mutations on type I collagen synthesis was not determined in 10 probands, in whom biochemical tests had not been performed previously and skin fibroblasts were not obtained.Molecular-genetic screening of the 89 probands identified 69 COL1A1 (81.5%) and 34 OI patients with COL1A2 mutations (18.5%).The mutations were confirmed in all the probands' participating affected relatives, resulting in a total number of 150 OI patients with For the investigation of potential associations between hearing loss and the underlying genotypic characteristics, only the subjects older than 40 years or those that already had developed hearing loss before 40 years of age were included. This cut-off age was introduced on the basis of the hearing loss onset, which was situated before the age of 40 years in 90.8% of all hearing losses, and in 98.4% of the hearing losses with a conductive component. Two patients meeting these criteria were excluded because of pure sensorineural loss that was probably due to noise exposure. The selected 114 subjects, called 'the selected sample', are listed per family (N = 64) including characteristics of hearing and genotype . The remaining 95 subjects had hearing loss in one (12.2%) or both ears (71.1%). Of the total number of 228 ears in the selected sample, 54 ears presented normal hearing (23.7%), whereas 31 ears were diagnosed with pure conductive loss (13.6%), 101 ears with mixed hearing loss (44.3%), and 42 with ears pure sensorineural hearing loss (18.4%).COL1A1 was identified in 51 out of the 64 probands (79.7%) included in the selected sample. The mutational event was located in the COL1A2 gene in 13 other probands (20.3%). In 40/64 probands, the mutation caused haploinsufficiency of type I collagen (62.5%), whereas a structural type I collagen defect was encountered in 17 probands (26.6%). In 7 probands affected by splice site mutations (10.9%), the either quantitative or qualitative type I collagen defect was not determined due to the lack of skin fibroblasts and biochemical tests.A mutation in COL1A1 splice site mutations of which the effect on type I collagen was undetermined, conductive/mixed hearing loss was also found. Pure sensorineural hearing loss was observed in families in which OI was associated with haploinsufficiency of type I collagen due to a mutation in the triple helical domain (n = 12) or the C-terminal propeptide (n = 2) of the proα1(I) chain, and in families with a structural type I collagen defect due to a mutation in the triple helical domain of the proα1(I) (n = 1) or proα2(I) chain (n = 5). This hearing loss type was also diagnosed in three families with splice site mutations located in the triple helical domains of the proα1(I) chain (n = 2), of which the type I collagen defect was unknown. Application of Chi-square and Fisher's exact test could not demonstrate that development of hearing loss and the type of hearing loss in OI patients were dependent of the mutated gene, the effect of the mutation on type I collagen synthesis or the location of the mutation within the proα chains.In only eight out of the 64 families from the selected sample, none of the participating affected relatives demonstrated hearing loss (12.5%). In six of these families, quantitatively impaired type I collagen synthesis was caused by a mutation in the triple helical domain of the proα1(I) chain, whereas in the other two families a qualitative defect due to a mutation in the triple helical domain of the proα2(I) chain was found. In the remaining 56 families from the selected sample (87.5%), conductive/mixed (44/64 or 68.8%) and/or pure sensorineural hearing loss (20/64 or 31.2%) occurred in at least one affected relative. Conductive/mixed hearing loss occurred in OI families with mutations leading to quantitative type I collagen defect that were located in the N-terminal propeptide (n = 1), C-terminal propeptide (n = 2), and the triple helical domain (n = 25) of the proα1(I) chain, as well as in OI families with qualitatively impaired type I collagen caused by mutations located in the triple helical domain of the proα1(I) chain (n = 5) or the proα2(I) chain (n = 4). In seven families with COL1A1 or COL1A2 demonstrated heterogeneous hearing characteristics. In some families, subjects with conductive or mixed hearing loss had relatives with pure sensorineural hearing loss. Additionally, patients with conductive, mixed or pure sensorineural hearing loss had normal-hearing affected relatives. In contrast, in a number of families, certain correspondence was observed with respect to the presence of a conductive or sensorineural component in at least one ear of two or more relatives. The presence of a conductive component in at least one ear of two related subjects was seen in 18/26 families (69.2%) . Likewise, 18/26 families (69.2%) implicated at least two relatives with a sensorineural hearing loss component in one or both ears . Pure sensorineural hearing loss affecting two relatives from the same family was only seen in 4/26 families (15.4%) . A hearing loss with conductive component in all participating relatives was noted in 11 different families. In only one family with two or more participants, all relatives demonstrated bilaterally normal hearing (family No. 10). Furthermore, our selected sample included unrelated families that were sometimes affected by the same mutation. This applied to three different mutations, which were each found in two unrelated families . However, the subjects from two families affected by the same mutation demonstrated incongruous audiometric results. In contrast, all relatives from three unrelated families affected by the same underlying COL1A1 mutation (c.769G > A) were diagnosed with a hearing loss characterized by a conductive component .Investigation of the intrafamilial variability in 26 families from the selected sample with two to maximally five affected relatives revealed that OI relatives with an identical mutation in Finally, the selected sample was investigated for associations between hearing loss and positive history for otitis media, skull fracture or noise exposure. Although 25 out 27 of the OI patients with a history of recurrent otitis media currently demonstrated hearing loss (92.6%), the latter was not associated with a positive history of otitis media, because 70 of the 95 hearing-impaired OI patients did not report any episode of otitis media (73.7%) (Chi-square test). Five patients had sustained a skull fracture, of whom one presented bilaterally normal hearing, one unilaterally pure sensorineural loss, and three bilaterally mixed or conductive hearing loss. Noise exposure was confirmed by 14 subjects with mixed hearing loss and three normal-hearing patients. The results of Fisher's exact test were not indicative for significant associations between a history of noise exposure or a skull fracture and the development of hearing loss.th percentile of age- and sex-related thresholds in the healthy population, whereas under 30 years of age less than 50% of the OI subjects presented hearing loss.Hearing loss deserves attention in patients with OI, especially since its development, the age at onset, as well as the progression and site of lesion seem difficult to predict on the basis of genotype or hearing characteristics in affected relatives. The prevalence of OI patients affected by hearing loss in the present study amounted to 52.7%. Although a certain selection bias in favour of hearing loss cannot be ruled out, this value approximates the prevalence values established in other family and population studies -15,17,23Most authors agree that the majority of OI patients initially develop a conductive loss in the second to fourth decade of life which gradually progresses to a mixed hearing loss -17. MixePure sensorineural loss has been described to occur in smaller but almost constant proportions in all age groups ,13,15,16The hearing loss commonly develops bilaterally and symmetrically, independently of the type of hearing loss involved. Conductive and mixed losses are most often reported to start in the second decade whereas the onset of pure sensorineural loss may be situated at any age.Although hearing loss has been suggested to occur predominantly in OI type I , this waCOL1A1 or COL1A2 gene, no correlation was found between the mutated gene, the mutation type or type I collagen defect and the presence, type or severity of hearing loss. Consistently, the present study fails in its effort to interrelate the audiological phenotype from 114 OI patients originating from 64 distinct families with the underlying OI genotype. In 87.5% of the OI families, OI-related hearing loss of the conductive/mixed or pure sensorineural type is observed in at least one relative. Hearing loss affects both patients with familial OI and sporadic OI. We noted intrafamilial variability in hearing characteristics, with relatives sustaining different types of hearing loss. Neither the mutated gene, the quantitatively either qualitatively impaired type I collagen or the location of the mutation with respect to the triple helix appeared to play a role in the expression of hearing loss. Other genetic or environmental factors are likely to contribute to the development of hearing loss and its characteristics in OI.In the study by Hartikka et al., in whicIn an attempt to identify potential risk factors for the development of hearing loss, patients' histories of otitis media, head injury or noise exposure were documented. Despite the higher incidence of otitis media in the OI population reported in the literature, which has been hypothesized to follow from cranial molding and deformities ,25, a poIn this study among 184 Belgian, Dutch, and Italian OI patients, hearing loss presents in 53% of patients and the proportion of hearing-impaired patients rises with increasing age. The predominant type of hearing loss is a bilateral, symmetric, and progressive mixed hearing loss. In a subsample of 114 OI patients with hearing loss or older than 40 years, an attempt to link the audiological phenotype with the underlying OI genotype is performed. The manifestation, type or severity of hearing loss correlates neither with the mutated gene nor with the type I collagen defect or the location of the mutation in the gene. Furthermore, identical mutations are found to lead to considerable inter- and intrafamilial variability in hearing pattern. However, in the present study, inter- and intrafamilial comparisons of hearing characteristics are limitated by the dissimilar age of the subjects and relatives, while hearing loss characteristics may evolve over time. Furthermore, in the majority of the families included, not all affected relatives were examined because they declined to participate or were living abroad. Although history of otitis media, head trauma, and noise exposure were more often reported in the hearing-impaired OI patients, none of these potential risk factors were consistenly associated with the occurrence of hearing loss. In conclusion, the mutation causing OI is not sufficient for the expression of hearing loss. Therefore, an additional genetic trigger is assumed to be responsible for hearing loss in OI.The authors declare that they have no competing interests.FS contacted and invited the Belgian and Dutch patients for participation, performed audiological evaluation and molecular genetic analysis, collected and analyzed all data, and drafted the manuscript. PC substantially contributed to the concept of the study, coordinated the genetic tests, and assisted in structuring the manuscript. ADP assisted in the clinical diagnosis, genetical counseling and critically revised the text. SS supervised the molecular-genetic analysis, checked out the causality of the mutations and formulated valuable suggestions for the text of the manuscript. FM refered and recruted patients, assessed the clinical OI type, offered genetic counseling to the patients and provided valuable insights for data analysis. FG and LS executed molecular-genetic screening and analysis in the Italian patients and wrote out parts of the text. PDE recruted Italian OI patients and subjected them to examination of hearing. TG assisted in the recruitment and hearing evaluation of Dutch patients, and gave critical clues for data analysis. CC substantially contributed to recruitment of Dutch patients, data collection, performed clinical examination and hearing evaluation of patients in the Netherlands, and added critical notes to the manuscript. ID was the supervisor of the study, perfomed otological examination of patients and revised the manuscript. EDL was involved in the delineating the project, otological examination of the Belgian patients and in drafting the manuscript. All authors read and approved the final manuscript.Audiological and molecular-genetic findings in the selected sample of 114 osteogenesis imperfecta patients. The hearing loss characteristics and results from molecular genetic tests in 114 individuals with osteogenesis imperfecta, grouped per family, are presented. These data reflect inter- and intrafamilial variability in audiological phenotype.Click here for file


Using electron microscopy (EM) and electron microscope tomography (ET), we further investigated the interstitial cell network of TCs and found that TCs form ‘atypical’ junctions with virtually all types of cells in the human heart. EM and ET showed different junction types connecting TCs in a network . The connections between TCs and cardiomyocytes are ‘dot’ junctions with nanocontacts or asymmetric junctions. Junctions between stem cells and TCs are either ‘stromal synapses’ or adhaerens junctions. An unexpected finding was that TCs have direct cell–cell (nano)contacts with Schwann cells, endothelial cells and pericytes. Therefore, ultrastructural analysis proved that the cardiac TC network could integrate the overall ‘information’ from vascular system , nervous system (Schwann cells), immune system , interstitium , stem cells/progenitors and working cardiomyocytes. Generally, heterocellular contacts occur by means of minute junctions  and the mean intermembrane distance is within the macromolecular interaction range (10–30 nm). In conclusion, TCs make a network in the myocardial interstitium, which is involved in the long-distance intercellular signaling coordination. This integrated interstitial system appears to be composed of large homotropic zones (TC–TC junctions) and limited (distinct) heterotropic zones (heterocellular junctions of TCs).Telocytes (TCs) form a cardiac network of interstitial cells. Our previous studies have shown that TCs are involved in heterocellular contacts with cardiomyocytes and cardiac stem/progenitor cells. In addition, TCs frequently establish ‘stromal synapses’ with several types of immunoreactive cells in various organs ( Tp are an alternation of thin segments (podomers) and dilated segments (podoms). Podomers are very thin (less than 0.2 μm), often below the resolving power of light microscopy, explaining the fact that TCs have been overlooked up to now. In the heart, TCs have been found in the myocardium, epicardium, endocardium and cardiac stem cell niches  is a unique type of interstitial cell with specific prolongations named telopodes (Tp)  were obtained from patients undergoing heart surgery. Mouse heart samples were obtained from four 1-year-old C57BL/6 mice.Transmission electron microscopy (EM) was performed on cardiac samples processed according to a routine fixation and Epon embedding procedure, as previously described  was performed by using a Tecnai G2 Spirit BioTwin transmission electron microscope with single-tilt specimen holder (FEI Company) at 100 kV as previously described (Gherghiceanu and Popescu Telocytes (TCs) are clearly defined by their ultrastructural features: interstitial cells with extremely long prolongations named telopodes (Tp). The shortest definition of TCs is: cell with Tp Popescu .Number : 1–5/cell, usually 1–3 Figs. ;Branching: dichotomous pattern Fig. ;Length: usually tens of micrometers up to 100) ;Podomers Fig.  — 50–1002+ uptake/release units’) ;Podoms Fig.  — dilateConnected with each other via homocellular junctions Fig.  form an Telopodes (Tp) have particular characteristics and limitations Figs.  and 11:FOne of the most striking features of TCs is their organization in a 3D network by Tp connections through homocellular junctions. Non-characteristic junctions connecting TCs usually occur at the level of Tp but junctions between the Tp and TCs cell body are also encountered Fig. . Moreovepuncta adhaerentia minima  and clusters of microvesicles or exosomes (diameters: 250 – 350 nm up to 1 μm) were frequently emerging from Tp Fig. . The meaElectron microscopy revealed that cardiac TCs could establish heterocellular junctions with all other cell types existing in the heart: cardiomyocytes (CM) Figs.  and 10b,Frequently, TCs are close to the basal lamina of cardiomyocytes and the distance between the two cellular membranes is about 150 nm. Occasionally, direct contacts between TCs and cardiomyocytes have also been observed Figs.  and 10b.recessus adhaerens’ - like junctions  and suggested that TC–CM might represent a ‘functional unit’  is often within the range of tens of nm (10 to 30 nm), which also fits in the macromolecular interactions domain but which molecules are involved in heterocellular communication remains to be established. Additionally, a paracrine and/or juxtacrine secretion of small molecules and long-distance signaling by shedding microvesicles may play distinct roles in horizontal transfer of important macromolecules among neighboring cells (Ramachandran and Palanisamy TCs seem to be active players in cardiac renewing, since they are ‘nursing’ CM progenitors in epicardial stem cell niches (Popescu et al. An enhanced understanding of the cells involved in and the signals, pathways that mediate the regenerative response may be useful in modulating the regenerative response of the injured heart. Irrespective of location, a stem cell niche capable of housing stem cells entails few constitutive elements with regulatory properties (Jones and Wagers The understanding of the interstitium as an integrating system is more sensitive nowadays when cellular therapy is a key word of science. The interstitial space seems to be the place where regenerative process happens but little is known about the cells involved and how they act together (Barile and Lionetti This study shows that homotropic and heterotropic ultrastructural interactions of TCs form an integrative interstitial cardiac system, which possibly assures physiological coordination of multicellular signals, essential for cardiac renewal, regeneration and repair. Further, molecular analysis must identify the key players involved in the telocytes communication network and their role in cardiac physiology and pathology.