The impact of rainwater-borne H2O2-induced Fenton process on root iron plaque formation and arsenic accumulation in rice

Arsenic (As) contamination is a global concern, especially in paddy fields, as it represents a significant pathway for As reaching in the food chain. This is primarily due to the high accumulation of As in rice grains, which is a staple food for billions of people globally. Here we investigated the effect of synthetic rainwater-borne hydrogen peroxide (H2O2)-induced Fenton oxidation process in paddy soil on As uptake and speciation in rice plants at different growth stages. Results showed that adding Fenton reagents significantly accelerated root iron (Fe) plaque formation, thereby enhancing As retention in soil. Arsenic accumulation in different rice plant parts followed the order: Fe plaque > root > stem > leaf. In rice grains, inorganic As and dimethylarsinic acid (DMA) were the major As species for the first and second-season crops. Notably, that the addition of Fenton reagents to paddy soil led to a significant reduction in As accumulation in rice grains. The synthetic rainwater-borne H2O2-induced Fenton reaction significantly promoted As(V) precipitation and decreased concentration of the dissolved As in soil porewater. The current study highlights that the H2O2-induced Fenton process is an important pathway decreasing As bioavailability in paddy soil and its accumulation in rice grain. The findings have implications for understanding As behavior in paddy fields receiving rainwater-borne H2O2 and for developing cost-effective remediation programs to reduce As accumulation in rice grains.

The use of urea hydrogen peroxide as an alternative N-fertilizer to reduce accumulation of arsenic in rice grains

A greenhouse experiment was conducted to examine the effects of urea hydrogen peroxide (UHP) on reducing the accumulation of As in rice grains. The results show that UHP effectively triggered Fenton-like reaction by reacting with Fe2+ in the paddy soils. This significantly inhibited the activities of As(V)-reducing microbes, causing impediment of As(V)-As(III) conversion following inundation of dryland crop soils for paddy rice cultivation. As-methylating microbes were also inhibited, adversely affecting As methylation in the soils. These processes led to the reduction in phyto-availability of As in the soil solutions for uptake by rice plant roots, and consequently reduced the accumulation of As in the rice grains. In this study, an UHP application rate of 0.0625% on three occasions (tillering, heading and filling) during the rice growth period was sufficient to lower the rice grain-borne As concentration to below 0.2 mg/kg, meeting the quality standard set by the Chinese government. No additive effect on reducing grain-borne As was observed for the joint application of UHP and biochar or biochar composite. The use of UHP for soil fertilization had no adverse impact on rice yield in comparison with the application of urea at an equal amount of nitrogen.

Clinicopathological and prognostic significance of PD-L1 and TIM-3 expression in medullary thyroid carcinoma: a retrospective immunohistochemistry study

PURPOSE

Expression of the programmed death-ligand 1 (PD-L1) and T-cell immunoglobulin and mucin-domain containing-3 (TIM-3) in medullary thyroid carcinoma (MTC) has been controversial and rarely reported.

METHODS

Surgical specimens of 190 MTC patients who had initial curative-intent surgery were collected. Immunohistochemistry of PD-L1 and TIM-3 was performed using 22C3 pharmDx (Dako, Carpinteria, CA) and anti-TIM-3 (1:500, ab241332, Abcam). Stained slides were scored using a combined positive score (CPS) with a cutoff of ≥ 1. We established correlations between PD-L1 expression, TIM-3 expression, clinicopathological, and survival data.

RESULTS

13 cases (13/190, 6.84%) were positive for PD-L1 expression, and 42 cases (42/154, 27.27%) for TIM-3 expression. PD-L1 expression was correlated to TIM-3 expression (P = 0.002), but was not related to overall survival (OS) or progression-free survival (PFS). TIM-3 expression was correlated to perineural invasion (P = 0.040). Multivariate Cox analysis showed that lymphovascular invasion (LVI) was independently associated with OS. And tumor size, LVI, and lymph node metastases were significantly associated with PFS. Furthermore, the multivariate logistic analysis showed multifocal status, LVI, pathological T stage and lymph node metastasis were independent risk factors for biochemical recurrence/persistent disease.

CONCLUSIONS

We demonstrated that PD-L1 and TIM-3 expression were not frequent in MTC and were not associated with survival prognosis. Our results should be considered when clinical trials of PD-L1 or TIM-3 blockades are implemented.

The application of mixed stabilizing materials promotes the feasibility of the intercropping system of Gynostemma pentaphyllum/Helianthus annuus L. on arsenic contaminated soil

Intercropping technology and stabilizing materials are common remediation techniques for soils contaminated with heavy metals. This study investigated the feasibility of the Gynostemma pentaphyllum (G. pentaphyllum)/Helianthus annuus L. (H. annuus) intercropping system on arsenic (As) contaminated farmland through field and pot experiments and the regulation of plant As absorption by the application of mixed stabilizing materials in this intercropping system. Field experiments demonstrated that intercropping with H. annuus increased the As concentration in G. pentaphyllum leaves to 1.79 mg kg-1 but still met the requirements of the national food standard of China (2 mg kg-1) (GB2762-2017). Meanwhile, G. pentaphyllum yield in the intercropping system decreased by 15.09%, but the difference was insignificant (P > 0.05). Additionally, the As bioconcentration (BCA) per H. annuus plant in the intercropping system was significantly higher than that in the monoculture system, increasing by 76.37% (P < 0.05). The pot experiment demonstrated that when granite powder, iron sulfate mineral, and "Weidikang" soil conditioner were applied to the soil collectively, G. pentaphyllum leaf As concentration in the intercropping system could be significantly reduced by 42.17%. Rhizosphere pH is the most crucial factor affecting As absorption by G. pentaphyllum in intercropping systems. When these three stabilizing materials were applied simultaneously, the As bioaccumulation (BCA) per H. annuus plant was significantly higher than that of normal intercropping treatment, which increased by 71.12% (P < 0.05), indicating that the application of these stabilizing materials significantly improved the As removal efficiency of the intercropping system. Dissolved organic carbon (DOC) concentration in the rhizosphere soil is the most pivotal factor affecting As absorption by H. annuus. In summary, the G. pentaphyllum-H. annuus intercropping model is worthy of being promoted in moderately As polluted farmland. The application of granite powder, iron sulfate mineral, and "Weidikang" soil conditioner collectively to the soil can effectively enhance the potential of this intercropping model to achieve "production while repairing" in the As polluted farmland.

Risk factors in ICU patients with initial acquisition of carbapenemase-resistant Klebsiella Pneumoniae

OBJECTIVE: To identify the risk factors associated with antimicrobial use on the initial acquisition of carbapenem-resistant Klebsiella pneumoniae (CRKP) in elderly intensive care unit (ICU) patients.METHODS: Respiratory secretion, blood, urine, anal swab and peritoneal drainage samples from all elderly patients with non-colonised CRKP who had been hospitalised from January 2021 to December 2022 were collected, and screened for CRKP colonisation using surveillance culture at the time of the first ICU admission and weekly thereafter in Zhejiang Provincial Hospital of Chinese Medicine, Zhejiang, China. Cumulative antibiotic variables included duration of antibiotic use, total amount of antimicrobials received in grams, total antibiotic consumption (defined daily dose) and the types of antimicrobial exposure. A time-dependent model based on Cox regression analysis was used to investigate the effect of each variable on the initial acquisition of CRKP infection or colonisation.RESULTS: Of 214 patients, 44 were infected or had CRKP colonies and death rate was 34.1%. males were the risk factor for acquiring CRKP in culture (HR 2.12, 95% CI 1.06-4.21; P = 0.033). It is notable that the hazard of acquiring CRKP increased by 9% with every single-point increase in the APACHE II score (HR 1.09, 95% CI 1.01-1.18; P = 0.025). The hazard of acquiring CRKP doubled when carbapenems were administered (HR 1.81, 95% CI 1.42-2.30; P < 0.001), In contrast, exposure to quinolone antimicrobials had a smaller effect on acquiring CRKP (HR 1.07; 95% CI 1.01-1.14; P = 0.024).CONCLUSION: This study found that male sex, APACHE II score and exposure to quinolones and carbapenems were independent risk factors for acquiring CRKP.

Rainwater input reduces greenhouse gas emission and arsenic uptake in paddy rice systems

This work aimed to test the hypothesis that rainwater-borne hydrogen peroxide (H2O2) can affect arsenic uptake by rice plants and emission of greenhouse gases in paddy rice systems. A mesocosm rice plant growth experiment, in conjunction with rainwater monitoring, was conducted to examine the effects of rainwater input on functional groups of soil microorganisms related to transformation of arsenic, carbon and nitrogen as well as various arsenic species in the soil and plant systems. The fluxes of methane (CH4), nitrous oxide (N2O) and carbon dioxide (CO2) were measured during selected rainfall events. The results showed that rainwater-borne H2O2 effectively reacted with Fe2+ present in paddy soil to trigger a Fenton-like reaction to produce •OH. Both H2O2 and •OH inhibited As(V)-reducing microbes but promoted As(III)-oxidizing microbes, leading to a net increase in arsenate-As that is less phytoavailable compared to arsenite-As. This impeded uptake of soil-borne As by the rice plant roots, and consequently reduced the accumulation of As in the rice grains. The input of H2O2 into the soil caused more inhibition to methanogens than to methane-oxidizing microbes, resulting in a reduction in CH4 flux. The microbes mediating the transformation of inorganic nitrogen were also under oxidative stresses upon exposure to the rainwater-derived H2O2. And the limited conversion of NO3- to NO played a crucial role in reducing N2O emission from the paddy soils. The results also indicated that the rainwater-borne H2O2 could significantly affect other biogeochemical processes that shape the wider ecosystems, which is worth further investigations.

Inter-fraction Dynamics during Adaptive Hypofractionated Radiotherapy for Brain Metastases with a MR LINAC

PURPOSE/OBJECTIVE(S)

This study examined the displacement and deformation in brain metastases (BMs) during adaptive hypofractionated radiotherapy (HFRT) on a magnetic resonance imaging linear accelerator (MR LINAC). In addition, the contouring variability between enhanced T1 (T1+c) and T2/FLAIR (T2f) sequence to define gross tumor volume (GTV) was compared.

MATERIALS/METHODS

Patients with 1-3 BMs and treated with MR LINAC were enrolled. T1+c sequence was acquired at initial planning, while T2/T2f was acquired during each fraction. GTV at initial planning (GTVi) and fraction 1-n (GTV1-n) were contoured in all images. Dice similarity coefficient (DSC) was used to quantify the contouring variability between different sequences at initial planning. The three-dimensional coordinate values of geometric centers of GTVi and GTV1-n were recorded and the distance was calculated. Statistical analysis was performed using two-sided paired t-test.

RESULTS

Between December 2019 and October 2022, 19 patients with 22 BMs were analyzed. The median age was 64 y (37-84 y) and the major primary tumor was lung cancer (89.5%). The median dose was 52 Gy in 13 fractions (30 Gy/5f- 60 Gy/20 f). The median GTVi on T1c, T2f and T2 sequences were 6.70cc (0.41-84.85 cc), 6.70 cc (0.35-84.14 cc, p = 0.924) and 6.16 cc (0.32-79.44 cc, p = 0.117), respectively. The mean DSC was 0.95 (0.76-1.00) and 0.86 (0.64-0.97) when comparing GTVi on T1c/T2f and T1c/T2, respectively. All of the lesions achieved volume reduction during HFRT and the mean reduction rate was 28.8% (4.8%-71.0%) at the end of HFRT. 54.5% of the BMs were reduced by more than 20%. The median treatment course and BED to get 20% reduction was 2/3 (40%-93%) and 40.8 Gy (24.5-67.5 Gy), respectively. The median shift of center of GTV1-n was 0.8 mm (0-2.5mm). The center of 7 lesions (31.8%) deviated more than 1mm from GTVi.

CONCLUSION

GTV contouring variability was seen between T1c, T2f and T2 sequences. The coincidence of T1+c and T2f was better than T1+c and T2 in BMs. Since reductions in volume and changes of lesion center was observed during HFRT, the use of MR-guided radiation therapy (RT) and treatment adaptation is needed. The optimal timing for treatment plan modification might be when the course of treatment reaches 2/3 for most large BMs. Further research to find out patients who may benefit form MR-guided adaptive RT is ongoing.

Effects of different planting distances and fertilizer use on the remediation of farmland contaminated with Cd by intercropping Cucurbita moschata and Amaranthus hypochondriacus L

Selecting suitable agronomic measures can strengthen the application of intercropping in the remediation of cadmium (Cd)-contaminated soil. In this study, the effects of different planting densities and fertilizer applications on the crop growth and Cd absorption of a pumpkin (Cucurbita moschata)-Amaranthus hypochondriacus L. intercropping system was determined. The goal was to provide enhanced means and a scientific basis for the promotion and application of this intercropping system. The Cd content of pumpkin in different planting systems was lower than the national food safety standard (0.05 mg kg^-1). In the IN-1 (4 pumpkin plants intercropped with 200 A. hypochondriacus plants) and IN-2 (4 pumpkin plants intercropped with 400 A. hypochondriacus plants) intercropping systems, the bioconcentration amount (BCA) per plant of Cd in A. hypochondriacus increased by 32.43% and 25.25%, respectively, compared with that of the monocropping system (P < 0.05). The IN-2 system had the highest equivalent ratio of heavy metal removal (3.08), indicating that this model had a substantial advantage for removing Cd. The land equivalent ratio of IN-1 (2.89) and IN-2 (2.60) was significantly higher than that of other intercropping systems, indicating that these two models had obvious yield advantages. In our study, chicken manure was the best at promoting the growth and yield of the two plants and sludge treatment significantly enhance Cd absorption of A. hypochondriacus. In general, intercropping four pumpkin plants with 400 A. hypochondriacus plants and applying chicken manure fertilizer can strengthen the application of this intercropping system in Cd-contaminated soil.

[Efficacy of sacubitril/valsartan in peritoneal dialysis patients with HFpEF and its effect on residual renal function]

Objective: To investigate the efficacy of sacubitril/valsartan in peritoneal dialysis (PD) patients with heart failure with preserved ejection fraction (HFpEF) and its effect on residual renal function. Methods: PD patients with HFpEF in Ningbo First Hospital from March 2018 to August 2021 were retrospectively enrolled and divided into study group with sacubitril/valsartan and control group with valsartan. The clinical baseline data before treatment and clinical indicators during follow-up (6 and 12 months after treatment) were collected and compared between the two groups, and the adverse reactions were also recorded. Results: A total of 99 patients were included in the study. There were 61 patients in the study group, including 44 males and 17 females, with a mean age of (52±13) years. Meanwhile, there were 38 patients in the control group, including 23 males and 15 females, with a mean age of (57±14) years. There was no statistically significant difference in clinical baseline data between the two groups (e.g., age, sex, body mass index, duration of dialysis) (all P>0.05). The N-terminal pro-B-type natriuretic peptide (NT-proBNP) and left ventricular end-systolic dimension (LVDs) were lower, but the left ventricular ejection fraction (LVEF) was higher in the study group than those in the control group at 6 and 12 months after treatment (all P<0.05). The systolic blood pressure (SBP) and diastolic blood pressure (DBP) of the two groups were lower than baseline values at 6 and 12 months after treatment respectively, with statistically significant differences (all P<0.05). However, there were no statistically significant differences in the decreases of SBP and DBP between the two groups at 6 and 12 months after treatment (all P>0.05). The decrease extents in residual estimated glomerular filtration rate (eGFR) [0.52 (-0.05, 1.19) vs 1.72 (0.97, 2.39) ml·min^-1·(1.73 m²)^-1, P<0.001]and 24-h residual urine volume [200 (-100, 300) vs 300 (137, 400) ml, P=0.018] at 12 months after treatment were lower in the study group than those in the control group. During the follow-up period, hyperkalemia occurred in 16 cases (26.2%) and 13 cases (34.2%) in the study group and the control group, and hypotension occurred in 3 cases (4.9%) and 1 case (2.6%) in the study group and the control group, respectively. There were no adverse reactions such as cough and angioneurotic edema in the two groups. Conclusions: Sacubitril/valsartan can safely and effectively improve cardiac function and lower blood pressure in PD patients with HFpEF. Compared with valsartan, sacubitril/valsartan may be more beneficial to delay the loss of residual renal function in PD patients with HFpEF.

Luffa cylindrica Intercropping with Semen cassiae-A Production Practice of Improving Land Use in Soil Contaminated with Arsenic

In recent years, research on the safe utilization and green remediation of contaminated soil by intercropping has become common. In this study, the growth of an intercropping system of Luffa cylindrica-Semen cassiae in soil contaminated with medium amounts of arsenic (As) was studied using field (91.60 mg kg^-1) and pot (83.34 mg kg^-1) experiments. The field experiments showed that intercropping significantly increased the yield per plant of L. cylindrica by 27.36%, while the yield per plant of S. cassiae decreased by 21.66%; however, this difference was not significant. Intercropping reduced the concentration of As in all organs of L. cylindrica but increased the concentration of As in all parts of S. cassiae. The accumulation of As per plant of L. cylindrica was reduced by 20.72%, while that in a single plant of S. cassiae was increased by 201.93%. In addition, the concentration of As in the fruit of these two crops in these two planting modes was low enough to meet the National Food Safety Standard of China (GB2762-2017). In addition, the land equivalent ratio and As metal removal equivalent ratio of the intercropping mode was 1.03 and 2.34, indicating that the intercropping mode had advantages in land use and As removal. In the pot experiment, the biomass and As concentration of L. cylindrica and S. cassiae were roughly consistent with those in the field experiment. During the sampling period, intercropping reduced the concentration of As in the rhizosphere soil solution of L. cylindrica by 3.1-23.77%, while it increased the concentration of As in the rhizosphere soil solution of S. cassiae by 13.30-59.40%. The changes in pH and redox potential were also closely related to the content of water-soluble As in the rhizosphere environment, which affects the absorption of As by plants. In general, the L. cylindrica-S. cassiae intercropping system is a planting mode that can effectively treat soil that is moderately contaminated with As and remove it from the soil to an extent.

Behaviors of Organic Ligands and Phosphate during Biochar-Driven Nitrate Adsorption in the Presence of Low-Molecular-Weight Organic Acids

A batch experiment was conducted to examine the behavior of nitrate, organic ligands, and phosphate in the co-presence of biochar and three common low-molecular-weight organic acids (LMWOAs). The results show that citrate, oxalate, and malate ions competed with nitrate ion for the available adsorption sites on the biochar surfaces. The removal rate of LMWOA ligands by the biochar via adsorption grew with increasing solution pH. The adsorbed divalent organic ligands created negatively charged sites to allow binding of cationic metal nitrate complexes. A higher degree of biochar surface protonation does not necessarily enhance nitrate adsorption. More acidic conditions formed under a higher dose of LMWOAs tended to make organic ligands predominantly in monovalent forms and failed to create negatively charged sites to bind cationic metal nitrate complexes. This could adversely affect nitrate removal efficiency in the investigated systems. LMWOAs caused significant release of phosphate from the biochar. The phosphate in the malic acid treatment tended to decrease over time, while the opposite was observed in the citric- and oxalic-acid treatments. This was caused by re-immobilization of phosphate in the former due to the marked increase in solution pH over time.

Biochar Is Not Durable for Remediation of Heavy Metal-Contaminated Soils Affected by Acid-Mine Drainage

Biochar is a soil conditioner for enhancing plant growth and reducing plants' uptake of heavy metals. However, the protonation of biochar surfaces in acid soils can weaken the capacity of biochar to reduce the phytoavailability of soil-borne heavy metals over time. The aim of this study was to test this hypothesis by performing a plant-growth experiment with five harvest cycles to examine the durability of rice-straw biochar for the remediation of an acidic-mine-water-contaminated soil. The application of the biochar significantly reduced the phytoavailability of the heavy metals and inhibited the plant uptake of cationic heavy metals but not anionic Cr. The beneficial effects of the biochar were weakened with the increasing number of harvest cycles caused by the gradual protonation of the biochar surfaces, which resulted in the desorption of the adsorbed heavy metals. The weakening capacity of the biochar to reduce the heavy-metal uptake by the vegetable plants was more evident for Cu, Zn, and Pb compared to Ni and Cd. The experimental results generally confirmed the hypothesis. It was also observed that the bioaccessible amount of various metals in the edible portion of the vegetable was also reduced as a result of the biochar application.

Erratum: Evolution of π^{0} Suppression in Au+Au Collisions from sqrt[s_{NN}]=39 to 200 GeV [Phys. Rev. Lett. 109, 152301 (2012)]

This corrects the article DOI: 10.1103/PhysRevLett.109.152301.

Beam Energy and Centrality Dependence of Direct-Photon Emission from Ultrarelativistic Heavy-Ion Collisions

The PHENIX collaboration presents first measurements of low-momentum (0.4<p_{T}<3  GeV/c) direct-photon yields from Au+Au collisions at sqrt[s_{NN}]=39 and 62.4 GeV. For both beam energies the direct-photon yields are substantially enhanced with respect to expectations from prompt processes, similar to the yields observed in Au+Au collisions at sqrt[s_{NN}]=200. Analyzing the photon yield as a function of the experimental observable dN_{ch}/dη reveals that the low-momentum (>1  GeV/c) direct-photon yield dN_{γ}^{dir}/dη is a smooth function of dN_{ch}/dη and can be well described as proportional to (dN_{ch}/dη)^{α} with α≈1.25. This scaling behavior holds for a wide range of beam energies at the Relativistic Heavy Ion Collider and the Large Hadron Collider, for centrality selected samples, as well as for different A+A collision systems. At a given beam energy, the scaling also holds for high p_{T} (>5  GeV/c), but when results from different collision energies are compared, an additional sqrt[s_{NN}]-dependent multiplicative factor is needed to describe the integrated-direct-photon yield.

[Classification of sudden deafness prognosis based on deep learning method]

Objective:This study aimed to develop predictive models for sudden sensorineural hearing loss through deep belief network (DBN) and explore whether the model performances differ when adopting different outcome criteria. Method: 228 potential predictors involving the clinical characteristics, audio logical data, and serological parameters out of 1 220 hospitalized SSHL patients who were admitted from June 2008 to December 2015 were analyzed retrospectively. The hearing data of sudden deafness were classified into two or four categories based on Chinese criteria and Siegel criteria, which were used to develop the DBN models. The area under the receiver operating characteristic curve (ROC-AUC) and accuracy were used to compare the predictive performance of different models. Result: The DBN model developed for predicting the dichotomized outcomes had better performance than that of the fourcategory outcomes. When the iteration number reached 500 times, DBN model constructed for prediction of dichotomized outcomes based on Siegel's criteria had demonstrated the best performance with an accuracy of 76.25% and an AUC of 0.81. According to indices from first layer weights, DBN gave a rank of top 10 sensitive features for hearing outcome prediction focusing on indicators regarding coagulation, demographics and pre-treatment hearing levels independent of the outcome assessment criteria. Conclusion: DBN provides a robust outcome prediction ability in SSHL datasets with rich and complex variables, especially when utilized to predict dichotomized outcomes based on the Siegel criteria. In addition, this advanced deep learning technique can automatically extract valuable predictors, which is consistent with those that had been verified in previous studies by traditional statistical methods. This study provides further evidence for extending the use of DBN algorithm to the field of developing prediction or classification models for other otological diseases in the future..

Predicting the hearing outcome in sudden sensorineural hearing loss via machine learning models

OBJECTIVE

Sudden sensorineural hearing loss (SSHL) is a multifactorial disorder with high heterogeneity, thus the outcomes vary widely. This study aimed to develop predictive models based on four machine learning methods for SSHL, identifying the best performer for clinical application.

DESIGN

Single-centre retrospective study.

SETTING

Chinese People's liberation army (PLA) hospital, Beijing, China.

PARTICIPANTS

A total of 1220 in-patient SSHL patients were enrolled between June 2008 and December 2015.

MAIN OUTCOME MEASURES

An advanced deep learning technique, deep belief network (DBN), together with the conventional logistic regression (LR), support vector machine (SVM) and multilayer perceptron (MLP) were developed to predict the dichotomised hearing outcome of SSHL by inputting six feature collections derived from 149 potential predictors. Accuracy, precision, recall, F-score and the area under the receiver operator characteristic curves (ROC-AUC) were exploited to compare the prediction performance of different models.

RESULTS

Overall the best predictive ability was provided by the DBN model when tested in the raw data set with 149 variables, achieving an accuracy of 77.58% and AUC of 0.84. Nevertheless, DBN yielded inferior performance after feature pruning. In contrast, the LR, SVM and MLP models demonstrated opposite trend as the greatest individual prediction powers were obtained when included merely three variables, with the ROC-AUC ranging from 0.79 to 0.81, and then decreased with the increasing size of input features combinations.

CONCLUSIONS

With the input of enough features, DBN can be a robust prediction tool for SSHL. But LR is more practical for early prediction in routine clinical application using three readily available variables, that is time elapse between symptom onset and study entry, initial hearing level and audiogram.