Default mode network (DMN) plays a key role in the pathophysiology of in bipolar disorder (BD). However, the homogeneity of this network in BD is still poorly understood. This study aimed to investigate abnormalities in the NH of the DMN at rest and the correlation between the NH of DMN and clinical variables in patients with BD. Forty drug-naive patients with BD and thirty-seven healthy control subjects participated in the study. Network homogeneity (NH) and independent component analysis (ICA) methods were used for data analysis. Support vector machines (SVM) method was used to analyze NH in different brain regions. Compared with healthy controls, significantly increased NH in the left superior medial prefrontal cortex (MPFC) and decreased NH in the right posterior cingulate cortex (PCC) and bilateral precuneus were found in patients with BD. NH in the right PCC was positively correlated with the verbal fluency test and verbal function total scores. NH in the left superior MPFC was negatively correlated with triglyceride (TG). NH in the right PCC was positively correlated with TG but negatively correlated with high-density lipoprotein cholesterol (HDL-C). NH in the bilateral precuneus was positively correlated with cholesterol and low-density lipoprotein cholesterol (LDL-C). In addition, NH in the left superior MPFC showed high sensitivity (80.00%), specificity (71.43%), and accuracy (75.61%) in the SVM results. These findings contribute new evidence of the participation of the altered NH of the DMN in the pathophysiology of BD. Bipolar disorder (BD) is a severe mental disorder, mainly characterized by repeated episodes of depression and mania. Depending on its manic level, BD can be further categorized into two types: BD type I  or BD type II (with mild manic episodes) . AbnormaDespite the abnormal functional connectivity (FC) regarding the DMN reported in some BD studies, these findings are still inconsistent . In BD tNetwork homogeneity (NH), a new method for functional neuroimaging data analysis suggested by Uddin et al. , is one Cognitive dysfunction is one of the hallmarks in patients with BD, with ~40–60% of BD patients suffering different degrees of cognitive deficits, especially in verbal and visual memory as well as executive function . InteresDifferent degrees of dyslipidemia, such as increased triglycerides (TG) , increasThe present study applied the NH method to analyze the changes in the DMN in drug-naive BD patients. The primary aim was to explore the relationship between such changes with cognition and/or blood lipid levels. We hypothesized that abnormalities of homogeneity in the DMN would be present in the NH analysis for patients with BD and that these abnormalities would be associated with cognitive impairment and/or changes in blood lipid level.From March to November 2019, right-handed patients with BD aged 16–45 were recruited from the Second Xiangya Hospital of Central South University, Changsha, Hunan province, China. Patients were diagnosed with BD by two experienced psychiatrists using the Structural Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). It is important to note that these patients had never taken any medication or psychotherapy to treat their BD and that the medical history of BD from onset did not exceed 5 years. The exclusion criteria were as follows: (1) other psychiatric disorders according to the DSM-5; (2) any severe physical diseases such as kidney, cardiovascular, neuropsychiatric disorders or liver diseases; (4) any forms of traumatic brain injury; (5) any history of use of electroconvulsive therapy; (6) pregnancy; and (7) any contraindication(s) for MRI scan. Clinical symptoms of BD were assessed with the Hamilton Depression Rating Scale-17 (HAMD-17) , the YouRight-handed healthy controls were recruited from the local community through advertisements. The age, sex ratio, and years of education of the recruited patients and healthy controls were matched. The healthy controls were screened using the Structured Clinical Interview for DSM-5-Nonpatient Version. The exclusion criteria were: (1) any psychosis symptoms, neurological disease, or substance abuse, (2) first-degree relatives having a history of psychiatric illness.The study was approved by the ethics committee of the Second Xiangya Hospital of Central South University and was performed in accordance with the Helsinki Declaration. All subjects provided written informed consent after a complete explanation. Parental consent was obtained for participants below 18 years of age.Samples from the patient group were collected to analyze the following parameters: liver and kidney function, blood glucose, TG, CHOL, HDL-C, and LDL-C. Fasting blood samples were taken for biochemical analysis between 7 and 9 a.m. to avoid circadian disruption. The samples were centrifuged at 3,000 rpm for 10 min to separate serum, both of which were later stored at −80°C until analysis.Imaging was obtained on a Siemens 3 T scanner. Subjects were asked to remain awake, keep their eyes closed and lie quietly. A foam padding was utilized to limit head motion. The following parameters were used for functional imaging: repetition time/echo time (TR/TE) = 2,000/30 ms, 30 slices, 64 × 64 matrix, 90° flip angle, 24 cm FOV, 4 mm slice thickness, 0.4 mm gap, and 250 volumes (500 s).The purpose of data preprocessing is to standardize the brains of different individuals to make them comparable. Besides, data drift caused by head movement and machine instability is eliminated to ensure data quality. In this study, the resting-state fMRI data were preprocessed in the DPABI software  Supplem.t-tests, independent t-tests, or a chi-square test when necessary.We analyzed NH group differences by voxel-wise cross-subject statistics of the DMN. The ages and mean of the FD were utilized as confounders during the computations. The significance level was set as p < 0.05 by using the family wise error (FWE) correction method. Bonferroni approach was used to adjust the p-value in the cluster level. Pearson's correlation coefficient was used to analyze the correlations between the NH values and clinical variables in patients with BD.The demographics and clinical characteristics of the two groups were analyzed using two-sample http://www.csie.ntu.edu.tw/~cjlin/libsvm/) (Support vector machine (SVM), as a form of supervised learning, was adopted for classification. With SVM, classification is still feasible even with a small sample . The clalibsvm/) . The LIBA total of 43 patients with BD and 37 healthy controls were enrolled in this study. As three patients had excessive head movements, their data were ruled out in the final analysis. Among the remaining 40 patients, 34 patients (85%) experienced depressive episode, 6 (15%) with a mixed episode. No significant differences were observed in age, sex ratios, and years of education between groups .Using a group ICA methods, the DMN mask was selected from the control group. DMN included bilateral MPFC, ventral ACC, PCC, precuneus, lateral temporal cortex, medial, lateral, inferior parietal lobe, and cerebellum Crus I and II . The obtvia voxel-wise cross-subject comparisons within the DMN mask. Compared with the healthy controls, BD patients had lower NH values in the PCC and bilateral precuneus. Significantly higher NH values in the left precuneus and left superior MPFC were observed in the patient group compared with the control group , verbal fluency test , and verbal function total score . A negative correlation was observed between the NH values in the right PCC and HDL-C  in patients with BD. Positive correlations were observed between the NH values in the bilateral precuneus and CHOL and LDL-C in patients with BD. A negative correlation was observed between the NH values in the left superior MPFC and the TG  in patients with BD , high specificity (77.78%) and high accuracy (76.47%) .Using the NH method, we provided an unbiased survey of the DMN in first-episode, drug-naive BD at rest. The dissociation pattern of NH in the DMN  was identified in the present study. Significant correlations were found between abnormal NH values in the three above-mentioned brain regions and blood lipid level as well as cognitive dysfunction in the patient group. To our knowledge, this is the first study that used NH method to explore changes of the DMN in drug-naive patients with BD and the first to explore the relationship between DMN changes and dyslipidemia. The findings of abnormal NH in the DMN are in line with previous results showing altered FC in the DMN in BD , 33, andThe first significant finding of this study is a dissociation mode in DMN. To our best knowledge, a DMN dissociation in BD was never reported in other studies. We speculate that the dissociation between anterior region (left superior MPFC) and posterior regions  could be partially due to the possibility of a functional specialization within the DMN . AnterioMPFC is an important component of the anterior DMN as it plays a key role in the adjustment of cognitive function, emotional behavior and self-reference processes , 38. ThiAs the posterior midline core region of DMN, PCC is mainly associated with autobiographical memory, but it is also involved in maintaining self-awareness, self-guided thinking activities at rest, and the regulation of cognition, emotion, action, and intuition . Hypo-acSimilar to PCC, the precuneus is also a posterior node of the DMN that is consistently identified in the pathophysiology of BD  due to iAnother important finding of this study is that using a multivariate method, dyslipidemia could be associated with functional connections in the brain. The similarities of schizophrenia and BD in clinical manifestations and etiology have been discussed in many recent works, one of which is a multivariate analysis providing an accurate characterization of the relationship of functional brain activities and psychosis . A studyApart from the small sample size, some other limitations also need to be considered. Firstly, the control group did not take a cognitive assessment or had the blood lipid checked, which limits comparisons of BD and healthy controls. Secondly, this study is only focused on the study of the DMN, and may ignore the changes in the FC of other brain areas. Finally, patients were not categorized into BD type I or II or mixed state, also did not include other affective disorders, so the presented results were unable to differentiate BD from other affective disorders. The “latent” forms of bipolarity, mixed, and sub-threshold affective syndromes will be collected in the future study. Approximately 85% of patients in this study were in the depressive state so this dissociation pattern in BD could be related with the depressive state as similar DMN dissociation was reported previously . WhetherThis study found a dissociative pattern of NH in the DMN  in patients with BD. NH abnormalities in the left superior MPFC, right PCC, and bilateral precuneus could be associated with emotional and cognitive dysfunction in the DMN. In addition, NH value in the left superior MPFC can serve as a potential marker to distinguish patients with BD from the healthy. Our study is the first to explore the connection between dyslipidemia and brain function in patients with BD and provide preliminary evidence that dyslipidemia could be related to abnormal DMN connections in BD. In future studies, larger sample size with a longitudinal study design should be considered to explore the possibility of blood lipid level as a marker for identifying brain abnormalities at different stages of BD.The original contributions presented in the study are included in the article/The study was approved by the ethics committee of the Second Xiangya Hospital of Central South University. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.HW, BW, and JC conducted and designed the study. SL, YQ, ZT, PP, CW, and LW collected the data. WG and HW analyzed and interpreted the data. HW drafted the manuscript. BW, KJ, SD, JH, and HX provided critical text revision. All authors have contributed to and approve the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Introduction: Rheumatoid arthritis (RA) is associated with various autoimmune disorders, including thyroid dysfunction. However, local data studying the prevalence of thyroid dysfunction in newly diagnosed RA patients are limited.Methods: This case-control study was conducted between January 2019 to December 2020 in the Internal Medicine Department of Liaquat University of Medical and Health Sciences. The study group of 400 newly diagnosed patients with RA was enrolled in the study. Another 400 patients without the diagnosis of RA, adjusted for age and gender, were enrolled in the study as a control group and their thyroid functions were compared.Results: Patients with RA had more participants with thyroid dysfunction compared to patients without RA . In addition, more patients with RA had concomitant primary hypothyroidism compared to the control group . Furthermore, patients with RA also had a higher prevalence of subclinical hypothyroidism .Conclusion: Our study indicates that thyroid dysfunction is significantly prevalent in patients with RA. Based on our findings, it is suggested that management and follow-up of RA patients should include the screening of thyroid auto-antibodies and thyroid dysfunction. Rheumatoid arthritis (RA) is an autoimmune disorder that results in chronic inflammation of the joints leading to consecutive joint destruction, which results in reduced mobility and increased disability . In the Hyperthyroidism is defined as the excessive secretion of thyroid hormones, and its most common etiology is Graves’ disease. Hypothyroidism is defined as a condition where the thyroid gland does not release sufficient thyroid hormones into the bloodstream, and its most common etiology is Hashimoto’s thyroiditis. Both the types are further categorized into overt and subclinical stages . Both hyThere are very limited data available on the association between RA patients and thyroid function, particularly in the South Asian region. Therefore, this study aims to further investigate the prevalence of thyroid dysfunction in RA patients.This case-control study was conducted between January 2019 to December 2020 in the Internal Medicine Department of Liaquat University of Medical and Health Sciences. The study group of 400 newly diagnosed patients with RA was enrolled in the study. These patients presented to the outpatient department (OPD) with complaints of fever, fatigue, joint pain, tenderness, swelling, and stiffness. The diagnosis of RA was made on the basis of clinical symptoms such as joint pain, X-ray findings such as bony erosions, soft tissue swelling, and joint space narrowing, and the presence of anti-cyclic citrullinated peptide (anti-CCP). Ethical review board approval was taken from Liaquat University of Medical and Health Sciences (LUMHS/IRB-OFC/2019-12-02). Another 400 participants, mainly the attendants accompanying patients, without the diagnosis of RA and adjusted for age and gender, were enrolled in the study as a control group. Exclusion criteria included patients with a prior diagnosis of thyroid disorder, patients who had recent surgery or major illness such as myocardial infarction or stroke, and patients who were on medications known to influence thyroid hormones such as metformin, interferon, amiodarone, and anti-epileptics.After the process of enrollment was completed, each patient's venous blood sample was taken from the cubital vein and sent to the laboratory for thyroid hormone assessment. Serum free thyroxine (FT4) was determined by radioimmunoassay (RIA) and thyroid-stimulating hormone (TSH) was evaluated by immunoradiometric assay (IRMA) techniques using commercial kits of Immunotech Inc. . Normal ranges for FT4, free triiodothyronine (FT3), and TSH, as standardized in our laboratory, are 11.0-22.0 pmol/L, 2.5-5.8 pmol/L, and 0.3-4.0 mIU/L, respectively. Thyroid dysfunctions were labeled based on Table Data were analyzed using the Statistical Package for the Social Sciences (SPSS v. 21.0) . Numerical data were represented by mean and standard deviation, while categorical data were tabulated as frequency and percentages. Unpaired t-test was used to compare numerical values, while chi-square test was used to compare categorical values between patients with and without RA. A p-value lower than 0.05 meant that the difference between the case group and control group was significant and the null hypothesis was not valid.The mean age of RA patients in the case group was found to be 36 ± 08 years, whereas that of the control group was 37 ± 07 years; however, the difference was not significant. Thyroid hormone values were also compared between the two groups and no significant difference was found Table .Patients with RA had more participants with thyroid dysfunction compared to patients without RA . In addition, more patients with RA had concomitant primary hypothyroidism compared to the control group . Furthermore, patients with RA also had a higher prevalence of subclinical hypothyroidism   . Other sSince both thyroid disorder and RA are autoimmune in nature, their origin may be similar. However, the exact mechanism is not yet understood. It is believed that genetic and environmental factors are involved in the association between RA and thyroid dysfunction -12. It iTo the best of our knowledge, this is the first study in a local setting to study the association between RA and thyroid function. However, the study has the following limitations. First, since the study was conducted in a single institute, the sample size was very limited. Secondly, thyroid hormones were only evaluated at the time of enrollment, and not during the course of the disease. Hence, we do not know the impact of rheumatoid arthritis on thyroid over the course of time. Third, the impact of thyroid dysfunction on the treatment of RA was not evaluated.Our study indicates that thyroid dysfunction is quite prevalent in patients with RA. Based on our findings, it is suggested that management and follow-up of RA patients should include the screening of thyroid auto-antibodies and thyroid dysfunction. Further studies to understand the mechanism of association between thyroid function and RA should be conducted.


Negative experiences with childbirth might have a negative impact on a woman’s overall health, including a higher risk of postpartum depression. The aim of the study was to examine the association between birth satisfaction and the risk of postpartum depression (PPD). A 30-item version of the Birth Satisfaction Scale (BSS) and the Edinburgh Postnatal Depression Scale (EPDS) were used, as well as the Perceived Stress Scale (PSS). The study included 584 women (mean age 30.6 ± 4.9), 2 to 4 days postpartum. In the regression model, the negative effect of birth satisfaction on the risk of postpartum depression was shown: a lower level of satisfaction with childbirth was a significant predictor of a higher risk of PPD . The regression model was controlled for the effect of the sociodemographic factors  and clinical variables . Levels of prenatal stress , psychiatric history , parity  and type of delivery  were also significantly associated with the levels of postnatal depression. The current study confirmed the association between the level of birth satisfaction and the risk of developing PPD, i.e., a lower satisfaction with childbirth may increase the risk of developing PPD. Hollins, Martin, and Fleming identified three basic areas related to childbirth satisfaction, which they transformed into an effective measurement tool: service provision ; personal attributes ; and stress experienced during labor  . SatisfaThe overall experience of maternity care can also have a positive or negative impact on the health and emotional well-being of a woman, a child and the wider family system, whereby the impact can be immediate or long term ,5. A posPositive childbirth experiences can act as an effective prevention of psychological postpartum trauma. In a systematic review and meta-analysis of prenatal and intrapartum interventions, Taheri et al. define effective strategies that shape a positive perception of childbirth: support for women, minimal interventions in the birth process and birth preparedness. However, interestingly, strategies for relaxation and pain relief do not fall into this category . To a laApproximately 2–4% of women after childbirth develop post-traumatic stress disorder (PTSD), which is also strongly associated with the level of childbirth satisfaction and which has potentially far-reaching negative consequences for the quality of the couple’s relationship ,14,15. MWomen’s satisfaction with childbirth, as a very important attribute of obstetric care, can be objectively measured. Patient satisfaction is an important result of the evaluation and development of health services . Thus, mMany research studies have confirmed that birth satisfaction can be a significant predictor of the increased risk of postpartum depression (PPD) ,19,20,21Postpartum depression is a disease with clearly defined diagnostic criteria listed in the International Classification of Diseases, where the main symptoms include mood swings, decreased interest in daily activities, fatigue and loss of energy, difficulty concentrating, serious worries about the child, sadness and crying, expressing doubts, decreased libido, appetite disorders, sleep disorders, or even thoughts of death and suicide ,23. The In addition to birth satisfaction, stress is also a significant factor contributing to PPD. A study by Scheyer and Urizar showed that increased stress levels, especially in the early stages of pregnancy, subsequently lead to a risk of developing PPD. Factors affecting stress probably are: low-income in pregnant women and related childbirth responsibilities, fear of parenthood and lack of social support . HoweverThe aim of our study is to determine the association between childbirth satisfaction and the risk of postpartum depression, controlling for the effect of potential factors that could increase the risk of postpartum depression: sociodemographic factors , and clinical factors . Other objectives of the study were the relationships in the subgroups between stress, type of childbirth, parity, positive psychiatric history and the risk of postpartum depression as well as the relationships in the above-mentioned subgroups and birth satisfaction.In particular, we would like to point out the importance of the study from the point of view of the country where it was carried out. This topic is explored minimally or not at all in post-communist countries. Post-communist countries have specific problems in providing quality maternity care. It is very important to highlight this issue.A cross-sectional correlational design was used.The research was carried out in two university hospital birth centers, which are located in the capital (Bratislava) and in the central part of Slovakia (Martin). A convenience sampling method was chosen to select participants. In addition to the postpartum period, the inclusion criteria were the birth of a living child, willingness to cooperate and informed consent. The research sample consisted of 584 women  at two to four days after giving birth, i.e., in the early postpartum period, when a rapid decrease in hormones affects CNS  function . In totaThe management of each university hospital acknowledged the approval of the Ethics Committee of Jessenius Faculty of Medicine in Martin, Slovakia, no. EK 36/2018. Based on this fact, the heads of the Gynecology and Obstetrics Departments agreed to conduct the research and did not require any further permission from the hospital ethics committees. More detailed characteristics of the research sample are given in Data collection took place between September 2018 and February 2020 via paper-and-pencil questionnaires administered by midwives in a clinical setting. Participants received information about study aims, and each participant signed the informed consent form before administering the questionnaire. After obtaining consent, the midwife completed the date of collection and the specific day after giving birth in each participant’s questionnaire. The response rate of the questionnaires was 82.3%.The original 30-item version of the Birth Satisfaction Scale (BSS) by C.J. Hollins Martin was used to assess birth satisfaction. The BSS contains 30 self-report items, rated on a 5-point Likert scale, that assess women’s perceptions of: 1) quality of care provision; (2) women’s personal attributes; and (3) stress experienced during labor—8, 8 and 14 items per factor [ quality The risk of postpartum depression in respondents was assessed using the Edinburgh Postnatal Depression Scale (EPDS). The scale consists of 10 short statements. A mother checks off one of four possible answers that is closest to how she has felt during the past week. Responses are scored 0, 1, 2 and 3 based on the seriousness of the symptom. The total score is found by adding together the scores for each of the 10 items . In thisAnother research tool used in our study was the 10-item Perceived Stress Scale (PSS-10), which is the most widely used psychological instrument for measuring the perception of stress. It is a measure of the degree to which situations in human life are assessed as stressful. The PSS was designed as a measurement tool for use in different communities, as the items are generally designed and easy to understand. The questions in this scale ask about feelings and thoughts during the last month. In each case, respondents are asked how often they felt a certain way . For theStatistical data analysis was performed using PSPP  and IBM SPSS Statistics for Windows . Descriptive statistics were used to describe the basic characteristics. A hierarchical linear regression model (enter method) was used to determine whether birth satisfaction predicts levels of postpartum depression, while controlling for sociodemographic factors  and clinical factors . Student’s t-test for independent samples was used to determine differences in the mean score of the risk of depression and childbirth satisfaction between key variables. The statistical processing also included determination of the internal consistency of the scales used (research tools) by means of the Cronbach’s alpha coefficient.In the 30-item BSS, the respondents achieved a total mean score of 111.14 ± 15.45 (min. 61.00–max. 149.00) out of a maximum score of 150, i.e., the highest possible childbirth satisfaction. The highest satisfaction was achieved in the subscale quality of care in the percentage conversion of the achieved score to the maximum score (77.05%), followed by the subscale women’s personal attributes (73.6%) and the lowest satisfaction was recorded in the subscale stress experienced during labor (72.61%).In the whole sample, the risk of postnatal depression, which was investigated using the EPDS tool, achieved an average score of 5.24 ± 4.35. Ninety-six women scored 10 points or more. In 35 women, the cut-off score was more than 13 points, i.e., the clinical criterion where there is a high risk of major depressive disorder.In the whole sample, the level of stress experienced during pregnancy and childbirth was investigated using the Perceived Stress Scale with a mean score of 14.18 ± 5.68, which is considered moderate stress. A more detailed evaluation of specific scales is given in A linear regression model, which allows for multivariate analysis, i.e., evaluation of the association between several factors and the outcome variable  was used to examine the effect of birth satisfaction on the risk of postpartum depression. In the regression model, the main predictor (the risk factor) was birth satisfaction, and the model was controlled for the effect of potential confounding variables: sociodemographic factors , and clinical factors .For the purposes of statistical analysis, the dichotomous variables inserted into the model were coded as follows: psychiatric history—yes/no; chronic disease in pregnancy—yes/no; newborn disease—yes/no; support person—yes/no; preterm labor—yes/no; parity—primipara/multipara; type of birth—vaginal/operative; gestational diabetes—yes/no; perinatal loss—yes/no; education—primary/secondary/higher; financial status—very good/quite good/not very good; religiosity participation —no/sometimes/regularly; marital status—with a partner/without a partner.In regression model 1, the association between sociodemographic factors and the risk of postpartum depression was investigated (Model 1). Age  and financial status  were significantly associated with the postpartum depression levels in this model. The adjusted R2 of this model was 0.03.Clinical variables were added in model 2, where the adjusted R2 value was 0.30, and the effects of prenatal stress , psychiatric history , newborn disease , parity  and type of birth  were statistically significant.In the final regression model (Model 3), the effect of both sociodemographic and clinical factors together with birth satisfaction was assessed. In this model, the associations between EPDS levels and the following variables were statistically significant: birth satisfaction , stress , psychiatric history , parity  and type of delivery . The total explained variance  in this model was 0.32 .p ≤ 0.000) and, at the same time, statistically significant lower birth satisfaction (p ≤ 0.003) than respondents with a negative psychiatric history.Student’s t-test showed that respondents with a positive psychiatric history had a statistically significant risk of postpartum depression (p ≤ 0.000) than after natural birth. At the same time, there was a statistically significant lower birth satisfaction after caesarean delivery (p ≤ 0.000) than after normal birth.Furthermore, concerning the type of delivery , there was a statistically significant level of maternal postpartum depression after caesarean delivery (p ≤ 0.020) and lower birth satisfaction (p ≤ 0.017) than multiparous ones. The average score between EPDS and BSS in these groups is shown in In terms of parity, primiparous women had a statistically significant higher level of postpartum depression  and multiparas 40%), with primiparas showing significantly lower birth satisfaction than multiparas. In a cohort study including 16,000 postpartum women with a focus on obstetric interventions by Falk, Nelson and Blomberg, lower birth satisfaction in primiparous women was assessed/proven %, with p.Parity has a significant effect on the overall birthing process. In primiparous women, a labor progression is slower than in multiparous . Thus, tp ≤ 0.003) than respondents with a negative psychiatric history. Pregnancy is a period of increased vulnerability for the development of anxiety and depressive episodes [Some studies also confirmed an association between a positive psychiatric history or various mental health problems during pregnancy and birth satisfaction ,52. Our episodes , which cThe prevalence of the onset of depressive symptoms with the EPDS at ≥10 points (research criterion) was 16.7% and the prevalence of severe depressive symptoms (EPDS ≥13 points) was 6.07%. Previous studies conducted in Slovakia found a prevalence of PPD (major depressive symptoms) in the early postpartum period ranging from 14 up to 25.3% using various research tools ,55. BaseMultivariate analysis, used in this study, allowed associations to be examined between several factors related to postpartum depression. In addition to the strongest predictor, satisfaction with childbirth, other significant predictors were: the level of stress experienced during pregnancy, the type of childbirth, parity, and a positive psychiatric history.A number of studies report lower birth satisfaction as a significant risk factor for PPD ,20,21,57Biaggi et al. identified adverse life events and increased levels of perceived stress as the main risk factors associated with PPD . SimilarThe issue of stress and its impact is very broad. In a systematic review by Yim, Tanner Stapleton, Guardino, Hahn-Holbrook and Dunkel Schetter, focusing on the biological and psychological predictors of PPD, stressors are divided into two major groups: episodic stressors  and chronic stressors  . We did In our sample, 74% of the respondents reported vaginal delivery and 26% had operative delivery. The type of birth seems to be significantly associated with PPD, too. There was a significantly higher risk of postpartum depression in the group of women after operative delivery than in the women who delivered vaginally. Our findings are similar to the other studies ,20,59. AThe effect of parity on the postpartum period has not been sufficiently studied and the study results are inconsistent . SeveralAccording to the Centers for Disease Control and Prevention (CDC), previous episodes of depression, anxiety, and mood disorders are the primary risk factors for PPD . In our Among other sociodemographic and clinical factors and the risk of PPD, the association between age, financial status and newborn disease was identified. No other significant association occurred between the other variables , which were investigated using a linear regression model and the resulting variable, i.e., PPD.n = 13). During data collection in the clinical setting, these women were reluctant to complete the questionnaire. Some of them even refused introductory verbal and written information about the research because of lack of interest in the research, shortage of time or care of the newborn. On the contrary, women with higher education, who made up more than 50% of the sample, showed the greatest interest in our research study. In the sample, education does not correspond to the educational structure of women in Slovakia, as most women have completed secondary education, followed by women with lower education and university degrees [We consider a relatively small sample size to be a study limitation. Although the sample consisted of 584 women, several studies dealing with similar issues had a much higher sample size. As the research was conducted in two university hospitals in western and central Slovakia, women from the eastern part of the Slovak Republic are minimally represented in the sample. The lack of respondents with lower education can also be considered a very limiting factor. In our sample, they made up only 2.2% , type of childbirth (caesarean delivery), parity (primiparity) and a positive psychiatric history. The same risk factors that were associated with the risk of developing PPD also negatively affected birth satisfaction. Further research on PPD predictors is needed, whose impact is contradictory, since some studies confirm the impact of PPD predictors, but others do not. These predictors include parity, i.e., primiparas vs. multiparas, and type of birth, i.e., vaginal vs. surgical delivery. In the case of surgical births, the type of birth should be consistently differentiated in the future, as, e.g., elective cesarean section may be more acceptable for a woman than emergency cesarean section. Support and care for women throughout labor and childbirth should consider the constant strengthening of the mother’s positive birth experience, which can act as a protective factor for the development of various postpartum complications, including the risk of developing PPD.


This study aimed to compare the perceived hearing difficulties of a community sample of older adults to two clinical samples of older adults, one with no hearing aid experience and the other with hearing aid experience.N = 243) and compared to scores from two clinical samples, one without (N = 342) and one with prior hearing-aid experience (N = 179). General linear model (GLM) analyses were performed to examine the effects of data sample type and other factors on CPHI scale scores. Scores for the Hearing Handicap Inventory for the Elderly (HHIE) were also available for most participants and were analyzed.Scale scores from the Communication Profile for the Hearing Impaired (CPHI) were analyzed for a community sample of older adults (GLM analyses of each of the 20 CPHI scale scores showed significant effects of sample type with hearing-loss severity and age most frequently showing significant effects as well. GLM analyses controlling for hearing-loss severity and age across sample types found significant differences on most CPHI scales between the community sample and each of the two clinical samples. Significant differences between the two clinical samples were also found on several CPHI scales and on the HHIE.Older adults from the community who did not seek help for hearing difficulties self-reported less difficulty and a greater denial or lack of awareness of communication problems than those who sought assistance at an audiology clinic. For those presumed to have sought a hearing evaluation, those acquiring hearing aids perceived greater communication difficulties in all environments, had greater awareness of communication difficulties, were more accepting of their hearing loss, but tended to allocate more responsibility for their difficulties to others, compared to those who sought clinical assistance but did not acquire hearing aids. The prevalence of hearing loss increases with advancing age . WorldwiDue to the poor uptake of hearing aids, millions of older adults with untreated hearing loss continue to suffer broader consequences. It is well known, for example, that the loss of audibility alone causes many difficulties for everyday speech communication, including poor speech perception e.g.,  and incrAn assumption underlying the foregoing is that the audiogram (and better-ear PTA4 derived from it) is the most appropriate way to define candidacy for amplification as well as the potential benefit to be experienced from hearing aids. It has long been known that older adults with identical audiograms can have markedly different perceived hearing difficulties e.g., . If one Among those who do seek help, many do not follow through with recommendations to obtain hearing aids. For example, Perhaps the most detailed assessment of perceived hearing difficulties, and the individual's reaction to those difficulties, is the Communication Profile for the Hearing Impaired CPHI; , 1987. Tn = 26) was compared to two groups of adherents, one group who had accepted hearing aids after the 30-day trial period and was still using them 6 months later (n = 26) and one group who had discontinued using their hearing aids six months later (n = 24), about half of whom returned their hearing aids during the initial 30-day trial. Significant differences in CPHI scale scores were observed on several CPHI scales between adherents and nonadherents in the studies by Two studies have examined differences in CPHI scores between older adults seen at the audiology clinic who were advised to pursue hearing aids and did (adherents) and those who received the same advice but chose not to do so (non adherents). Aside from these two studies of CPHI scores in adherents and nonadherents, there are several large studies of CPHI scores from clinical samples. The CPHI was originally normed, for example, on a large sample of 827 patients at the Walter Reed Army Medical Center . GarstecIt appears, however, that little is known about the communication difficulties and reactions to them for older adults in the broader community, that is, those who have not sought help at an audiology clinic or acquired hearing aids. To our knowledge, detailed analyses of the communication problems experienced and the reactions to those problems via the CPHI have not been provided for such a community-based sample. Rather, to date, the focus of the CPHI has been to obtain profiles of communication difficulties and reactions to those difficulties from individuals, including older adults, who have been seen at an audiology clinic. The CPHI was envisioned as a tool to assess perceived hearing difficulties and reactions to those problems and guide the subsequent rehabilitation of adults with or without measurable hearing loss as determined at the audiologic evaluation.n = 243); (b) a combined clinical sample comprised of those referred to the MUSC longitudinal study after being seen at the MUSC audiology clinic who were not also current hearing aid wearers (n = 77), and older adults from the Bloomington, Indiana community who had responded to ads for participation in hearing-aid research at Indiana University (IU) and had not worn hearing aids previously (n = 265), resulting in a total population size of 342 for this group; and (c) a combined MUSC and IU clinical sample who were either current hearing aid wearers  or had ever worn hearing aids  for a total population size of 179 for this group of older adults. As will be seen, the nonclinical MUSC community sample of older adults includes many older adults with impaired hearing, yet they have opted, it appears, to not pursue audiologic evaluation, albeit they did volunteer to participate in a longitudinal study of hearing. Also, it is not possible to confirm from the information available whether any of these individuals sought hearing evaluations outside of the MUSC clinic. It is assumed here that the vast majority did not do so, consistent with the modeling of This study sought to fill this gap by analyzing CPHI scores from 764 older adults divided into three groups: (a) a convenience sample of the Charleston, South Carolina community recruited for participation in a longitudinal study of hearing over the adult lifespan at the Medical University of South Carolina , those who obtained an audiology evaluation but did not acquire hearing aids (Clinic–No Hearing Aid [Clinic–No HA] sample), and those who obtained an audiology evaluation and acquired hearing aids (Clinic–Hearing Aid [Clinic–HA] sample). Through such evaluation, it is hoped to gain a better understanding of whether and how differences in perceived hearing difficulties underlie the help-seeking behaviors of older adults with impaired hearing.SD = 6.1 years) for the females and a mean age of 68.2 years (SD = 6.5 years) for the males. The Clinic–No HA sample included individuals from the Charleston, SC area recruited for the longitudinal study of hearing (n = 77) and individuals from the Bloomington, IN area recruited for a study of hearing-aid outcomes (n = 265). All individuals in this combined sample (n = 342) were recruited from the affiliated university clinics or were volunteering for a study on hearing-aid outcomes in which they knew hearing-aid purchase was required. At the time of the completion of the CPHI, however, no individuals in this group self-reported current hearing aid use (MUSC data set) or ever having used hearing aids (IU data set). Of the 342 individuals in this sample, 39% were female. Ages ranged from 57 to 89 years with a mean age of 74.5 years (SD = 7.0 years) for the females and 70.8 years (SD = 6.8 years) for the males. The Clinic–HA sample included 127 members of the Bloomington, IN community who had volunteered for the study of hearing-aid outcomes who reported that they had previously worn hearing aids and 52 members of the Charleston, SC community who had volunteered for the longitudinal study of hearing who reported that they were currently using hearing aids. As noted previously, about two thirds of those from the Bloomington community who had reported prior hearing aid use were current hearing aid users. The Clinic–Hearing Aid sample, total n = 179, ranged in age from 52 to 87 years with a mean age of 75.7 years (SD = 6.7 years) for the females and a mean age of 71.8 years (SD = 7.0 years) for the males.There were three samples of older adults included in these analyses. The Community sample was entirely from the Charleston, SC area and responded to ads placed in the community for participation in a longitudinal study of hearing over the adult lifespan. Of the 243 members of this sample, 141 (58%) were female. Ages for this sample ranged from 50 to 88 years with a mean age of 68.6 years  age between 60 and 89 years; (b) hearing loss that was flat or gently sloping ; (c) hearing loss that was of sensorineural origin ; (d) hearing loss that was bilaterally symmetrical ; (e) pure-tone thresholds within the following ranges at frequencies of 250, 500, 1000, 1500, 2000, 3000, 4000, and 6000 Hz, respectively: 5–85, 5–85, 10–90, 20–95, 25–95, 30–120, 30–120, and 30–120 dB HL ; (f) no For the IU data set, from 1997 to 2008, there was a total of 930 individuals who responded to the ads and were screened for study eligibility. For the period 2004–2008, when this information was collected more formally and in detail, approximately 30% of those screened were found to be ineligible. This percentage was applied to the entire sample of 930 screened individuals, leaving 651 eligible individuals. Of the estimated 651 eligible individuals, 392 (60.2%) enrolled in the studies of hearing-aid outcomes. They paid the full purchase price for the devices at the time of enrollment and were paid as research subjects for the completion of other data-collection sessions.As noted above, an audiogram was completed as a part of the eligibility criteria for the IU data set. After completion of the audiological evaluation, the results were explained briefly to the individual and, if eligible for study enrollment, they were informed about the study at this time. As noted, the study was investigating hearing-aid outcomes and they were informed that they would be required to purchase hearing aids for that study. Those interested in participating were consented and enrolled. No other counseling was provided to these individuals until after the hearing-aid fitting, which took place after the completion of all pre-fit measures, including the CPHI.For the MUSC data set, the following inclusion criteria applied: (a) age 18 and over, (b) good general health , (c) no evidence of conductive hearing loss or active otologic/neurologic disease, and (d) ability to provide reliable results for a majority of the protocol measures. The consent form and all procedures used in this study were approved by the MUSC Institutional Review Board. During a screening visit, the study was explained briefly to the individual and, if eligible for study enrollment, they were informed about the study. Those interested in participating were consented and enrolled. No counseling was provided to study participants until after completion of the CPHI or Hearing Handicap Inventory for the Elderly (HHIE).For the MUSC data set, from the start of this longitudinal study in 1987, approximately 90% of individuals screened for eligibility were enrolled in the study. The average attrition rate is approximately 14%; however, a large proportion of participants who withdrew from the study were less than 50 years of age, which is the minimum age of participants whose baseline data were included in the current analyses.Prior to completing the CPHI, each participant in each group received a complete audiological evaluation at study enrollment, including pure-tone and speech audiometry, as well as immittance measures. The CPHI was administered at each site using a paper-and-pencil response format with the participant seated in a quiet room. Booklets were provided to the participant that contained the standardized written instructions for each section of the CPHI. For each item, one of five response choices is selected. Computer software supplied by Marilyn Demorest was used to score the CPHI . As indiIn addition, almost 80% of the participants included in the current CPHI analyses had also completed the full 25-item HHIE . The HHI2 (2) = 45.5, p < .001, and follow-up z-tests of the proportion of females in each group found that all three samples differed from one another (p < .05). The Community sample was 58.0% female, the Clinic–No HA sample was 38.6% female, and the Clinic–HA sample was 26.3% female. Because of these significant differences in male/female proportions for each sample, as well as the mixed findings regarding the influence of this variable on CPHI scores as noted earlier, sex will serve as another independent variable for all comparisons of the three samples.Chi-squared analysis indicated that there were significant differences in the proportion of males and females across the three samples, χF = 24.3, p < .001, and sample type, F = 38.6, p < .001, emerged. The interaction between sex and sample type, however, was also significant, F = 4.7, p < .01. Post hoc paired comparisons revealed that there were no significant differences in age between the males and females for the Community sample (p > .05), but females were significantly older than males (p < .05) for the other two samples. As a result, as well as the prior literature reviewed earlier that documented effects of age on CPHI scores, age will also serve as a covariate when comparing CPHI results across sample types.When the age composition of each of the three samples was analyzed using general linear models (GLMs) with sex as another independent variable, significant main effects of sex, F = 175.8, p < .001, and sex, F = 32.0, p < .001, but the interaction of sample type and sex was also significant, F = 5.9, p < .01. Regarding the effects of test frequency for the right ear, the main effect was significant, F = 1,253.9, p < .001, as were all of the interactions with frequency: Frequency × Sample Type, F = 11.3, p < .001; Frequency × Sex, F = 77.4, p < .001; Frequency × Sample Type × Sex, F = 2.0, p < .05. For the left ear, significant main effects were observed for sample type, F = 170.9, p < .001, and sex, F = 51.0, p < .001, but the interaction of sample type and sex was also significant, F = 5.0, p < .01. Regarding the effects of test frequency for the right ear, the main effect was significant, F = 1,441.6, p < .001, as were all of the interactions with frequency: Frequency × Sample Type, F = 9.7, p < .001; Frequency × Sex, F = 75.1, p < .001; Frequency × Sample Type × Sex, F = 2.2, p < .01. When these GLM analyses of the audiograms in F = 2.5, p > .05.The three data sample types also differed regarding their pure-tone air-conduction hearing thresholds. Mean hearing thresholds for the males and females comprising each sample type are shown in Difference in audiograms between males and females, especially in the higher frequencies, are well known and are not of primary interest here other than to note that examination of the effects of sex on CPHI scale scores must control for differences in hearing loss between males and females. The differences in audiograms among the three sample types, moreover, are also expected. The vertical bars in N = 1,004) derived across five sites by SD of the normative mean, is observed between the norms and the means of the Clinic–HA sample with similarly good agreement between the norms and the means of the Clinic–No HA sample for 18 of the 20 scales. The Clinic–No HA sample shows means slightly higher than the clinic norms for the PA-stress and PA-withdrawal CPHI scales. In general, however, the clinical data reported here are in good agreement with the previously published clinical norms for the CPHI (The filled circles with error bars appearing in both panels of the CPHI .p < .001) of sample type was found, all F > 7.23. Moreover, the partial eta-squared effect sizes for the 19 significant results were large in 11 cases, medium in seven, and small for one  or .0026, revealed that, for 15 of the 19 significant effects of sample type, all three samples differed from one another. For the remaining four significant effects of sample type , the Community sample had higher scale scores than both of the two clinic samples (indicating better outcomes) and the two clinics samples did not differ from one another. Where significant effects of sample type were observed, that is, 19 of the 20 CPHI scales, the Community sample had significantly higher scores for 15 scales, but had significantly lower scores for four CPHI scales, CP-problem awareness, CS-verbal strategies, CS-nonverbal strategies, and the PA-denial scales.Visual inspection of the means in F > 12.2, p < .001, except for CE-physical characteristics, F = 3.3, p > .05. Moreover, the partial eta-squared effect sizes for better-ear PTA4 were large for five scales , small for two , and medium for all other CPHI scales  > 4.2, p < .05. Based on partial eta-squared effect sizes for age, six of the seven had small effect sizes  and one had a medium effect size (CE-communication need).As noted previously, the sample types differed significantly in hearing loss, age, and sex. The significant effects of sample type on CPHI scales appearing in I scales . RegardiF > 4.3, p < .05. The estimated marginal means, at a mean PTA4 of 34.0 dB HL and a mean age of 71.1 years, are shown in the top panel of Regarding the effect of sex on CPHI scale scores, a significant main effect, without interaction with sample type, was observed for four CPHI scales, all F > 3.1, p < .05. The partial eta-squared effect sizes for these three significant interactions between sex and sample type were all small (p < .05) from one another and in the direction reflected in the bottom panel of p < .05). For the CE-physical characteristics scale (middle panel), for females, all three sample types again differed significantly (p < .05) from one another. For males, the Community sample differed significantly (p < .05) from both clinic samples but the two clinic samples did not differ significantly (p > .05) from one another. Finally, for the CS-nonverbal strategies CPHI scale, as shown in the bottom panel of p < .05) higher scale score than each of the other two sample types, but the Community and Clinic–No HA samples did not differ significantly (p > .05) from one another on this scale.For three additional CPHI scales, CP-social, CE-physical characteristics, and CS-nonverbal strategies, there were significant interactions between sex and the other independent variable, sample type, all ll small . The botF > 3.3, p < .05, with 11 of the 12 having small partial eta-squared effect sizes and one (CP-problem awareness) having a medium effect size (p < .05) from the two clinic sample types but the latter did not differ from one another. The two exceptions were CP-work, for which the Community sample only differed significantly (p < .05) from the Clinic–HA sample, and CE-attitudes of others, for which the Community sample differed only from the Clinic–No HA sample. Regarding the six PA scales in the bottom panel of p < .05) from the two clinic samples but the two clinic samples did not differ from one another. For two PA scales, PA-discouragement and PA-withdrawal, the only significant paired comparison was between the Community and Clinic–HA samples. For the remaining PA scale in the bottom panel of p < .05).Finally, the main effect of sample type, free from significant interactions with sex, was significant for 12 of the 20 scales after controlling for age and better-ear PTA4, all ect size . Figure In summary, these GLM analyses found significant main effects of sample type, after controlling for sample differences in age and better-ear PTA4, on 12 of the 20 CPHI scales and the prevailing pattern was for the Community sample to differ significantly from one or both of the clinic samples with those clinic samples not differing from one another. In addition, recall that there were three other CPHI scales for which there were significant interactions between sample type and sex . When the effects of sample type were examined separately for each sex for these three CPHI scales, the Community sample always differed from one or both clinic samples. In total, the Community sample differed from the clinic samples on 15 of the 20 CPHI scales after controlling for age and better-ear PTA4. The direction of the difference was not consistent across the CPHI scales such that sometimes the Community sample had higher scale scores and for other scales that sample had the lowest score.F > 8.1, p < .01, and mostly medium or large effect sizes  were observed. Age was a significant covariate for six of 20 CPHI scales, all F > 4.0, p < .05. When statistically controlling for better-ear PTA4 and age, significant differences were observed between the Clinic–No HA and the Clinic–HA samples on seven of the 20 CPHI scales, all F > 4.1, p < .05. Partial eta-squared effect sizes were small for five of the six scales and medium for the remaining scales with significant effects of sample type. For the most part, however, differences were seldom observed between the two clinic samples, those with and without hearing aids. To examine this more closely and with greater statistical power, another series of GLM analyses was performed comparing only the two clinical samples and removing sex as a second independent variable. As noted earlier, sex was found to have a significant effect somewhat infrequently and these effects were not the primary focus of this evaluation. Age and better-ear PTA4 remained as covariates. PTA4 was a significant covariate for 19 of the 20 CPHI scales, all F = 120.3, p < .001, and post hoc Bonferroni-adjusted paired comparisons revealed that all sample types differed significantly (p < .05) in HHIE score from one another. This was without controlling for age and better-ear PTA4, the two main covariates based the CPHI analyses, which are likely to impact HHIE scores significantly and are known from the prior analyses of CPHI scores to differ significantly across the sample types. The GLM analysis of HHIE scores was repeated with age and better-ear PTA4 as covariates. Age, F = 7.8, p < .01, PTA4, F = 201.4, p < .001, and sample type, F = 10.1, p < .001, all had significant effects on HHIE-total scores. Post hoc Bonferroni-adjusted paired comparisons among the three sample types found that all sample types differed significantly (p < .05) from one another when evaluated at a mean age of 70.4 years and a mean better-ear PTA4 of 32.2 dB HL. These findings from most participants included in the CPHI analyses support the principal findings of those CPHI analyses. First, there are significant differences in age, hearing loss, and perceived hearing difficulties across the three sample types, but the latter may be mediated to some extent by the differences across the sample types in age and hearing loss. Second, when the differences across sample types in age and hearing loss were controlled statistically, residual differences in perceived hearing difficulties remain across the three sample types.In addition to the full CPHI, 596 of the 764 (78%) participants included in the MUSC and IU data sets also had completed the full 25-item HHIE measure. Those with HHIE scores available constituted 100% of the Community sample, 64% of the Clinic–No HA sample, and 75% of the Clinic–HA sample. The HHIE-total scores were used to corroborate the effects of sample type on perceived hearing difficulties reported here for the CPHI. The mean (standard error) HHIE scores for the three sample types were 12.8 (1.1), 27.2 (1.2), and 41.6 (1.5) for the Community, Clinic–No HA, and Clinic–HA samples, respectively (lower scores indicating less perceived hearing handicap). There was a significant effect of sample type on HHIE scores, All told, the clinical data from the present analyses of CPHI scale scores from older adults are consistent with the prior data from large-scale studies of clinical samples . These pWithout controlling for age, hearing loss (PTA4), or sex differences across the three sample types, significant effects of sample type were observed for 19 of the 20 CPHI scales; all except CE-communication need. Subsequent post hoc paired comparisons among the three sample types for these 19 CPHI scales revealed that all three sample types differed significantly most often  with the Community sample differing from both of the clinic samples but the two clinic samples not differing significantly from one another. Recall that the Community sample was younger and had lower better-ear PTA4 values than the two clinic samples whereas the two clinic samples differed only in PTA4 with the hearing-aid adopters having more audiometric hearing loss. This suggests, not surprisingly, that an older adult with more hearing loss and a more advanced age is more likely to have an audiologic evaluation, and further increases in hearing loss increase the likelihood of adhering to recommendations to acquiring hearing aids.A more interesting question, however, is whether differences in older adults' perceived communication difficulties and their reactions to those difficulties among the sample types remain after controlling for hearing loss and age. This was addressed here by a series of GLM analyses examining the effects of sex and sample type while statistically controlling for age and better-ear hearing loss (PTA4). Here, the Community sample still consistently differed significantly from the two clinic samples. In particular, even when controlling for the significant differences between sample types in age and hearing loss, the Community sample reported better communication performance in all settings and had less awareness of communication problems relative to one or both clinical samples . The low, the Community sample differed from one or both clinical samples on 15 of 20 scales  and nonadherents (who did not). p < .05) in HHIE total scores between groups akin to the Clinic–No HA and Clinic–HA sample types investigated here.The results obtained for the HHIE for most participants included in the CPHI analyses support the principal findings on the impact of sample type on the CPHI. The greatest limitation to the study relates to the way in which membership in one of the three samples was determined. For the Community sample, for instance, it is known that the members of that sample, (a) volunteered for the MUSC longitudinal study of hearing, (b) were not referred to the study from the MUSC audiology clinic, and (c) were not current hearing-aid users. As noted previously, this does not preclude them from having had a hearing evaluation previously but at a non-MUSC clinic or from having tried hearing aids previously but discontinued their use prior to enrollment in the longitudinal study. Likewise, for the Clinic–No HA sample, it is known that they received an audiological evaluation at either the MUSC or the IU clinic, but for the MUSC members of that sample, it is only known that they were not currently using hearing aids. That is, it is possible that they had tried hearing aids (adherents) but stopped using them prior to enrollment in the MUSC longitudinal study. Whereas, the MUSC study confirmed current hearing aid usage, inquiries about prior hearing aid usage were not made. For the members of the Clinic–No HA sample from IU, those who had never tried hearing aids comprised the presumed group of nonadherents. Furthermore, for the entire Clinic–No HA sample, it is presumed that hearing aids were recommended for every member of this sample, but they declined to pursue them, thereby making them nonadherents. For the Clinic–HA sample, considered to be adherents, it is again assumed that they adhered to the recommendation which was to acquire hearing aids. It is, of course, unlikely that hearing aids were acquired without a clinical evaluation and recommendation. Nonetheless, because this was not asked directly of each participant at the time of enrollment in either the MUSC or the IU studies, this cannot be confirmed directly.In addition to this main limitation, there are other common limitations on the generalization of these findings. For example, older adults from only two communities, Charleston, SC and Bloomington, IN, participated and the participants were overwhelming White and non-Hispanic. This limits the broad generalization of the findings to other demographic groups. In addition, all members of all three samples were research volunteers and those who volunteer for research studies may not be representative of the broader community from which they were drawn.In conclusion, this study found significant differences in CPHI scale scores (and HHIE scores) across Community, Clinic–No HA, and Clinic–HA sample types. Hearing loss, and to a lesser extent, age and sex, impacted the effects of sample type on these self-report measures. It is not surprising that an individual's likelihood of taking action, whether to get a hearing evaluation or to acquire hearing aids after such an evaluation, increases as with age and the severity of hearing loss. Importantly, even when controlling for hearing loss and age, many significant differences in CPHI scale scores (and HHIE scores) remained across these sample types. Those who sought clinical evaluation of their hearing loss, regardless of hearing-aid decision, differed from those in the community who did not. The major differences were in the degree of perceived communication difficulty, with those not seeking clinical evaluation reporting less perceived difficulty, and a greater denial or lack of awareness of communication problems among those in the community who did not seek clinical assistance. For the two groups who did seek clinical evaluation of their hearing difficulties, one obtaining hearing aids and the other not doing so, those who acquired hearing aids perceived greater difficulty in communicating in all environments, had greater awareness of communication difficulties, were more likely to use nonverbal strategies to compensate for their difficulties, were more accepting of their hearing loss, but tended to allocate more responsibility for difficulties to their communication partners. Thus, beyond the differences in measured audiometric hearing loss and age across the three sample types examined here, there were real differences in their perceived hearing difficulties and their reactions to them. This reinforces the notion that, ultimately, it is the older adult's self-awareness of hearing difficulties that is most critical to seeking help for hearing problems, as well as remediation for those problems. Efforts to promote and make available self-assessment of hearing difficulties by older adults should be advocated and included in opportunities for hearing screening. In that regard,


Hyaluronan (HA) has been shown to play important roles in the growth, invasion, and metastasis of malignant tumors. KIAA1199, which has potent HA-degrading activity, has been reported to be expressed in various malignancies and associated with patient prognosis. However, there are no reports on the expression of KIAA1199 in osteosarcoma. The aim of this study was to investigate the impact of KIAA1199 and HA expression in osteosarcoma tissues on the prognosis and other clinical characteristics of osteosarcoma patients.From 2003 to 2013, we included 49 patients with osteosarcoma at our institution, whose FFPE  tissue was available at the time of biopsy. The expressions of KIAA1199 and HA in each sample were assessed by immunohistochemistry using the primary antibody for KIAA1199 and HA-binding protein (HABP), respectively. For evaluation of the positivity of KIAA1199 staining, we divided the samples into two groups: High group with more than 75% positive staining and Low group with less than 75% positive staining. In the HABP staining, those with more than and less than 60% were assigned to a High group, and Low group respectively. Various clinical features were correlated with staining positivity. Prognostic factors including positivity of the staining were analyzed. Levels of mRNA expression for enzymes related to HA metabolism were assessed in two osteosarcoma cell lines using real-time RT-PCR.In KIAA1199 staining, high positivity was significantly correlated with occurrence of distant metastases (P = 0.002). The necrosis rate after preoperative chemotherapy was significantly lower in the High positivity group (59%), compared to that in the Low group (84.8%) (P = 0.003). HABP positivity was not correlated with any demographic variables, although the Low positivity group had a significantly better overall survival than the High group with KIAA1199 and HABP staining . In multivariable analysis, KIAA1199 (P = 0.036) and HABP staining (P = 0.002), location (P = 0.001), and distant metastasis at initial diagnosis (P < 0.001) were identified as significant prognostic factors. KIAA1199 and hyaluronan synthase mRNA were expressed at different levels in the two osteosarcoma cell lines.Our results showed that high expression of KIAA1199 and HA are both poor prognostic factors in osteosarcoma. KIAA1199 may be a useful marker for distant metastasis and chemoresistance. Osteosarcoma is the most common primary malignant bone tumor in the pediatric and adolescent population . Its annHyaluronan (HA) is a high molecular weight glycosaminoglycan that is one of the main components of the extracellular matrix (ECM). HA is known to play important roles in matrix assembly, cell proliferation, differentiation, and migration during development, normal tissue homeostasis, and disease . HA syntKIAA1199 is the first gene identified in association with non-syndromic hearing loss  and has The aim of this study is to investigate the relationship between the expression levels of KIAA1199 in addition to HA, which could be detected by HA-binding protein (HABP) with immunostaining for osteosarcoma tissues, and their correlation with various clinical characteristics and patients’ prognosis.Between January 2003 and December 2013, 54 patients with osteosarcoma were treated in our institution. Five of them were excluded because of the lack of clinical information and/or biopsy specimens. Forty-nine patients with osteosarcoma, for whom FFPE  tissues were available at the time of biopsy, were enrolled in this study. Biopsy specimens unexposed to chemotherapeutic agents were subjected to the analyses. All diagnoses were confirmed by an experienced pathologist (Y. S.). Clinical information including age, gender, tumor size, tumor location, histology, distant metastasis, staging, tumor necrosis rate after pre-operative chemotherapy, and prognostic status was reviewed from the patients’ medical records. Disease staging was determined according to the AJCC (The American Joint Committee on Cancer) classification system, 8th edition . Forty-f2 in DMEM medium supplemented with 10% fetal bovine serum (FBS), 100 units/ml penicillin, and 100 mg/ml streptomycin.Two human osteosarcoma cell lines, HOS and Saos-2, were used in this study. These cell lines were a kind gift from Dr. Akihiko Takeuchi . These cell lines were grown in a humidified atmosphere at 37 °C with 5% COAll tumor samples were obtained by incisional biopsy in advance of pre-operative chemotherapy. Tumor sections cut to 4 μm thickness were subjected to the staining for KIAA1199 and HA. Next, the specimens were treated with the corresponding antibodies at 4 °C overnight in a moist chamber: polyclonal rabbit anti-KIAA1199 antibody  and biotinylated HA-binding protein . When staining with b-HABP, prior to the inactivation of endogenous peroxidase, sections were incubated with chondroitinase ABC  at 37 °C for 60 min. Stained sections incubated without primary antibodies were used as negative controls.Breast cancer tissues were used as a positive control for KIAA1199 staining , and norThree fields (magnification ×400) were randomly selected in each section. KIAA1199-positive cells or HABP-positive cells in these fields were counted, and divided by the total number of tumor cells in each field. For positivity of KIAA1199 staining, we divided the patients into two groups, High group (≧ 75% positive cells) and Low group (< 75% positive cells). Similarly, in positivity of HABP staining, the patients with > 60% positive cells were defined as High group and those with < 60% were defined as Low group. These cutoff values, 75% and 60% for KIAA1199 and HABP, respectively, were determined by C-index as the most sensitive values for overall survival (OS).All slides were evaluated independently by two blinded observers (KI and HK). A joint analysis by the two observers was performed where discrepancies were observed to reach a consensus.Expression levels of mRNA for HAS1, HAS2, HAS3, HYAL1, HYAL2, KIAA1199, and GAPDH were determined in two osteosarcoma cell lines, HOS and Saos-2. Total cellular RNA was isolated using RNeasy Mini Kit , according to the manufacturer’s instructions. Following conventional reverse transcriptase-polymerase chain reaction (RT-PCR), cDNA was subjected to real-time RT-PCR for semi-quantification of mRNAs for each enzyme using a LightCycler (Roche Diagnostics). The relative levels of mRNA were expressed as relative quantification normalized with expression levels of GAPDH mRNA. Each enzyme’s primer pairs are shown in Table We determined the optimal cutoffs for KIAA1199 and HABP staining to divide the patients into two groups, High and Low groups. We created 10,000 candidate cutoffs by dividing the KIAA1199 positivity evenly between 0 and 100%. For each candidate cutoffs, we performed univariate Cox proportional hazard models for OS. A line graph was then created with each cutoff on the horizontal axis and the C-index , which iInterobserver reliability in categorizing into two groups, the High group and the Low group, in immunostaining was evaluated using Cohen’s kappa. To evaluate the relationship between clinicopathological features and immunohistochemical positivity, Pearson’s chi-square test was used for categorical variables, and Mann-Whitney’s U test for continuous variables. OS period and disease-free survival (DFS) period were calculated from the date of the first visit to that of death or final follow-up, or the first event recorded , respectively. For DFS, 12 patients with distant metastasis at the first visit or non-operative patients, and one patient with insufficient information were excluded, resulting in 36 patients being included in the analysis. Survivorship was determined with the Kaplan-Meier method, and the association between patient prognosis and various factors including the positivity of immunostaining was assessed by the log-rank test. Factors with P value < 0.05 in the univariate analysis by log-rank test were subjected to multivariable analysis using a Cox proportional hazard model. Because of small number of patients, the Cox proportional hazard model was corrected by Firth’s method . ProceduKIAA1199 and HA expressions in osteosarcoma tissues obtained from the 49 patients were measured by immunostaining. KIAA 1199 was localized principally in tumor cell cytoplasm, and HA in cytoplasmic/nuclear and extracellular areas. We evaluated the positivity focusing on the cytoplasmic staining for KIAA1199 and cytoplasmic/nuclear staining for HA. Figure The C-index took a maximum value of 0.646 when the staining positivity of KIAA1199 was 72.90-77.19%. As a representative of the range, 75% was determined as the cut-off value . Among the 38 patients with localized disease at the initial diagnosis, distant metastases also occurred significantly more frequently in the High group (P = 0.009). In addition, the necrosis rate evaluated in resected tumor tissue after pre-operative chemotherapy was significantly lower in the High group compared to that in the Low group (P = 0.003). On the other hand, HABP staining showed no significant difference between the two groups in any of the clinicopathological variables.The results of survival analysis in KIAA staining showed that the 5-year DFS was 69.2% in the Low group and 39.1% in the High group , plays a role in the development and maintenance of cancer metastasis. Wang et al. researched the function of KIAA1199 in gastric cancer and reported that the introduction of or cells . Other sor cells , 17, 30.Common prognostic factors for osteosarcoma have been reported to be tumor site, size, distant metastasis, response to chemotherapy, and complete resection . In thisIn this study, distant metastasis and necrosis rate were significantly correlated with the positivity of KIAA1199 staining. This result suggests that KIAA1199 can be a possible marker for prediction of distant metastasis and necrosis rate. The necrosis rate was not identified as a prognostic factor in the univariate analysis in our results, unlike the results of previous reports , 6, 10. There was not a sufficiently significant difference in DFS between the High and Low groups (P = 0.054) in the present study. This may be attributable to the fact that only 36 patients were analyzed, excluding patients with distant metastasis at initial diagnosis and non-surgical patients. If the number of patients had been greater, a significant difference might have been found in DFS between the two groups. In the evaluation of HABP staining, there was no significant difference in DFS between the High and Low groups (P = 0.275), or in the incidence of metastasis between the two groups. These results suggest that the metastatic ability of osteosarcoma is more likely associated with high expression of KIAA1199 than that of HA.HA is produced by three HA synthases  at the intracellular border of the plasma membrane and extruded to the cell surface and extracellular matrix . PreviouIn the present study, we also observed the mRNA expression of HA metabolism-related enzymes in the human osteosarcoma cell lines, HOS and Saos-2. The expression levels of HAS1-3 and KIAA1199 were different between these cell lines. These results suggest that HA metabolism actively occurs in osteosarcoma cells and that the pattern of metabolism varies among cells, probably reflecting individual differences. A previous report demonstrated that cell growth of HOS cells was much faster than that of Saos-2 cells, while gene expression of VEGF was sixfold higher in Saos-2 cells than that in HOS cells . Since tThe reciprocal nature of the expression of KIAA1199 and HA is unknown. The results of this study did not show a meaningful correlation between KIAA1199 and HAS expression. It should be further analyzed whether KIAA1199 and HAS expressions are correlated or not.There are several limitations to this study. First, the number of patients included was small. Second, due to the retrospective study design, there was a lack of detailed patient information for some patients, particularly the necrosis rate in nine patients. Third, the precise mechanism of KIAA1199 involvement in the tumorigenicity of osteosarcoma was not clarified.This study suggests that KIAA1199, which has strong HA degradation activity, may have the potential to predict chemoresistance and distant metastasis. In addition, high expressions of KIAA1199 and HA were both shown to be poor prognostic factors for osteosarcoma. Since these expressions are relatively easy to assess by immunostaining, they may be clinically useful in assessing the prognosis of osteosarcoma patients. Furthermore, KIAA1199 might be a novel therapeutic target in osteosarcoma.


The influence of fruit and vegetable consumption on semen quality by reducing oxidative stress is inconsistent. Thus, the association between the consumption of these products, antioxidant status, and semen quality was investigated in 90 men aged 18–40. The consumption of fruit and vegetables was collected using the 3-day food record method. Antioxidant status: total antioxidant capacity in semen (TAC-s) and blood (TAC-b), blood superoxide dismutase (SOD-b), glutathione reductase (GR-b), glutathione peroxidase (GPx-b), catalase (CAT-b) activity, and malondialdehyde concentration in blood (MDA-b) were measured. Sperm concentration, leukocytes in the ejaculate, vitality, motility, and sperm morphology were examined using computer-aided semen analysis (CASA). The consumption of fruit and vegetables was positively correlated with sperm concentration, vitality, motility, TAC-s, TAC-b, and SOD-b activity. The TAC-s and TAC-b were positively related to motility, TAC-s was inversely correlated with sperm tail defects. The SOD-b activity was positively correlated with vitality, motility, sperm morphology, and inversely with sperm tail defects and leukocytes in the ejaculate. Compared to the men in the first quartile of fruit and vegetable consumption (<318 g/day), those in the highest quartile (>734 g/day) had the highest sperm concentration, vitality, motility, TAC-s, TAC-b, GPx-b activity, and the lowest MDA-b concentration (based on multivariate regression models). A high consumption of fruit and vegetables may positively influence selected sperm quality parameters by improving the antioxidant status of semen and blood. Results of epidemiological studies confirm the growing problem of idiopathic infertility in men. It is estimated that the problem of male infertility may affect up to 50% of couples in the world; however, this value may be underestimated because it does not reflect all world regions . Many faReactive oxygen species (ROS) play a physiological role in spermatogenesis, i.a. they regulate the sperm maturation process and ability to fertilize –7. HowevThe defense system, against ROS in male reproductive cells includes antioxidant enzymes and non-enzymatic substances like vitamin C, A, β-carotene, folate, and polyphenols, present among others in fruit and vegetables , 12, 13.Considering that the influence of fruit and vegetable consumption on semen quality is inconsistent and no study has analyzed their consumption in relation to antioxidant status and semen quality simultaneously, this study aimed to examine the association between fruit and vegetable consumption, antioxidant status, and semen quality in adult men.The cross-sectional study was conducted on 90 men, aged 18–40 years old, from 2018 to 2019. Men were recruited based on voluntary applications. Information encouraging participation was disseminated on social media, in gyms, and in sports clubs located in Warsaw. Inclusion criteria were: male gender and age (2 (kg/m2). Physical activity (MET-h/week) was assessed base on the long version of the validated International Physical Activity Questionnaire (IPAQ), which considers the average time and frequency of individual activities related to everyday life and sports  as weight/heightd sports .Fruit and vegetable consumption as well as energy intake were assessed using the 3-day food record method covering two weekdays and one weekend day. During the same week as the diet data, blood collection, and sperm donation were conducted. Before filling in the food records, the participants were trained how to record detailed information about the foods and drinks consumed, preparation meals methods and recipes, and how to determine the estimate portion size by using kitchen scales and household measures , and were given an album of photographs of food products and dishes. A qualified interviewer accurately checked the returned questionnaires, and possible missing or imprecise information about the food consumed and portion sizes were completed. The obtained data were entered into the “Dieta 6” software developed by the National Institute of Public Health–National Institute of Hygiene in Poland (NIPH–NIH). The software contains current food composition tables also developed by NIPH–NIH.The fasting blood samples were collected in the morning by a registered nurse at a clinic. Anticoagulant (heparin or EDTA) tubes were used to obtain whole blood samples. The tubes without anticoagulant were centrifuged at 2,000 × g for 15 min and at 4°C to obtain the serum. All blood samples were partitioned and stored at −80°C for further analysis. The hemoglobin level in whole blood, as well as the concentration of total testosterone, prolactin, the follicle-stimulating hormone (FSH), and high-sensitivity C-reactive protein (hs-CRP) in serum, were determined by a certified laboratory. The assay kits  and Cobas 8000 analyser  were used to measure the hormone level using the electrochemiluminescence method, and the hs-CRP by applying the immunoturbidimetric method.The semen samples were obtained by masturbation into a sterile container in a certified laboratory's private room 2–7 days after last ejaculation. Analyses were performed according to the World Health Organization (WHO) laboratory manual for the examination and processing of human semen by an experienced technician . The speParallel to quality analysis, the total antioxidant capacity in semen (TAC-s) was assessed (the methodology was presented in the section Antioxidant Status).The measurement of total antioxidant capacity in semen (TAC-s) and blood serum (TAC-b) was based on the Trolox equivalent antioxidant capacity method (TEAC) and was determined using an assay kit . This colorimetric method allows to determine the capacity of a sample's antioxidants to inhibit ABTS+∙ . The results were compared to the Trolox , which constitutes a reference antioxidant standard.Ready-to-use kits  were used to determine superoxide dismutase (SOD-b) and glutathione reductase (GR-b) activity in the blood. For this purpose, the samples of EDTA whole blood were centrifuged  to separate plasma from erythrocytes. The received erythrocytes were washed four times with 0.9% NaCl, diluted in 0.01 mol/l phosphate buffer and incubated (37°C) with xanthine oxidase and INT (2-(4-indophenyl)-5-phenyltetrasodium chloride) to determine SOD-b activity, and with NADPH (nicotinamide adenine dinucleotide phosphate) to determine GR-b activity. Enzyme activity was determined spectrophotometrically  based on the degree of inhibition of this reaction .Glutathione peroxidase (GPx-b) activity in the whole blood was determined using a RANSEL kit . The samples, diluted in Drabkin's reagent, were incubated at 37°C with cumene hydroperoxide. The decrease of absorbance over time was measured at 340 nm .The level of decomposition of hydrogen peroxide  was a measure of catalase activity in blood serum (CAT-b). The intensity of the colored complex formed by the mixture of purpald  and formaldehyde  was measured using the spectrophotometric method  .To determine lipid peroxidation levels, the concentration of malondialdehyde (MDA) in blood serum was measured using the spectrophotometric method . This naturally occurring product of lipid peroxidation in reaction with thiobarbituric acid (TBA) at high temperatures (90–100°C) formed a color complex—thiobarbituric acid-reactive substances (TBARS) , 43.Statistical analyses were performed using Statistica software . The characteristics data were shown as mean values ± standard deviation (SD) and as percentages of men by smoking status, alcohol consumption and supplements usage. The results were presented separately for four groups of men, which were created based on their semen quality .The Chi-square test was used to determine statistically significant differences between categorical variables and groups of men with different semen quality. Based on the Shapiro-Wilks test, the hypothesis of normality of continuous variables was rejected; therefore, the Kruskal-Wallis and Mann-Whitney U-tests were used to determine statistically significant differences between groups.x)] to obtain normal distributions, Pearson correlation coefficients were used to determine associations between fruit and vegetable consumption and antioxidant status vs. the parameters of semen quality. Partial correlations were assessed to take into account the potential effect of the following parameters on the observed associations: age , BMI , sitting time , physical activity level , smoking , alcohol consumption , supplement use , wearing briefs and boxer shorts , and energy intake .After transforming data [log. The results with The characteristics of the studied men by semen quality were presented in Significantly fewer men in the G2 group declared wearing briefs and boxer shorts than men in other groups. Men classified into different semen quality groups did not differ in terms of age, BMI, sleeping time, sitting time, physical activity, smoking status, alcohol consumption, supplement use, and energy intake. Moreover, no statistically significant differences in hemoglobin levels, analyzed hormones, and hsCRP were observed between the groups of men.Semen analysis showed the highest average sperm concentration in the G1 group and a statistically significantly higher percentage of morphologically normal sperm in the G1 and G2 groups compared to other groups . In the Moreover, in comparison to the groups of men with sperm abnormalities , the group of men with normozoospermia (G1) had the statistically significantly highest TAC levels in semen and blood as well as SOD-b activity . The gror = 0.30), vitality (r = 0.28), as well as total and progressive motility . Significant positive correlations were also found between the consumption of fruit and vegetables vs. TAC-s (r = 0.42), TAC-b (r = 0.28), and SOD-b activity (r = 0.29).The results of the Pearson correlation between fruit and vegetable consumption, antioxidant status, and selected semen quality parameters were shown in r ranged from 0.22 to 0.35). The TAC-s was inversely correlated with sperm tail defects (r = −0.25). A positive correlation was found between SOD-b activity vs. vitality (r = 0.31), total and progressive motility  and morphologically normal sperm (r = 0.20). An inverse correlation of sperm tail defects (r = −0.27) and leukocytes in ejaculate (r = −0.27) with SOD-b activity were observed.Moreover, the TAC-s and TAC-b were positively related to total and progressive motility  on total motility as well as consumption of legumes  on sperm morphology was observed , 27. MorIt is well-known that a balanced diet rich in antioxidant substances also plays an important role in the prooxidative-antioxidant balance of the body. The TAC level and antioxidant enzymes activity are significantly related to consumed food ingredients with antioxidant properties such as vitamin C, E, carotenes, polyphenols, and folate. In this study, the TAC in semen and blood and SOD activity in blood were positively associated with fruit and vegetable consumption. Moreover, the semen and blood TAC and GPx blood activity were highest in men characterized by the highest consumption of these products. Also, the lowest concentration of MDA in blood was observed in the same men. The results of intervention studies indicate that a higher consumption of antioxidant nutrients  increased TAC levels in the blood and semen of infertile men –49. In aIn the present study, higher semen and blood TAC as well as higher blood SOD activity in men with normozoospermia than in men with confirmed abnormalities in semen quality were observed. At the same time, TAC in both semen and blood was positively correlated with total and progressive sperm motility; TAC in semen was inversely correlated with sperm tail defects. Additionally, SOD activity in blood was positively related to vitality, total and progressive motility and morphology, and negatively correlated with the level of leukocytes in the ejaculate. The relationship between TAC level, antioxidant enzymes activity, and fertility were also observed by other authors. Men with astheno- and oligoasthenoteratozoospermia had a lower seminal TAC level and SOD activity compared to normozoospermic men –55. In tConsidering the results of this study and other studies, the conclusion can be drawn that semen TAC can be used as a good biomarker to assess the redox status in semen and identify the defensive ability against oxidative stress of the male reproductive system. The determination of its level should be combined with the measurement of other parameters of semen quality. Moreover, TAC assessment in male infertility may justify nutritional intervention based on increasing antioxidant intake as therapy for some patients .Moreover, fruit and vegetables are one of the main sources of fiber in a diet. It has been shown that dietary fiber may have a beneficial effect on reducing oxidative stress in the body by participating in the assimilation of antioxidants in the intestine present in fruit and vegetables, such as polyphenols and carotenoids , 21. IncAlthough most studies have shown a positive role of fruit and vegetable consumption on male sperm quality, in several of them, no such beneficial associations were observed. Their consumption was not related to any sperm quality indicators  in 188 healthy men aged 18–22 . Also, tIt is also worth noting that some of the investigated semen parameters (sperm morphology and leukocytes in the ejaculate) were not related to the consumption of fruit and vegetables in our study. Independently from antioxidant dietary intake, morphological sperm damage could be generated by other factors like genetic, enzymatic, or ROS-related factors during spermatogenesis , 5.The role and potential mechanisms of some non-dietary lifestyle factors on semen quality are still inconsistent. In this study, we did not observe any differences among groups of men in terms of age, BMI, sleeping time, sitting time, physical activity, smoking status, alcohol consumption, supplement use, and energy intake. Also, in some studies, the impact of sleep duration  or physiThe strength of the study was the use of the 3-day food record method to collect data about food consumption and assess fruit and vegetable consumption. A qualified interviewer accurately checked the returned questionnaires, and possible missing or imprecise information about the food consumed and portion sizes were completed. Also, this method is not based on the respondents' memory, thus it is free from recall bias. Since data was collected in the early spring and autumn, some restrictions in access to certain fruit and vegetables may have potentially affected their consumption. Another limitation of this study is the number of studied men and that they were not randomly selected but volunteered to participate in the study. However, they were qualified based on strict inclusion and exclusion criteria. Moreover, because of the cross-sectional design of the study, it cannot be predicted if increasing fruit and vegetable consumption has a beneficial effect on antioxidant status and sperm quality but the indicated interrelations might for a basis for intervention in further studies. Also, only one semen sample was analyzed; nonetheless, some authors have shown that one sample is sufficient to assess the quality of semen in epidemiological studies .In summary, the results indicate that high fruit and vegetable consumption may be positively associated with semen quality, and this relationship seems to be involved in antioxidant status underlying the etiology of sperm quality disorders. Taking into account the results of this study and the results of other authors, it can be concluded that the nutritional strategy based on a high consumption of fruit and vegetables to prevent and treat infertility by improving the redox status should be analyzed in future clinical studies.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Ethical Committee at the Institute of Human Nutrition Sciences, Warsaw University of Life Sciences (N08/2016) and has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. The patients/participants provided their written informed consent to participate in this study.DM: conceptualization, methodology, formal analysis, investigation, and writing—original draft. DG, ES and, JK: writing—review and editing and visualization. All authors have read and agreed to the published version of the manuscript.The study was supported by a grant from the National Science Center (NCN), Poland (No. 2018/02/X/NZ9/01103). The research for this study was carried out with the use of research equipment purchased as part of the Food and Nutrition Center—modernization of the WULS campus to create a Food and Nutrition Research and Development Center (CZiZ) co-financed by the European Union from the European Regional Development Fund under the Regional Operational Programme of the Mazowieckie Voivodeship for 2014–2020 (Project No. RPMA.01.01.00-14-8276/17).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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