Setting up regional diagnostic reference levels for pediatric interventional cardiology in Latin America and the Caribbean countries: preliminary results and identified challenges.

The goal of the present study was to propose a set of preliminary regional diagnostic reference levels (DRLs) for pediatric interventional cardiology (IC) procedures in Latin America and the Caribbean countries, classified by age and weight groups. The study was conducted in the framework of the Optimization of Protection in Pediatric Interventional Radiology in Latin America and the Caribbean program coordinated by the World Health Organization and the Pan American Health Organization in cooperation with the International Atomic Energy Agency. The first step of the program was focused on pediatric IC. Dose data from diagnostic and therapeutic procedures were collected between December 2020 and December 2021. Regional DRLs were set as the third quartile of patient dose data (kerma area product) collected in 18 hospitals from 10 countries in an initial sample of 968 procedures. DRLs were set for four age bands and five weight ranges. The values obtained for the four age bands (<1 yr, 1 to <5 yr, 5 to <10 yr and 10 to <16 yr) were 2.9, 6.1, 8.8 and 14.4 Gy cm2for diagnostic procedures, and 4.0, 5.0, 10.0 and 38.1 Gy cm2for therapeutic procedures, respectively. The values obtained for the five weight bands (<5 kg, 5 to <15 kg, 15 to <30 kg, 30 to <50 kg and 50 to <80 kg) were 3.0, 4.5, 8.1, 9.2 and 26.8 Gy cm2for diagnostic procedures and 3.7, 4,3, 7.3, 16.1 and 53.4 Gy cm2for therapeutic procedures, respectively. While initial data were collected manually as patient dose management systems (DMSs) were not available in most of the hospitals involved in the program, a centralized automatic DMS for the collection and management of patient dose indicators has now been introduced and is envisaged to increase the sample size. The possibility of alerting on high dose values and introducing corrective actions will help in optimization.

[Symptoms during sleep among patients with obstructive sleep apnea]. / Síntomas durante el sueño en pacientes con sospecha de Síndrome de Apnea e Hipopnea Obstruciva del sueño.

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) is a frequent sleep-related breathing disorder being associated with cardiovascular, metabolic and neurobehavioral consequences. Most patients with OSAS are untreated because they are not timely diagnosed. AIM: to determine the association of sleep symptoms and body mass index in patients with OSAS diagnosed by polysomnography. MATERIAL AND METHODS: We studied 144 patients aged 47 ± 14 years (75% males) in whom a polysomnography was done. These patients answered a sleep symptom questionnaire and the Epworth sleepiness scale. Their weight and body mass index was also recorded. RESULTS: Snoring and the presence of pauses during breathing were the symptoms with the higher sensitivity to predict the presence of OSAS. Body mass index was significantly higher among patients with OSAS. No differences in the Epworth scale were observed between patients with and without OSAS. CONCLUSIONS: Snoring and apneas while sleeping are symptoms that should lead to the suspicion of the presence of OSAS.

The reliability of the Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI) among dermatologists, rheumatologists and neurologists.

BACKGROUND: Previous studies have shown that skin disease in dermatomyositis (DM) is best assessed using the Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI). Although the CDASI has been validated for use by dermatologists, it has not been validated for use by other physicians such as rheumatologists and neurologists, who also manage patients with DM and assess skin activity in clinical trials. OBJECTIVES: To assess the reliability of the CDASI among dermatologists, rheumatologists and neurologists. METHODS: Fifteen patients with cutaneous DM were assessed using the CDASI and the Physician Global Assessment (PGA) by five dermatologists, five rheumatologists and five neurologists. RESULTS: The mean CDASI activity scores for dermatologists, rheumatologists and neurologists were 21·0, 21·8 and 20·8, respectively. These mean scores were not different among the specialists. The CDASI damage score means for dermatologists, rheumatologists and neurologists were 5·3, 7·0 and 4·8, respectively. The mean scores between dermatologists and rheumatologists were significantly different, but the means between dermatologists and neurologists were not. The intraclass correlation coefficients (ICCs) for interrater reliability for CDASI activity and damage were good to excellent for dermatologists and rheumatologists, and moderate to excellent for neurologists. The ICCs for intrarater reliability for CDASI activity and damage were excellent for dermatologists and rheumatologists and moderate to excellent for neurologists. The PGA displayed lower interrater and intrarater reliability relative to the CDASI. CONCLUSIONS: Our results confirm the reliability of the CDASI when used by dermatologists and rheumatologists. The data for its use by neurologists were not as robust.

Effect of the partial substitution of mango and ground chia on the antioxidant capacity in the elaboration of nectar based on sachatomate.

The consumption of products with high nutritional value and antioxidant capacity has increased notably in recent years. Due to health problems such as triglycerides and cardiovascular problems, its use is becoming reduced. So that, chia (Salvia hispánica) and sachatomate (Cyphomandra betacea) have gained interest as an alternative to develop nutraceutical products, compared to conventional products. The objective of the study was to determine the effect of the partial substitution of mango (Mangifera indica) and ground chia (Salvia hispánica) on the antioxidant capacity in the elaboration of nectar based on Sachatomate. The physicochemical characteristics were determined where sample 11 complies with the established parameters: 13.4° Brix, pH 4.323, 0.354 of C6-H8-O7 and viscosity 3967.3 mPas, according to the NTP 203.110 standard. Regarding the antioxidant capacity, sample 12 was the most optimal, according to the DPPH method, it has been determined 104.3 micromoles Trolox equivalents; according to the ABTS method, it was determined with an antioxidant content of 187.4 micromoles Trolox equivalents. Regarding the proximal chemical evaluation, sample 12 was determined to be the most suitable with a moisture percentage of 87.45%, ash 0.32%, crude fiber 0.09%, fat 0.10%, protein 0.45% and carbohydrates 11.59%. Concluding that substituting sachatomate and ground chia significantly influences the antioxidant capacity, increasing to 104.3 and 187.4 micromoles Trolox equivalents, determined by both methods, indicates that nectar consumption can be used to improve the health of consumers.

Effect of different concentrations of stem juice of Oxalis tuberosa Mol. and juice of the fruit of Gaultheria glomerata (Cav.) Sleumer on the antioxidant activity of the heat-treated functional beverage.

Functional beverages with added health benefits are popular among peoples and athletes because they help them recover faster from intense workouts and perform better overall. This research set out to determine how well heat-treated stem juice from Oxalis tuberosa Mol. "oca" and fruit juice from Gaultheria glomerata (Cav.) Sleumer "laqa-laqa" performed as an antioxidant in a functional drink. The "oca" stems and the "laqa-laqa" fruit were collected to obtain the juice. For this study, 30 semi-trained panellists used sensory evaluation to rate four treatments (Bo, B1, B2, and B3) with varying quantities of "oca" and "laqa-laqa" juice. The results concluded that the treatment B2, which included 300 ml of "oca" stem juice, 800 ml of "laqa-laqa" juice, 1000 ml of treated water, and 220 g of refined sugar, was given the highest score after a physicochemical evaluation of its colour, smell, taste, and overall appearance. Similarly, the results showed that the protein content increased by 1.38%, the fat content by 1.08%, the moisture percentage by 99.5%, the ash content by 1.82%, and the carbohydrate content by 6.22% after B2 treatment. Similarly, results revealed significant enhancement in antioxidant profiling such as total polyphenols: 1825 mg of gallic acid/100 g and antioxidant Activity: 89.56% µmol of trolox /100 g. In conclusion, due to its high energy content and antioxidant activity, it may be a viable nutritional option for athletes who engage in rigorous, frequent physical exertion.

Disease progression in mothers of children enrolled in the Research Registry for Neonatal Lupus.

OBJECTIVE: To evaluate autoimmune disease progression in asymptomatic and pauci-symptomatic mothers of children with neonatal lupus (NL). METHODS: Clinical information on mothers enrolled in the Research Registry for NL (RRNL) was obtained from medical records. Genotyping was performed for -308A/G tumour necrosis factor (TNF)alpha, 869T/C transforming growth factor (TGF)beta and -889C/T interleukin (IL)1alpha. RESULTS: Of the 321 mothers enrolled, 229 had at least 6 months of follow-up. Of the 51 mothers who were asymptomatic at the NL child's birth, 26 progressed: 12 developed pauci-undifferentiated autoimmune syndrome (pauci-UAS), 2 poly-UAS, 7 SS, 4 SLE and 1 SLE/SS. The median time to develop any symptom was 3.15 years. Of the 37 mothers classified as pauci-UAS at the NL child's birth, 16 progressed: 5 developed poly-UAS, 6 Sjögren syndrome (SS), 4 systemic lupus erythematosus (SLE) and 1 SLE/SS. Of the pauci-UAS mothers enrolled within 1 year, the median time to progression was 6.7 years. Four mothers developed lupus nephritis (two asymptomatic, two pauci-UAS). The probability of an asymptomatic mother developing SLE by 10 years was 18.6%, and developing probable/definite SS was 27.9%. NL manifestations did not predict disease progression in an asymptomatic mother. Mothers with anti-Sjögren syndrome A antigen (SSA/)Ro and anti-Sjögren syndrome B antigen (SSB)/La were nearly twice as likely to develop an autoimmune disease as mothers with anti-SSA/Ro only. Only TGFbetaT/T was significantly higher in SLE mothers compared to asymptomatic mothers (p = 0.03). CONCLUSIONS: Continued follow-up of asymptomatic NL mothers is warranted since nearly half progress, albeit few develop SLE. While the anti-SSB/La antibodies may be a risk factor for progression, further work is needed to determine reliable biomarkers in otherwise healthy women with anti-SSA/Ro antibodies identified solely because of an NL child.

Exploratory survey of initial image quality in new digital mammography units prior to use in patients in Mexico.

In Mexico, previous studies performed to evaluate the image quality in 2D digital mammography facilities show a poor image quality that is not compatible with mammography screening that may modify breast cancer mortality rate. Image quality is lost due to the quality assurance programs are not implemented. We carried out an exploratory survey of thirty-six new (FFDM) units from a single manufacturer installed in several cities of the Mexican Republic with two types of target/filter combination (Mo/Mo and W/Rh). Tests were performed according to NOM-041-SSA1-2011 (Mexico), the regulation indicates that all facilities using digital mammography systems must maintain a QC program equal to the QC program recommended by the manufacturer. However, QC program recommended by the manufacturer meets with FDA and ACR Regulations. Digital mammography units evaluated exceeds quality image standards established by the ACR and FDA, even though, the W/Rh combination achieved a higher performance and reduces the average glandular dose. All mammography units met the quality control standards established by ACR, FDA and Mexican regulations. Then, the objective of this study was to evaluate the initial image quality and compliances with the manufacturer's quality control specifications before use it in patients in new full-field 2D digital mammography (FFDM) units and compares average glandular dose (AGD) with FFDM units using different anode/filter combinations (Mo/Mo and W/Rh).

Evolución del estado nutricional y de la función pulmonar en una cohorte de pacientes con fibrosis quística seguidos en un centro de atención integral / Change over time of nutritional status and lung function in a cohort of patients with cystic fibrosis followed in a multidisciplinary care center

Cystic Fibrosis is a multisystemic inherited disease that requires ongoing care by multidisciplinary teams. The objective of this study is to describe changes on nutrition and lung function in a cohort of patients in a Cystic Fibrosis (CF) Care Center at the Hospital Infantil Universitario San José in Bogotá (HIUSJ), between 2010 and 2013.Is a descriptive study in a cohort of CF patients during four years of follow-up. The quantitative variables were described using medians and interquartile ranges, and the qualitative variables with absolute frequencies and percentages. Descriptive statistics was used to summarize the findings. Of the 63 patients in the initial group, 47 (74.6%) completed the follow-up time. The age range was between 3 to 30 years. The median BMI increased as follows: 17.9 (RIQ: 12.5-25.6) in 2010, 18.6 (RIQ: 12.9-24.8) in 2011, 18.9 RIQ (13.6-26.5) in 2012 and 19.0 (RIQ: 13.5-25.8) in 2013, with lower values in men. The forced expiratory volume in the first second (FEV1) at admission was classified as severe (FEV1 <40%) in 7.1%, moderate (FEV1 40-69%) in 35.7%, mild (FEV1 70-79%) in 7.1% and as normal (FEV1> 80%) in 50%. It is concluded that during the 4 years of follow-up at the HIUSJ CF Center there is an improvement in BMI and a deterioration in lung function in the whole group. The importance of establishing more reference centers to improve clinical outcomes and of implement a National registry to follow up over time are highlighted.

La fibrosis quística es una enfermedad hereditaria, multisistémica, cuyo manejo continuo requiere de equipos multidisciplinarios de salud. El objetivo de este trabajo es describir la evolución nutricional y de la función pulmonar en una cohorte de pacientes en el centro de atención integral de la fibrosis quística (FQ), del Hospital Infantil Universitario San José de Bogotá (HIUSJB), entre 2010 y 2013. Estudio descriptivo, en una cohorte de pacientes, en seguimiento durante cuatro años. Las variables cuantitativas fueron descritas mediante medianas y rangos intercuartílicos y las cualitativas con frecuencias absolutas y porcentajes. De los 63 pacientes del grupo inicial, 47 (74.6%), completaron el tiempo de seguimiento. El rango de edad fue de 3 a 30 años. La mediana del IMC (índice de masa corporal) se incrementó así: 17.9 (RIQ:12.5-25.6) en el 2010, 18.6 (RIQ:12.9-24.8) en el 2011, 18.9 ( RIQ(13.6-26.5) en el 2012 y 19.0 (RIQ:13.5-25.8) en el 2013, con menores valores en los hombres. El volumen espiratorio forzado en el primer segundo (VEF1) al ingreso fue clasificado como severo (VEF1<40%) en el 7.1%, moderado (VEF1 40-69%) en el 35.7%, leve (VEF1 70-79%) en el 7.1% y como normal (VEF1>80%) en el 50%. Se concluye que durante los 4 años de seguimiento en el programa de FQ del HIUSJ, ocurre una mejoría del IMC en todo el grupo y un deterioro de la función pulmonar. Se resalta la importancia de constituir más centros de referencia para mejorar los desenlaces clínicos e implementar un registro Nacional para hacer seguimiento a través del tiempo.

Synthesis and evaluation of compounds that facilitate the gastrointestinal absorption of heparin.

A family of novel compounds (delivery agents) that promote the gastrointestinal absorption of USP heparin in rats and primates has been discovered. The delivery agents in combination with heparin were administered either orally or intracolonically in an aqueous propylene glycol solution and caused dramatic increases in both plasma heparin concentrations (anti-Factor Xa) and clotting times (APTT). Using one of the most effective delivery agents in this series, an estimated relative bioavailability of 8% can be achieved following oral administration to cynomolgus monkeys. To establish a correlation between the in vivo data and an in vitro parameter, immobilized artificial membrane (IAM) chromatography was performed. Log relative k' values were correlated to the efficiency of oral heparin delivery.

Alagille syndrome associated with caudal dysplasia sequence.

A 36 day-old male with typical features of Alagille syndrome presented at birth additional features consistent with the diagnosis of caudal dysplasia sequence: imperforate anus, rectourethral fistula, lumbosacral abnormalities, and dysplastic right kidney. The association of these 2 conditions has not been previously reported, and could indicate the existence of an axial mesodermal dysplasia, of variable extension, in the Alagille syndrome.

Acylated non-alpha-amino acids as novel agents for the oral delivery of heparin sodium, USP.

Ten N-acylated, non-alpha-amino acids have been prepared as oral delivery agents and used to demonstrate the oral delivery of heparin in vivo in rats and primates. Following the oral administration of solutions containing a combination of heparin and a delivery agent to rats or primates, significant plasma heparin concentrations were evidenced by APTT and anti-Factor Xa assays. The estimated pharmacodynamic equivalence for an oral dosing solution containing heparin and a delivery agent is 39% in primates. In vitro experiments based on heparin affinity chromatography or heparin/methylene blue complexation were also performed to begin investigation of the mechanism by which these compounds facilitate heparin oral delivery. Results of in vitro studies suggest that absorption of the drug across the gastrointestinal membrane is the result of a non-covalent interaction between heparin and the delivery agent.

Prevalence of intestinal parasites in the human population of León, Nicaragua.

Intestinal parasites appear to be prevalent in Nicaragua, which motivated a more extensive prevalence study in which socioeconomic conditions such as degree of crowding, quality of water supply, type of floor and disposal of excretion, were considered. The study was performed on 1267 stool samples from about 8% of the citizens of the city of León. The overall prevalence of intestinal pathogenic parasites among the 1267 individuals was found to be 47.2%. The prevalence of Entamoeba histolytica/dispar was 18.6% followed by Giardia (15.9%) and Ascaris (13.4%). Other helminths such as hookworms and Strongyloides sp. were found at very low rates. Giardia, in contrast to worm infections, was prevalent already in children under 5 years of age. E. histolytica/dispar increased with age and remained high. Of 595 individuals with intestinal parasites 81% were living in 'poor' conditions and in 13 clusters of households, a lower prevalence of parasites was seen in households characterised as having good socioeconomic conditions. However, several variables appear to be important in determining the prevalence of the individual intestinal protozoa and helminths encountered.

Rural origin as a risk factor for maternal and child health in periurban Bolivia.

Rapid migration in Latin America is settling rural women and their families next to those of urban origin in sprawling urban settings. Those born and reared in rural areas bring with them knowledge and skills learned and adapted to rural areas; those same skills may be maladaptive in urban areas. Hypothesized is that urban women of rural origin are more likely to have poorer health outcomes for themselves and their children than lifelong urban counterparts. Identification of specific risk factors affecting child and/or maternal health status in peri-urban barrios can assist health workers to target limited resources to those least likely to access available services.

Seroepidemiological and clinical study of Chagas' disease in Nicaragua.

With the aim of determining the prevalence, immunological profile, and knowing the electrocardiographic alterations, a clinical and seroepidemiological study of Chagas' disease was performed in three rural settlements located at the North, East and West of Nicaragua. Anti T. cruzi antibodies were searched by indirect immunofluorescence (IFI) and hemagglutination (IHA) in a total of 803 subjects. Seropositives and the same number of seronegatives, matched by age and sex, were included in a case-control design for the electrocardiographic assessment. Antibody prevalence was 13.1, 4.3 and 3.2% in the respective settlements. In the first two the immunological profile corresponds to that of an endemic zone of long standing, were transmission has decreased, and in the third the pattern is of a zone under control. Electrocardiographic changes compatible with Chagas' disease were found in seropositive individuals, but difference with control group was not statistically significant. It is concluded that the disease is endemic in the three settlements and the clinical aspect requires further evaluation, including additional cardiologic techniques.

Stromal tumors of the stomach. Review of our experience and reclassification of a series of patients.

OBJECTIVE: To retrospectively review a series of 12 patients operated on in our department for stromal tumor of the stomach. Clinical and morphological data, and the patients' postoperative course, were analyzed. METHODS: Medical records for 12 patients (mean age 63.3 years) were retrospectively reviewed to obtain data on clinical presentation, diagnosis and treatment. Surgical morbidity and mortality were analyzed. A pathologist reviewed the resected specimens to determine the morphological factors of prognostic value. The biological nature of the tumor was reclassified based exclusively on mitotic index, and all tumors were staged according to the TGM system. Recurrence and survival rates were also calculated. RESULTS: The most frequent clinical presentation was abdominal pain and gastrointestinal bleeding. The most sensitive diagnostic methods were computerized tomography and echographic endoscopy. Operability and resectability rates were 100% and 91.6% respectively. Local resection was done in 5 patients, partial gastrectomy in 5, and extended total gastrectomy in 1. Histologically, 6 cases were muscular tumors (2 leiomyomas, 3 low-grade leiomyosarcomas and 1 high-grade leiomyosarcoma), 2 were gastrointestinal autonomic nerve (GAN) tumors, and 4 were pure stomal tumors. The morbidity rate was 33.3% and the mortality rate was 8.3% (1 patient). All patients were followed up: 1 patient each died after 9 months and 4 years, 1 developed liver metastases after a disease-free interval of 14 months, and the other 9 patients were still alive and free of disease after intervals ranging from 4 months to 7 years. CONCLUSIONS: Stromal tumors include a group of tumors which may present muscular differentiation (the most frequent type), neural differentiation (GAN tumors) or no differentiation at all (pure stromal tumors). The mitotic index is the most valid parameter to determine biological nature, considering that classification as a benign tumor requires the total absence of mitoses. Treatment was mostly surgical, and local resection with adequate safety margins was effective. Prognosis was relatively good, but long-term follow-up is needed to assess the malignant potential of these tumors.

Thermoluminescent response of ZrO2 + PTFE prepared in Mexico to 90Sr/90Y beta particles.

Results of studying the thermoluminescent response of undoped ZrO2 + PTFE pellets irradiated with 90Sr/90Y beta particles are presented. Previously, TL characteristics of ZrO2 films doped with rare earths were studied. Phosphor powder was obtained by evaporating a solution of zirconium nitrate in ethanol. In order to stabilise the traps in ZrO2 this phosphor was submitted to different thermal treatments. Optimal thermal treatment consisted in heating at 1100 degrees C for 24 h. With this powder. pressing at room temperature a mixture (2:1) of ZrO2 and polytetrafluoroethylene (PTFE), pellets of 5 mm diameter and 0.8 mm thickness were made. The glow curve of ZrO2 + PTFE pellets exhibited two peaks at 200 and 250 degrees C: its TL response as a function of beta particles dose was linear in the range from 2 to 60 Gy. Repeatability over 10 cycles was 1.8%. Fading at room temperature was 3.8% per month.

Preparation and thermoluminescence properties of aluminium oxide doped with europium.

There is little information concerning the use of rare earths as dopants of Al2O3. This paper presents the preparation method and the results of studying the thermoluminescence characteristics of Al2O3:Eu exposed to ultraviolet light. Phosphor powder was obtained by the evaporation method. Optimum dopant concentration was 10% at an evaporation temperature of 700 degrees C. The powder obtained was submitted to thermal treatments at high temperatures in order to stabilise the traps. Diffraction patterns showed amorphous powder up to 500 degrees C; as the temperature was raised crystalline phases of Al2O3 appeared. The photoluminescence spectrum induced by 250 nm UV light exhibited four well defined peaks characteristic of the Eu3+ ion. The glow curve exhibited two peaks at 180 and 350 degrees C. The sensitivity of Al2O3:Eu was 10 times lower than Al2O3:C. The thermoluminescence response was linear from 2.4 to 3000 microJ.cm(-2) of spectral irradiance, and the fading 2% in a month. From these results it can be concluded that Al2O3:Eu has potential as an UV dosemeter.

How effectively do you function in a cardiac arrest? A creative program approach to code skills.

Novice and experienced nurses are consistently concerned about their knowledge, skills and abilities to function appropriately in arrest situations. The clinical teachers at Mount Sinai Hospital in Toronto have established an innovative, creative, practical and cost-effective workshop that addresses nurses' code skills. The 500 evaluations received from nurses who have attended the workshops show the program is a resounding success. The 4-hour workshop concentrates on the nurses' role during cardiac arrests in four key areas: leadership, drug administration, suctioning, and airway management. The program is complete with goals and objectives, props, specific evaluation forms, and a take-home examination. The hands-on component of the workshop allows the application of new information under close observation and supervision of knowledgeable and skilled clinical teachers.

Burnout in Ghanaian hospitals: phase model findings in sub-Saharan Africa.

This replication shows the expected covariation of the phases of burnout with a set of 5 marker variables. As the phases progress I-->VIII, so do decreases or deficits occur on all the marker variables. All covariants far surpass usually-accepted levels of statistical significance, although the magnitudes are not as great as in much other research with the phases. The Ghanaian incidence of the phases is also compared with several panels of populations. Those comparisons at once indicate a substantial Ghanaian incidence of advanced phases, as well as a distribution comparable to North American worksettings and more favorable than a panel of global worksettings.

[Hearing screening in children with risk factors of hearing loss in the area 3 of Madrid]. / Screening auditivo en niños con factores de riesgo de hipoacusia en el área 3 de Madrid.

The early identification of the hearing loss is very important to begin a early rehabilitation and to get a normal development of the language. Because of reason, the newborn hearing screening started, mainly in cases with risk factors. The objective of this report is to study the incidence of hearing loss in children with risk factors in the area 3 of Madrid. We realized hearing screening in 138 children in a period of 3.5 years, by otoacoustic emissions in younger 1 year and auditory brain stem evoked response in older 1 year. The results show that the incidence of sensorineural hearing loss is 4.34% of cases in children with risk factors, and more specifically 2.8% of bilateral profound hearing loss, and too, we detected 6.5% of transmisive hearing loss. The age of identification of hearing loss decreased to 6 months with the hearing screening programs. These results support the need of realization of hearing screening programs with obligatory character, though we advocate for the universal screening to include all cases of hearing loss without risk factors.