Beauveria bassiana and Metarhizium anisopliae against whiteflies in Ethiopia.This study was aimed to assess the enzymatic activity and pathogenicity potential of Beauveria bassiana AAUMB-29, AAUMFB-77, and AAUEB-59 generated the highest chitinase (EI = 3.41), lipase (EI = 4.45), and protease activities (EI = 5.44) respectively. The pathogenicity study of isolates on whitefly nymphs and adults indicated significant variation (P < 0.05) with mortality ranging from 71.67 to 98.33% and 60 to 100% against Bemisia tabaci and Trialeurodes vaporariorum nymphs respectively. The mortality of adults was between 58 and 94.27% against B. tabaci and 59.03 to 95.37% against T.vaporariorum. The result also showed that AAUMB-29, AAUMFB-77, and AAUDM-43 were the most virulent with LC50 values of 2.7 × 104, 5.3 × 104, and 5.4 × 104 conidia/ml against nymphs of B. tabaci, and with LC50 values 6.8 × 104, 8.2 × 104, and 7.2 × 104 conidia/ml against nymphs of T. vaporariorum, respectively. The B. bassiana AAUMB-29, B. bassiana AAUMFB-77, and M. anisopliae AAUDM-43 induced the highest whitefly mortality than other isolates. These isolates can be recommended for further tests under field conditions to fully realize their potential as effective biocontrol agents against whitefly pests in tomato.The data showed that The online version contains supplementary material available at 10.1186/s13104-022-06004-4. Bemisia tabaci and Trialeurodes vaporariorum (Hemiptera: Aleyrodidae) are notorious sap-sucking pests causing serious damage to vegetable crops through direct feeding and transmission of several plant viruses [Solanum lycopersicum) is one of the most favorable hosts of B. tabaci and T. vaporariorum [Whiteflies  viruses . Tomato rariorum , and therariorum . The conrariorum , 5. Howerariorum .Beauveria bassiana and Metarhizium anisopliae are the most environmentally-friendly bio-control agents against sucking insect pests [B. bassiana and M. anisopliae provide an advantage to effectively control sap-sucking insect species over others [B. bassiana and M. anisopliae effectively controlled B. tabaci and T. vaporariorum with mortality ranging from 71 to 96.61% [Entomopathogenic fungi (EPF) ct pests . They prct pests , and toxct pests . These tr others . Differeo 96.61% –13.Aphis gossypiin [Pachnoda interrupta [Tuta absoluta [B. bassiana and M. anisopliae against whitefly species, B. tabaci and T. vaporariorum in Ethiopia.Increased interests in the use of entomopathogenic fungi in pest management options necessitate the selection of fungal isolates with high virulence that shows significant enzyme activities on target insects. In Ethiopia, locally isolated entomopathogenic fungi showed promising results for the control of agricultural pests such as ossypiin , Pachnodterrupta , and Tutabsoluta . HoweverB. bassiana and M. anisopliae were used in trials , KCl (0.5 g), MgSO4·7H2O (0.4 g), CaCl2·2H2O (0.1 g), powdered skim milk (25 ml of 15%), glucose (10 g), agar (12 g) and distilled H2O (1000 ml) [The 5 mm mycelial agar disc of each isolate was transferred in triplicates into casein hydrolysis agar composed of; (KH1000 ml) , and inc4)2 SO4 (1 g), K2HPO4 (1 g), KCl (0.5 g), NaCl (5 g), and MgSO4 (0.5 g), FeSO4 (0.01 g), agar–agar (20 g), colloidal chitin (5 g) and distilled H2O (1000 ml). They were incubated at 25 °C for 10 days.Isolates were screened for chitinase activity on the chitin-agar medium according to the method suggested by Maketon et al. . The 5-m. [2PO4 1.2, MgSO4·7H2O 0.3, KH2PO4 2, CaCl2 0.25, 0.003% NaCl, 2% agar, (NH4)2SO4 at 1%, and olive oil at 2% and incubated at 25 °C for 10 days. Enzymatic index (EI) was calculated using the following formula [Isolates were screened for lipase activity according to Falony et al. . The 5 m formula :\documen7 conidia/ml. After spraying, leaves were placed onto 0.2% water agar in a petri dish and adult whiteflies were released into treated leaves (15 adults/leaf) in triplicates and incubated at 25 °C for 10 days. Similarly, the mortality of whitefly nymphs was assessed by spraying leaf discs (30 mm in diameter) containing 20 nymphs with 3 ml of conidial suspension of 1 × 107 conidia/ml. Then leaf discs were placed onto 0.2% water agar medium in a Petri dish and incubated at 25 °C for 10 days. The median of lethal time (LT50) of each isolates at 10 days of post inoculation was calculated using probit analysis.Adult and nymph whiteflies were released to tomato leaves containing sprayed residues of fungal isolates as described by Mascarin et al. . Tomato The spore production of isolates was assessed according to Mascarin et al. . To quan5–1 × 108 conidia/ml) was evaluated to estimate the average lethal concentration (LC50) values of each isolate [The multiple-dose bioassay (1 × 10 isolate . Each tr(LT50) and the lethal concentration (LC50 and LC90) values were determined with probit analysis (IBM SPSS statics 20) [Mortality data were corrected using Abbott’s formula . The cortics 20) .B. bassiana AAUMB-29 performed best in chitinase activity (EI = 3.41), whereas B. bassiana AAUMFB-77 and B. bassiana AAUEB-59 exhibited the highest lipase (EI = 4.45), and protease activity (EI = 5.44) respectively.Entomopathogenic fungi were showed significant differences in their relative enzyme activities ranging from 1.20 to 3.41 for chitinase, 1.58 to 4.45 for lipase, and 1.72 to 5.44 for protease  in percentage mortality of hs Table . The mor50) mortality values, isolates fell within the range of 3.22 to 9.26 days for B. tabaci and 3.08 to 8.16 days for T. vaporariorum nymphs  with profuse sporulation ranging from 1.3 × 105 to 6.5 × 106 on B.tabaci and 1.6 × 105 to 5.8 × 106 conidia/cadaver on T. vaporariorum.Concerning lethal time at 50% (LT5–1 × 108 conidia/ml) response evaluations, the B. bassiana AAUMB-29 revealed the lowest LC50 values of 6.8 × 104 conidia/ml on T. vaporariorum,  against T. vaporariorum.Regarding the multiple dosage  of nymphs on B. tabaci and both isolates of B. bassiana AAUMB-29 and B. bassiana AAUMFB-77 achieved 100% nymph mortality on T. vaporariorum. Several studies also confirmed the great bio-efficacy of B. bassiana and M. anisopliae against B. tabaci and T. vaporariorum, with mortality values of 86.47 to 96.61% at the concentration of 1 × 106 conidia/ml in Italy [7 conidia/ml in Mexico [In this study, the in Italy , 71 to 8n Mexico . The disality 98.% of nympn Mexico .B. bassiana AAUMFB-77 yielded the highest numbers of spores with 6.5 × 106 conidia/cadaver on B. tabaci and 5.8 × 106 conidia/cadaver on T. vaporariorum nymphs. These numbers were slightly higher than the number of spores produced; 7.9 × 105 conidia/cadaver of whitefly nymph with B. bassiana [B. bassiana (8.3 × 107 per beetle cadaver) [B. bassiana AAUMB-29 which was highly effective against the nymphs of whitefly species gave the lowest LC50 values of 6.8 × 104 conidia/ml on T. vaporariorum  . The difcadaver) . With rereported .B. bassiana and M. anisopliae indicated differences in the production of chitinase, lipase, and protease enzymes. The B. bassiana AAUMB-29, B.bassiana AAUMFB-77, and M.anisopliae AAUDM-43 were the most virulent against whitefly nymphs and adults. The whitefly nymphs were more vulnerable to infection with M. anisopliae and B. bassiana than the adult stages of the whitefly species.This particular study showed that B. bassiana and M. anisopliae against whiteflies under in-vitro conditions. A future study is required under field conditions to realize the efficiency of isolates for the development of myco-insecticide.This study is limited to the enzymatic activities and bioassay study of Additional file 1: Table S1. Sources of Beauveria bassiana and Metarhizium anisopliae isolates used in this study. Table S2. The probit analysis of lethal concentrations values of B. bassiana and M. anisopliae in multiple dose-mortality response bioassays against T. vaporariorum nymphs 10 days post-fungal application. Table S3. The probit analysis of lethal concentrations values of B. bassiana and M. anisopliae in multiple dose-mortality response bioassays against B. tabaci nymphs 10 days post-fungal application. Figure S1. Extracellular activities of entomopathogenic fungi. Lipase activity of B. bassiana AAUMFB-77 (A), protease activity of B. bassiana AAUMB-29 (B), and Chitinase activity of M. anisopliae AAUDM-43 (C). Figure S2. Cultures of selected M. anisopliae and B. bassiana isolates on potato dextrose agar media. B. bassiana AAUMB-29 (A), B. bassiana AAUMFB-77 (B), and M. anisopliae AAUDM-43 (C). Figure S3. The mortality of whitefly adults with entomopathogenic fungi on tomato leaves. The mortality of whitefly adults by B. bassiana AAUMFB-77 (A), B. bassiana AAUMB-29 (B), and M. anisopliae AAUDM-43 (C).


COVID-19 continues to cause significant fatality worldwide. Glucocorticoids prove to play essential roles in COVID-19 management; however, the extensive use of steroids together with the virus immune dysregulation may increase the danger of secondary infections with mucormycosis, an angioinvasive fungal infection. Unfortunately, a definite correlation between COVID-19 and elevated mucormycosis infection cases is now clear worldwide. In this review, we discuss the historical record and epidemiology of mucormycosis as well as pathogenesis and associated host immune response, risk factors, clinical presentation, diagnosis and treatment. Special emphasis is given to its association with the current COVID-19 pandemic, including latest updates on COVID-19-associated mucormycosis cases globally, with recommendations for efficacious management. A definite correlation between COVID-19 and elevated mucormycosis infection cases is now clear worldwide. This article can be used as comprehensive tool to help clinicians and the healthcare team in getting a clearer look on the historical record and epidemiology of mucormycosis as well as pathogenesis and associated host immune response. Risk factors, clinical presentation, diagnosis, treatment options and also the latest updates on COVID-19-associated mucormycosis are also discussed, which will help in the understanding of the fatal mucormycosis infection. The whole world has experienced a pandemic due to COVID-19 caused by SARS-CoV-2. Since day 1 of its detection in December 2019 in Wuhan, China, and up to the present, various twists and turns in terms of disease pathophysiology, diagnosis, treatment and, most important, its sequelae and complications are being revealed. The COVID-19 symptom spectrum is continuously expanding ranging from initial dry cough and high-grade fever, to multisystem dysfunction that may eventually end with death [et al. reported 6000 critically ill patients admitted to the intensive care unit, with only 26 patients having invasive fungal infections. Of these 26 patients, half were infected with mucormycosis [Otorhinolaryngology has been intensively involved in COVID-19 diagnosis and management, starting from diagnosis by nasopharyngeal swab sampling or anosmia as a typical symptom marker, to the detection of virus isolates from the middle ear . A recenrmycosis . Althougrmycosis ,5. As weLichtheimia species are widespread in Europe and completely absent from the Americas [Mucormycosis is caused by Mucorales order, which is widely distributed in the environment, found in, for example, decaying food and air-conditioning filters . HoweverAmericas . MucormyAmericas . HoweverAmericas . ZygomycAmericas .Rhizopus. Additional cases then appeared, and the disease incidence gradually increased [Aspergillus, causing invasive fungal disease in malignancy, after transplantation or in diabetes [The first reported case of disseminated mucormycosis, termed ‘mycosis mucorina,’ was published in 1885 by Arnold Paltauf . Later, ncreased . Mucoraldiabetes ,16, the et al. carried out a phylogenetic analysis and concluded that Zygomycetes include two phyla; Mucoromycota and Zoopagomycota. The Mucoromycota included Glomeromycotina, Mucorales, and Mucoromycotina [Taxonomically, Mucorales classification has not been consistent over the years. In the past, the phylum Zygomycota comprised the Mucorales, Entomophtorales and others nonhuman pathogens . Zygomycmycotina .Rhizopus arrhizus [The genera of the Mucorales consist of 261 species, only 38 of which cause human infections . The mosarrhizus .Saksenaea erythrospora is a recently described species causing mucormycosis; PCR amplification and internal transcribed spacer sequencing are the gold standards for its identification [et al. published the first extensive analysis [et al. later published a review using the PRISMA guidelines and including mucormycosis cases solely amounting to 851 cases reported in the period 2000–2017 [www.zygomyco.net), which published 230 case reports from Europe in 2011 [Mucormycosis epidemiology develops with the appearance of new strategies in immunotherapy for cancer and autoimmune diseases, together with novel diagnostic methods that aid in the identification of a formerly uncommon species. For example, fication . Case reanalysis , which i000–2017 . Case se000–2017  or only 000–2017 . Another in 2011 .The incidence of mucormycosis is rising internationally. A study in the USA documented an increase in the mucormycosis incidence in hematological malignancy patients from 0.006 cases/100 autopsies in 1989–1993 to 0.018 cases in 2004–2008 .Prevalence has also been rising in Europe. A center in Switzerland reported an increased prevalence from 0.57 cases/100,000 admissions/year before 2003 to 6.3 cases/100,000 admissions/year after 2003, as a result of excessive voriconazole and caspofungin use . In a poet al. who issued 3 successive studies from the same center. Prevalence rose from 12.9 cases/year during 1990–1999 [In Asia, a comparable increase in prevalence was stated in several studies. A retrospective study from Iran including 208 mucormycosis cases from 2008 to 2014 demonstrated a substantial rise from 9.7% in 2008 to 23.7% in 2014 ,38. A na990–1999  to 35.6 990–1999  and then990–1999 .et al. reported 10 cases of mucormycosis, all detected at the Ain Shams University Specialized Hospital in Cairo, Egypt, during 2010 [Scarce data is known about mucormycosis prevalence in the Arabian countries . An annuing 2010 . Anothering 2010 .Recently, an article was published including analyzed cases of mucormycosis across the Middle East and North Africa region. Cases of proven or probable invasive mucormycosis were recognized from the FungiScope database and the medical literature. A total of 310 cases of mucormycosis were reported mostly from Iran (n = 74), Israel (n = 63) and Tunisia (n = 49). Others were reported from Lebanon (n = 28), Saudi Arabia (n = 28), Egypt (n = 20), Iraq (n = 11) and Qatar (n = 10), and other countries reported fewer than 10 cases. Reported cases rose from 23 before 1990 to 127 in the 2010s . Lack ofIn a comparison between the economies of the countries affected by mucormycosis, it was found, surprisingly, that high-income countries have an higher odds ratio for mortality than low-income countries. Looking into this observation revealed that the rare nature of mucormycosis in developed countries has led to fewer physicians being trained to manage this disease differently from other, similar diseases. Moreover, physicians from low-income countries may be more likely to report patients who survive than deceased cases .Difficulty in sample collection from deep tissues and low sensitivity of diagnostic tests leads to many cases remaining undiagnosed; thus, the actual prevalence of mucormycosis may be greater than that reported. According to the Leading International Fungal Education portal, which estimates the load of serious fungal infections worldwide, the yearly prevalence of mucormycosis may be ~10,000 cases worldwide, excluding India. The estimate rises to 910,000 cases globally if India is included in the data ,53. The Generally, the Mucorales can enter the host either through inhalation, percutaneous inoculation or ingestion . MucoralMucorales must scavenge ample iron from hosts to grow and evade the host’s phagocytic defense mechanisms . They gaThe body faces any infection through the cooperative interplay of the innate and adaptive immune system. The innate immune system is the first nonspecific host response against pathogens. It is composed mainly of physical barriers  and immune effector cells . The adaptive immune system is the second line of defense against pathogens and is composed of T and B cells. The severity of mucormycosis is mainly due to the failure of the immune system to fight those fungi .Initially the Mucorales cross the skin through the wounds and gut through ingestion, thus they successfully evade the physical barriers of the body ,67. The Rhizopus allows the entry of the deferoxamine iron complex via siderophore shuttle mechanism [Rhizopus uptakes the iron from the deferoxamine iron complex through an energy-dependent process using reductase enzyme to convert ferric to soluble ferrous [Glucose and iron increase the expression of GRP78  in diabeechanism  or Rhizo ferrous . In a nuet al. reported the effect of macrophages in healthy mice infected with Rhizopus, the absence of spore or conidia germination in histology samples of lung tissue. However, they observed that the spores remain viable for 10 days in the lung. Thus, they concluded that bronchoalveolar macrophages inhibit the germination of Rhizopus spores but were unable to kill them [et al. revealed the mechanism of inhibition of spore germination by macrophages through production of endotoxin and gamma interferon [Lichtheimia corymbifera, the macrophages’ role was totally unexpected and surprising. Through fluorescent microscopy, it was found that the phagocytosis ratio was higher in virulent strains of L. corymbifera rather than in attenuated strains. The authors suggested that L. corymbifera uses the macrophages as vectors for dissemination in the blood and as protection from the immune system and antifungal agents [Rhizopus conidia stopped swelling inside the macrophages, so melanin is accumulated in the cell wall of the fungus. This melanin inhibits the phagosome maturation by continued induction of Akt/PI3K signaling [Another entry for Mucorales is the respiratory tract, where the alveolar macrophages are the first line of defense . Macrophill them . Jornes terferon . In casel agents . Anotherignaling .Rhizopus infection, it was observed that its germinating spores (swollen) produce chemotactic factors to recruit the neutrophils via complement activation but the resting spores do not [Rhizopus, and no effect was observed on resting spores (same as macrophages effect) [Rhizopus hyphae by inducing proinflammatory gene expression, such as TNF-a and IL-1b, which leads to damage of the hyphae, but this damage is lower than that encountered with other fungi such as A. fumigatus [Rhizopus hyphae is impaired in hyperglycemia, which further increases the risk of diabetic patients to mucormycosis [The same effect of macrophages on germinating spores was observed in studying the effect of neutrophils, keeping in mind that neutrophils’ effect on pathogens is different from that of macrophages. In general, neutrophils produce catatonic peptides, induce oxidative burst and activate an inflammatory state in the body. In the case of s do not . As a re effect) . The neuumigatus . Some strmycosis .et al. reported that thrombocytopenia is a major risk factor for developing mucormycosis in organ transplant patients [et al. found that the platelets adhere to both the fungal hyphae and germinating spores and stop their elongation and germination, respectively [Rhizopus hyphae not the conidia. The direct contact between the NK cells and the hyphae induce the production of perforin. However, it was found that the hyphae have immunosuppressive effects which decrease the production of IFN-γ and regulated on activation, normal T cell expressed and secreted (RANTES); CCL5 [The hallmark of mucormycosis is angioinvasion and local thrombosis at site of infection. Also, Chang patients . All of ectively . NK cellectively . In caseS); CCL5 .H1) produces IFN-γ to provide immunity against fungal infection but IL-4 produced by TH2 increases the susceptibility to infection. Moreover, IL-17 produced by subset of TH1, TH17, provides mucosal immunity against fungal infection. Furthermore, dendritic cells after recognizing β-glucan of the fungal cell wall produces IL-23, which allows the development of TH17 [H17 leads to induction of an inflammatory state in the body, which leads to neutrophils recruitment. In case of Rhizopus infection, its hyphae stimulates the production of IL-23 by dendritic cells [Although the role of adaptive immunity in fighting fungal infection is crucial, it plays a secondary role in case of Mucorales infection. Traditionally, T helper 1(T of TH17 . The actic cells .Patients at high risk for mucormycosis are those having preexisting comorbidities such as uncontrolled diabetes mellitus (DM), DKA, lung diseases, ventilator-associated pneumonia, neutropenia or high iron levels . PatientThere are other conditions that may increase the risk of developing mucormycosis, such as renal insufficiency, presenting with HIV or AIDS , the useMucormycosis has even invaded the pediatric population . AdditioThere are five major forms of infection that can be summarized as rhino-orbito-cerebral, pulmonary, gastrointestinal, cutaneous and disseminated infection, with the rhinocerebral presentation being the most common form . The cliThe symptoms of the pulmonary type with the hyphal invasion of the pulmonary blood vessels include high-grade fever (>38°C), accompanied by nonproductive cough and airway obstruction. If the invasion has reached the hilar blood vessels, a massive hemoptysis may be present ,104. MeaSaksenaea is predominant in North and South America and is known to cause cutaneous manfestations and, to a lesser extent, rhino-orbital symptoms. An interesting meta- analysis linking the epidemiology and clinical manifestation was studied recently [Surprisingly, the clinical manifestations of mucormycosis differs by epidemiology because different species inhabit different habitats, leading to different clinical profile. For instance, recently . The dirrecently ,108.Finally, patients with profound iron overload, immunosuppression, neutropenia and active acute leukemia are the classic group of patients at risk for the disseminated form ,109–111.postmortem autopsy [et al. have shown that the delayed initiation of the treatment has resulted in twofold increase of mortality rate in the 12-week post-diagnosis assessment, compared with early treatment initiation (82.9% vs 48.6%) [The rapid dissemination of mucormycosis is believed to be an extraordinary phenomenon. A delay of only 12 h in the diagnosis can be lethal, and this is why 50% of the mucormycosis cases are diagnosed only in  autopsy . Chamilos 48.6%) . Indeed,Probable infection of invasive mucormycosis includes the involvement of a host factor , presence of a clinical criterion , a mycological criterion by direct or indirect techniques .Possible infection of invasive mucormycosis includes cases that comply with both the criteria for a host factor and a clinical criterion . MeanwhiPCR could be the diagnostic modality for molecular identification of the organism . The conAspergillum [Cunnighamella and Rhizopus [R. arrhizus directly in blood and tissue samples [To confirm the diagnosis of mucormycosis, laboratory methods for identification of the organisms and their culture are carried out . Direct ergillum . They haergillum . These fRhizopus . There aRhizopus . AlthougRhizopus . In caseRhizopus ,125. HowRhizopus . However samples .Early diagnosis and treatment is crucial because rapid progression of disease and higher mortality rate from intraorbital and intracranial complications can reach (50–80%) . Howeveret al. and Biltzer et al. [Although the uncontrolled DM is a major risk factor for mucormycosis, diabetic patients may have a better outcome when it comes to rhino-orbito-cerebral mucormycosis than nondiabetic patients, as reported by Yohai r et al. ,130; thor et al. .Starting with treating the patient’s underlying medical condition and tapering the immunosuppressive agents are the first steps toward treatment. The mainstay of treatment is surgical removal of the infected parts along with the use of systemic antifungal agents. However, the choice of the proper antifungal agent seems to be limited because the Mucorales are inherently resistant to most popular and widely used antifungals ,132.The treatment recommendations provided in this review are supported by the 2019 global guidelines for the diagnosis and treatment of mucormycosis, by the ECMM and the Consortium for Mycosis Education and Research , providiThe guidelines generally support prompt, early and complete surgical debridement of the infected area whenever possible. The start of a systemic antifungal treatment is crucial as well. There's a 1.5-fold increase in the survival rates when combining surgical interventions with early, high doses of systemic antifungal agents ,134. Suret al., to be well tolerated [According to the global guideline for the diagnosis and management of mucormycosis in 2019 , the firolerated . Amphoteolerated . Amphoteolerated .For decades, amphotericin B deoxycholate has been the drug of choice ,134. DesTriazoles, the largest class of antifungal agents in the clinical practice, can be added as well. They act on inhibiting the 14-α-demethylation, which in turn can lead to an increase in the toxic 14-α-methylsterols, the one that alters the permeability of the fungal membrane . IsavucoThe approved dose for isauvoconazole as a treatment for mucormycosis is 3 × 200 mg to be given for day 1–2, and 1 × 200 mg to be given from day 3. A dose of 372 mg of isavuconazonium sulfate (the currently available prodrug form of isauvoconazole) is equivalent to 200 mg isavoconazole . IsavocoPosaconazole, a second-generation triazole, is advised to be used prophylactically in high-risk patients such as neutropenic patients or those with grafts. Posaconazole is considered as a salvage therapy for patients who cannot withstand or intolerant to the amphotericin B . Until rHowever, the introduction of delayed-release tablet form of posaconazole has succeeded to address most of the absorption concerns The dose of posaconazole’s tablet for the treatment of fungal infections is 300 mg orally twice on the first day, followed by 300 mg orally once daily, regardless of food timing . The intThe use of combination therapy can be under the umbrella of lack of enhanced toxicity with possible but unproven added benefit. There is no definitive data to guide the use of antifungal combination therapies, and they are kept as marginal recommendation. However, the use of combination antifungal agents was addressed in large number of studies. Although the echinocandins have no inherent activity against mucormycosis, some evidence suggests that echinocandins may augment the polyene therapy. The benefit of adding the echinocandins is to provide a polyene backbone that enhances and augments therapy. They are believed to inhibit the β-1, 3-glucan, a cell-wall component . In a rein vitro [Hyperbaric oxygen has been proposed as a beneficial adjunctive treatment for mucormycosis, especially in patients with diabetes . High coin vitro . It can in vitro ,150,151.Both interferon and granulocyte-macrophage colony-stimulating factor act as enhancers to the granulocytes’ ability to damage the Mucorales . The treUnfortunately, despite aggressive surgical intervention and the use of systemic antifungals, poor prognosis and high mortality rates (33.8–80%) has been reported in disseminated infections ,158. UnfCOVID-19 continues to cause significant fatalities worldwide. Until the emergence of an effective antiviral therapy, glucocorticoids have proved to play essential roles in COVID-19 management – namely, reducing mortality in hypoxemic COVID-19 patients . Yet theet al. reported three subjects with COVID-19-associated mucormycosis lacking the traditional risk factors, such as DM, transplantation or hematological malignancies, which was one worrying finding. The development of mucormycosis was probably due to the use of glucocorticoids and hence, the utilization of higher doses of glucocorticoids should be prevented [et al. recently hypothesized that the COVID-19 generates an environment for proliferation of Mucorales and consequent mucormycosis. In their study, they proposed a new hypothesis for the incidence of mucormycosis with scientific proof that explains dysregulation of ACE-2 expression in lungs and several tissues and how this results in a cascade of pathways that creates a suitable milieu for mucormycosis. Hence, COVID-19 infected patients are at a higher risk of contracting mucormycosis [Although previously of low incidence rate, numerous mucormycosis cases have been reported recently as a consequence of the COVID pandemic, leading to a substantial rise in its incidence . Unforturevented . Steroidrevented . Pandiarrmycosis .In a new systematic review carried out through 13 May 2021, 101 cases of COVID-19-associated mucormycosis have been reported, including 82 cases from India and 19 from elsewhere. Mucormycosis was principally perceived in males (78.9%). Hyperglycemia at presentation was the central predisposing factor detected in most cases (83.3%), followed by cancer (3.0%). Preexisting DM accounted for 80% of cases, while associated DKA was present in ~15% of cases. Steroid intake was reported in 76.3% of cases, followed by remdesivir (20.6%). The most common organ involved with mucormycosis was nose and sinus (88.9%), followed by rhino-orbital (56.7%) and ROCM type (22.2%). Total mortality was recorded as 30.7% of the cases. Jointly, these observations imply that COVID-19, diabetes and steroids is a dreadful triad in mucormycosis patients . In addiet al. reported a post-COVID-19 patient in India, who was an uncontrolled type 2 diabetic male and was diagnosed with mucormycosis of the right maxilla [et al. reported the first case series of COVID-19 associated mucormycosis patients from India consisting of five cases of COVID-19 infection, who developed rhino-orbital mucormycosis during their treatment [In this review, we have reported the appearance of additional COVID-19 associated mucormycosis cases from India. A few days ago, Krishna  maxilla . Nehara reatment . NumerouIndeed, the situation in India is critical, where both COVID-19 and mucormycosis are considered a double health threat to their healthcare system. The use of corticosteroids in COVID-19 patients with diabetes mellitus is lifesaving . On the A sum of factors may trigger mucormycosis in COVID-19 patients. The principal reason enabling Mucorales spores to propagate in COVID-19 individuals is a perfect setting of hypoxia. COVID-19 also leads to endothelialitis, endothelial damage, thrombosis, lymphopenia and reduction in Mucorales-specific T cells (CD4+ and CD8+). These T cells produce cytokines including IL-4, IL-10 IL-17 and IFN-γ, which impair the fungal hyphae thus their reduction predisposes to secondary fungal infection . In addiIt is recommended to avoid the extensive overzealous use of steroids and wide-spectrum antibiotics in the treatment course of COVID-19. SARS-CoV-2 spikes glycoproteins were recently investigated for designing potential antiviral targets ; howeverFor efficacious management of mucormycosis, synchronized tasks from an integrative group including infectious diseases, ophthalmology, neurosurgery, otorhinolaryngology, pathology and microbiology sections are vital. The Indian Council of Medical Research has suggested that doctors should carry out basic tests such as sinus tenderness, vision and ocular motility in the physical assessment of severely ill or diabetic COVID-19 patients or those using steroids. Particular care should be given to patients showing mucormycosis signs including one-sided nasal obstruction or headache, sinus pain, swelling, numbness or toothache .It is important to spread awareness among both the healthcare system and the general public regarding how serious and fatal the mucormycosis infection is. It is crucial to educate the patients to report their symptoms as early as possible so they can help the healthcare team to have prompt onset of diagnosis of the infection. COVID-19 patients or those who have just recovered from COVID-19 infection should try not expose themselves to any of the natural habitats of the fungus. Mass vaccination against COVID-19 will also help to reduce the probability of severe or secondary complications. Hospitals have to ramp up their hygiene level, preventing the onset of damp areas that might be a breeding ground for mucormycosis. Caution should be taken particularly when dealing with oxygen cylinders, ventilators, and breathing pumps.Mucormycosis seems to be associated with the COVID-19 pandemic and role of the immune response in disease progression. The extensive use of steroids and wide spectrum antibiotics in the treatment course of COVID-19 should be avoided or at least closely monitored. Drugs targeting immune pathways should be prevented if not clearly beneficial and they should be monitored to achieve their therapeutic response at the lowest dose. There is a growing evidence about confirmed new cases of mucormycosis that has been associated with COVID-19. There is a need for better awareness regarding the importance of early identification, fast diagnosis and prompt treatment initiation of mucormycosis particularly, under the lack of active clinical trials.The collection of epidemiological data is important for taking appropriate and affordable measures against mucormycosis infection. Guidelines should be developed and implemented in all healthcare facilities to enable epidemiological data collection and rapid reporting of any outbreaks. Antifungal agents stewardship programs should be implemented for antifungal prescription and use as well as for the control and monitoring of infections caused by the clinically relevant pathogens in healthcare facilities. Rational use of corticosteroids as well as immunosuppressive agents should be undertaken and monitored. Alternative approaches for treating such infections should be considered, such as phage therapy or promising combination of antifungal agents. Finally, strict and protective measures must be taken to prevent dessimanation of this life-threatenging fungal pathogen.Mucormycosis seems to be associated with the COVID-19 pandemic.Historical records, taxonomy and epidemiology of mucormycosis are illustrated here.There are multiple risk factors of mucormycosis; patients with comorbidities or having hematological malignancies are on the top of the list.There are five major forms of infection that can be summarized as rhino-orbito-cerebral, pulmonary, gastrointestinal, cutaneous and disseminated infection, with the rhinocerebral presentation being the most common form.Early diagnosis and treatment is crucial.Steroid therapy appears to be a double-edged sword in the era of COVID-19.COVID-19 associated mucormycosis in now creating an epidemic in a global pandemic, particularly in the low- to middle-income countries.It is important to spread the awareness among both healthcare system and general public regarding how serious and fatal the mucormycosis infection is.


The Bonebridge implant can be a satisfactory solution for patients with conductive or mixed hearing loss (CHL or MHL), or with single-sided deafness (SSD). The aim of the study was to assess patients’ self-reported benefits with the Bonebridge and characterize the relationships between pre-implantation audiometric data, auditory functioning, and satisfaction after implantation. A focus was to see whether different types of hearing loss were associated with particular benefits. The study sample consisted of 81 patients. Procedures comprised pure tone audiometry before implantation, the Abbreviated Profile of Hearing Aid Benefit (APHAB) questionnaire, and a structured interview asking about satisfaction. Statistically significant improvements after implantation were found in all groups  on the APHAB questionnaire. In the structured interview, patients with SSD were the least satisfied. No significant correlation was found between pre-operative air-bone gap and bone conduction thresholds or with APHAB score. Bonebridge implantation is beneficial to patients with CHL or MHL, or with SSD. Assessment of patients for Bonebridge implantation is complex, and audiometric data should be complemented by patient-reported outcomes to provide deeper insight into their individual needs and attitudes. The World Health Organization estimates that hearing loss currently affects more than 1.5 billion people or 20% of the global population [The subjective auditory benefit gained from an intervention can be evaluated by researchers or clinicians using a range of different patient-reported outcome measures (PROMs). These include the APHAB, the Glasgow Benefit Inventory (GBI), the International Outcome Inventory for Hearing Aids (IOI-HA), the Speech, Spatial, and Qualities of Hearing (SSQ), the Hearing Device Satisfaction Scale (HDDS), and the Bern Benefit in Single-Sided Deafness (BBSS).On the basis of his own and related research, Cox has distinguished seven categories of self-reported outcome data: benefit, satisfaction, quality of life, use, impact on others, residual participation restrictions, and residual activity limitations . A measuSubjective benefit is typically measured in one or two dimensions: activity limitations and participation restrictions. One example of a measuring tool for residual activity limitation is the APHAB questionnaire .Magele et al. , in theiIn addition to gauging the auditory benefit of using a selected questionnaire, it is also important to assess the patient’s satisfaction with the medical intervention. Satisfaction is the aggregate of the individual physical, social, and psychological changes resulting from the use of a hearing prosthesis . Based oIn the present work, we assess the impact that one medical intervention–the Bonebridge (BB) system–had on the hearing functioning of three groups of patients: those with conductive hearing loss (CHL), mixed hearing loss (MHL), and single-sided deafness (SSD).The BB active bone conduction implant  is used in patients with conductive or mixed hearing loss, of various etiology, who have bone conduction thresholds not exceeding 45 dB HL, in the frequency range 500–3000 Hz. BB can also be a solution for patients after radical modified surgery or after unsuccessful tympanoplasty (with the aid of bioactive glass) ,7,8. MorThe aim of the study was to assess the self-reported benefits after implantation of the BB system and explore the relationships between pre-implantation audiometric data and perceived benefits and satisfaction. Efforts were also made to determine whether patients with different types of hearing loss  experienced different benefits and levels of satisfaction.The APHAB questionnaire and structured interview were sent via post to 151 BB users who underwent surgical intervention with the BB system between 2012 and 2019. The interview and questionnaire were returned by 103 patients, a response rate of 68%.There were 12 children who were excluded, as well as 10 other subjects who used the audio processor for less than 4 h per day. The final study sample comprised 81 adult subjects.There were 39 women and 42 men, aged from 18 to 74 years. Patients were stratified according to their type of hearing loss. There were 25 patients who had CHL, 36 patients who had MHL, and 20 who had SSD. Statistically significant differences in terms of age, use of a processor (hours/day), and length of use (years) were found. The MHL patients were significantly older than the CHL patients; they used a processor more hours per day than the SSD patients and had used their BB for more years than all other patients.χ2 = 2.13; p = 0.145).In the CHL group, 13 patients (52%) had unilateral, and 12 (48%) had bilateral, hearing loss. In the MHL group, the figures were 12 (33.3%) and 24 (66.7%), respectively. The difference was not statistically significant (M = 61.35 dB HL (SD = 10.38) in the CHL group; M = 75.17 dB HL (SD = 13.70) in the MHL group; and M = 111.94 dB HL (SD = 12.93) in the SSD group. In the SSD group, the opposite ear was a normal hearing ear with air conduction thresholds ≤ 20 dB HL.PTA4 for air conduction in the implanted ear was PTA4 for bone conduction in the implanted ear was M = 14.42 dB HL (SD = 3.47) in the CHL group, and M = 33.51 dB HL (SD = 9.95) in the MHL group.The socio-demographic characteristics of the patients are shown in In determining relationships between APHAB results and audiometric data (such as bone-conduction thresholds and air-bone gap), the CHL and MHL groups were combined.Before making the decision to implant, patients underwent a brief trial with a bone conduction device on a softband. The trial allowed an assessment to be made of the potential benefits from implantation and also gave the patient the opportunity to experience the sort of sensations an implant would provide.In all cases, surgery was conducted under general anesthesia following standard procedures suggested by the manufacturer of the device. The BCI 601 implant was placed in the sinodural angle in all cases. In the first step, a standard S-shape cut was made, as with a typical cochlear implant. The subcutaneous tissue was opened with a monopolar coagulator and a cut made in the periosteum parallel to the skin cut. The periosteum was carefully dissected to preserve tissue. Then, a cavity was made for the device with a cutting or diamond burr, and the dimensions of the cavity checked against the template provided with the implant. The implant was put in place, and small holes for the dedicated screws were made with a single-use burr. There was no need for a lift, which can sometimes be placed between the wing of the implant and the bone if space is lacking. After placing the implant in the correct position, three layers of sutures were added, and a strong dressing was applied to avoid hematoma. All surgeries were uneventful.Pure-tone audiometry was performed in an anechoic chamber with an Otometrics Madsen Itera II diagnostic audiometer. The air conduction threshold was measured with on-ear headphones TDH39 for 125–8000 Hz; bone conduction was measured using a calibrated bone transducer B-71 for 250–4000 Hz. Measurements were performed the day before implantation of the BB system. The audiological details for the CHL and MHL groups are presented in The Abbreviated Profile of Hearing Aid Benefit (APHAB)  was giveTo investigate patient satisfaction with the BB system, a structured interview was conducted. Three questions were asked to probe general satisfaction based on two of the six elements described by the Cox–sound quality and benefit. Responses were collected on a 5-point Likert scale .p-value < 0.05 was considered to indicate statistical significance. SPSS IBM Statistics software (v. 24) was used for analysis.The sociodemographics of the study groups were examined using descriptive statistics and percentages. A chi-square test or one-way analysis of variance (ANOVA) was used to evaluate differences between the CHL, MHL, and SSD groups. A mixed-design analysis of variance was applied to compare difficulties in hearing (APHAB outcomes) among the CHL, MHL, and SSD groups under aided and unaided conditions (with BB on and off). Relationships between difficulty in hearing and air-bone gap, bone conduction, duration of BB use (years), and duration of the processor use (hours/day) were established using a rho-Spearman correlation coefficient. A two-sided This study was an observational cross-sectional design with a questionnaire and structured interview form sent by post. The APHAB questionnaire and structured interview were given to each implanted patient to obtain information about auditory functioning and satisfaction with the BB system. All subjects signed an informed consent. The study protocol was approved by the Institutional Review Board of the Institute of Physiology and Pathology of Hearing (KB.IFPS:21/2018) and conformed with the Declaration of Helsinki.p < 0.01). Detailed structured interview outcomes are given in Most of the patients reported very good or good hearing  with the BB implant. They were generally satisfied with the achieved effect and noticed significant improvement. Subjective evaluation showed statistically significant differences between the three groups. Generally, the SSD patients rated their present hearing as not as good as that of the CHL and MHL patients, and they were less satisfied with the BB’s performance. Furthermore, the SSD patients assessed their hearing improvement (benefit) as being smaller than that of the CHL or MHL patients. All differences between the three groups were statistically significant  the patients belonged to. A group effect was also statistically non-significant.Mean scores and standard deviations for the APHAB subscales and global scores obtained under unaided and aided conditions in the three groups of patients are shown in The changes in APHAB scores are shown in An improvement of at least 22 points in the EC subscale was found in 57% of patients . A difference of at least 22 points in the RV subscale was found in 46% of patients . A difference of at least 22 points in the BN subscale was found in 41% of patients .A check was made whether hearing impairment in the contralateral ear had an impact on limitations in functioning and activity after BB implantation. Patients with CHL or MHL were divided into three subgroups depending on the hearing loss in their contralateral ear: those with normal hearing, with mild/moderate hearing loss, and with severe/very severe hearing loss. The division into degree of hearing loss was made according to the Bureau International d’Audiophonologie (BIAP) classification . It was rho = 0.21; p = 0.100 in the CHL and MHL group. Similarly, the correlation between APHAB global score and bone conduction was statistically non-significant , as can be seen in The correlation between APHAB global score and air-bone gap was statistically non-significant: rho = 0.09; p = 0.493 in the CHL and MHL group. The correlation was rho = 0.26; p = 0.268 in the SSD group.We did not find any significant correlation between difficulty in hearing measured with APHAB and duration of implant use. The relationship between APHAB global score and duration of BB use (in years) was rho = 0.01; p = 0.969 in the CHL and MHL group. The correlation was rho = −0.04; p = 0.863 in the SSD group.The relationship between hours of processor use per day and APHAB global score was The aim of our study was to determine the benefits to patients who had different types of hearing loss and used the BB system. PROMs outcomes indicated significant benefit after BB implantation in patients with conductive and mixed hearing loss. Many previous studies have given similar results ,17,18,25No significant correlation was observed between the audiological parameters obtained in the audiometry tests (before implantation of the BB system) and the achieved benefits reported in the APHAB questionnaire (after implantation). However, the level of hearing in the opposite ear in CHL and MHL patients seems to be interesting and important. The greater the hearing loss in the opposite ear, the greater the problems observable in everyday functioning under unaided conditions. It can be assumed that a patient qualified for a BB according to the set criteria will achieve significant benefits in auditory functioning after implantation. However, the bone conduction hearing thresholds, the size of the air-bone gap, and the hearing condition in the opposite ear at the qualifying stage for surgery do not provide any guidance as to the degree of subjective benefits obtained after surgery .This suggests that it is not the selected pre-operative audiological parameters, but some other internal and external factors that are key. For example, the individual’s needs, expectations, experience in using a hearing prosthesis, acoustic conditions, and the patient’s home environment can all have a significant impact on the change in functioning after BB implantation.The basic consequences of SSD hearing loss include problems with localizing a sound source, discriminating speech in noise, and comfortable hearing under various acoustic conditions, all of which affect the level of perceived disability ,27. For It is worth noting that normal hearing in the opposite ear plays a key role in SSD patients implanted with a bone conduction system. These devices work by contralaterally routing the signal (CROS) to the normal hearing side. The qualification criteria provide that the air conduction hearing thresholds in the better ear should be no worse than 20 dB HL. If the hearing in this ear deteriorates, as it might for physiological reasons in the elderly, it is expected that the effectiveness of this type of device will become progressively lower. In making a long-term prognosis, this risk should be considered a limitation of bone conduction devices of the CROS type.Recently, an increasingly common approach to patients with SSD is to use a cochlear implant ,31. BaseA limitation of collecting data through a postal questionnaire is not being sure of how representative the study group is. Non-return of a questionnaire can involve many factors, so it is important to try to contact the person by phone. Better chances of eliciting an answer come from ringing beforehand, attaching a stamped return envelope, providing written information about the survey, and including information about the funding of the survey, all of which affect its credibility. Following up with a reminder call is often effective. Even with the use of these tools, the response rate in our study was only 68%. A limitation of methods requiring indirect feedback from patients is its reliance on the patient’s cooperation. Wong et al. comment that “For healthcare research, those who are less satisfied  and have attained lower educational standing, income, and employment are less likely to respond . In contrast, Ware et al. (1983) reported more satisfied patients were less likely to return a satisfaction questionnaire. The discrepancies are probably related to the type of healthcare being evaluated, whether the patients believe that the responses provided would modify the care they receive and the outcome, and the reasons causing their dissatisfaction” . Of courAs far as the authors know, there is no study comparing outcomes of BB implantation in patients with CHL, MHL, and SSD in terms of self-assessment. If one assumes that each of these types of hearing loss involves a different type of auditory problem, our efforts were directed to investigating whether, after using the BB implant, each group would report different ratings on the auditory functioning scale, as well as on the satisfaction scale.According to WHO, the current classification of hearing loss means that only adults with a permanent unaided hearing impairment of more than 40 dB HL in the better ear are regarded as having a disabling hearing impairment . That deOverall, based on an assessment under unaided and aided conditions of the limitations in activity and functioning caused by hearing loss, the BB system appears to have the technological capability to compensate for conductive hearing loss, mixed hearing loss , as well as provide contralateral stimulation.In all groups of patients, there were no correlations between the years of using the system and the degree of obtained benefits. It can therefore be assumed that the benefit after BB implantation is stable over time.In this study, the PROMs indicated substantial benefit after BB implantation. In patients with CHL and MHL, no significant correlation was observed between bone conduction thresholds and air-bone gap (obtained by pure-tone audiometry before implantation) and the achieved benefits reported by the APHAB questionnaire after implantation. In all groups of users, there were also no correlations between the years of using the system and the degree of benefits obtained. In the APHAB questionnaire, no statistically significant differences were observed between the three groups of patients . Differences were observed in the structured interview asking about the satisfaction with BB: satisfaction was larger in patients with CHL and MHL than with SSD, but this issue requires further investigation. It is concluded that the Bonebridge is an effective intervention in patients with CHL and MHL as well as with SSD.


GRHL2 gene are an extremely rare cause of dominantly inherited hearing loss. Genetic testing is a crucial part of the identification of the etiology of hearing loss in individual patients, especially when performed with next-generation sequencing, enabling simultaneous analysis of numerous genes, including those rarely associated with hearing loss. We aimed to evaluate the genetic etiology of hearing loss in a family with moderate late-onset hearing loss using next-generation sequencing and to conduct a review of reported variants in the GRHL2 gene. We identified a novel disease-causing variant in the GRHL2 gene  in both affected members of the family. They both presented with moderate late-onset hearing loss with no additional clinical characteristics. Reviewing known GRHL2 variants associated with hearing loss, we can conclude that they are more likely to be truncating variants, while the associated onset of hearing loss is variable.In contrast to the recessive form, hearing loss inherited in a dominant manner is more often post-lingual and typically results in a progressive sensorineural hearing loss with variable severity and late onset. Variants in the  Inherited dominant hearing loss accounts for approximately 20% of non-syndromic hearing loss. In contrast to the recessive form, it is more often post-lingual  and typiGRHL2) gene, also known as transcription factor cellular promoter 2-like 3 (TFCP2L3) (OMIM *608576), is an encoding transcription factor expressed in human epithelial tissues [GRHL2 variants have been associated with age-related hearing impairment [Grainyhead-like 2 . Targeted NGS with a TruSight One Sequencing Panel was performed on the MiSeq platform desktop sequencer using MiSeq Reagent kit v3 . The collected NGS data were analyzed using the bcbio-nextgen toolkit, Version 1.2.3 . BioinfoBoth patients in the family, mother and daughter, had late-onset hearing loss. The 29-year-old daughter’s first visit to the otorhinolaryngology outpatient clinic was at the age of 28. At the time, she complained of being hard of hearing, which was primarily impeding her social encounters and causing everyday life limitations. She had no other otorhinolaryngological or other health complaints. In her otorhinolaryngological status, otomicroscopy revealed normal eardrums and no other pathological findings, while she had type A tympanometric curves in both ears. Pure-tone audiometry was performed in a standard environment for both ears at 0.25, 0.5, 1, 2, 4, 6, and 8 kHz for air conduction and at 0.5, 1, 2, and 4 kHz for bone conduction. There was no air–bone gap between the curves, and symmetrical sensorineural hearing loss in a W shape between 35–55–35–60 dB was diagnosed . In vestHer mother, age 53, had her first otorhinolaryngology exam when she was 39 years old. At the time, pure-tone audiometry revealed no air–bone gap between the curves, and symmetrical sensorineural hearing loss in a W shape between 30–55–35–60 dB was diagnosed, as had been diagnosed in her daughter . VestibuGRHL2 gene as a candidate pathogenic variant in the index patient. The same variant was identified in her mother using Sanger sequencing (GRHL2 variants were identified, while the coverage of the GRHL2 gene in the NGS sequencing was perfect.Following variant filtering and selection of the candidate variants, we identified a heterozygous missense variant NM_024915: c.1510C>T in the quencing . The genGRHL2 gene predicted to be related to late-onset hearing loss inherited in a dominant manner. The importance of genetic testing in hearing loss is not deniable. In addition to enabling identification of the genetic etiology and informed genetic counselling, it facilitates clinical interventions and targeted clinical monitoring to identify comorbidities, as reviewed in . The knoGRHL2 gene is an extremely rare cause of hearing loss. Currently, according to the professional version of the HGMD [, so those domains are crucial for its function. The majority of hearing-loss-related variants are truncating variants, while missense and deep intronic variants seem to be more likely to be associated with other GRHL2-related pathologies [GRHL2b induces midbrain–hindbrain boundary and otic vesicle defects [GRHL2 gene variants is required.The the HGMD , there athe HGMD , c.1276Cthe HGMD , or c.16the HGMD  located the HGMD , so thoshologies ,28,29,30 defects . It is tGRHL2-related hearing loss is reported to be moderate, progressive, bilateral, and late-onset [GRHL2 variant, the onset was in middle to late adulthood [GRHL2 [GRHL2 defect and an environmental cause, since she was exposed to occupational noise and some GRHL2 variants have previously been associated with noise-induced hearing loss in a Chinese population [The clinical presentation of te-onset ,7,25,26.pulation .GRHL2 genetic defect, such as diffuse capillary malformations and undergrowth [GRHL2 variant, was recently diagnosed with ALK-positive lung adenocarcinoma. Studies have reported that patients with high GRHL2 expression are associated with a poor prognosis in small-cell lung cancer [Other than hearing loss, the patients reported here had no additional clinical characteristics reported to be associated with the ergrowth , ectoderergrowth , or eye ergrowth . Recent ergrowth ,33, specergrowth . Howeverg cancer . HoweverGRHL2 gene related to moderate late-onset hearing loss with no additional clinical characteristics. Reviewing the known GRHL2 variants associated with hearing loss, it can be concluded that they are more likely to be truncating variants, while the associated onset of hearing loss is variable.We have reported a novel truncating disease-causing variant in the


Hearing loss is one of the most prevalent sensory disabilities worldwide with huge social and economic burdens. The leading cause of sensorineural hearing loss (SNHL) in children is congenital cytomegalovirus (CMV) infection. Though the implementation of universal screening and early intervention such as antiviral or anti-inflammatory ameliorate the severity of CMV-associated diseases, direct and targeted therapeutics is still seriously lacking. The major hurdle for it is that the mechanism of CMV induced SNHL has not yet been well understood. In this review, we focus on the impact of CMV infection on the key players in inner ear development including the Wnt and Notch signaling pathways. Investigations on these interactions may gain new insights into viral pathogenesis and reveal novel targets for therapy. Disabling hearing loss is defined by the World Health Organization (WHO) as a permanent hearing loss, in the better hearing ear of greater than 40 decibels (dB) in adults and 30 dB in children. It affects 466 million people including 34 million children worldwide. Most of the affected ones live in low- and middle-income countries with limited ear and hearing care services. Particularly for children, disabling hearing loss has devastating consequences because it seriously hinders them from developing language, communication and social skills with inferior long-term education and economic status. The leading nongenetic cause of sensorineural hearing loss (SNHL) in children is congenital human cytomegalovirus (HCMV) infection, which affects 0.5–3% of all live births worldwide . Up to 6HCMV is a member of subfamily β-herpesvirinae in the family Herpesviridae. Primary HCMV infection typically causes no symptoms, but HCMV establishes lifelong latent infection, which can be periodically reactivated with shedding of infectious virus. Women of reproductive age are predominantly affected by HCMV infection, with seroprevalence ranging from 45% to 100% . PrimaryCurrently, no vaccine is available to prevent primary or recurrent HCMV infection and medical treatment options are also very limited. A thorough understanding of how HCMV infection causes hearing loss will help to identify novel targets for therapeutic intervention. In this review, we first give a short overview of hearing loss and then discuss a few potential routes that CMV hijacks to disrupt the inner ear development. The role of connexin 43 in hearing loss and its connection to CMV infection are discussed. More importantly, two essential signaling pathways-Notch and Wnt pathways and their interplay with CMV are explored.In mammals, the ear can be divided into three parts: the outer ear, the middle ear and the inner ear. The inner ear is located within the temporal bone and lies between the middle ear and the internal acoustic meatus. It consists of three parts: the semicircular canals, the vestibular and the cochlear. The cochlea with a snail-shaped structure receives incoming soundwaves and transduces them into nerve impulses which are conveyed to the auditory nuclei in the brain where the signals are interpreted as sound. The transduction of auditory signals is carried out in the organ of Corti which sits upon the vestibular surface of the basilar membrane within the cochlear duct. Inside the organ of Corti, a single row of inner hair cells (IHCs) and three rows of outer hair cells (OHCs) are arranged along rows and are interspaced by the supporting cells (SCs) . The recThere are two main types of hearing loss based on the structure and function . First, Moreover, hearing loss can be categorized as congenital (present at birth) or acquired hearing loss (after birth) based on the timing that hearing loss appears. Almost 50% of all congenital SNHL cases are hereditary and caused by mutations in genes such as GJB2, GJB6, SLC26A4, and OTOF . Viral iThe pathogenesis of HCMV-related hearing loss is still not fully understood. Both direct virus-mediated cytopathology and virus-induced inner ear inflammation have been implicated in the auditory pathogenesis ,9. ViralMany genes involved in genetic congenital hearing loss encode gap junction proteins, which belong to the connexins (Cx) gene family. Connexins are co-translationally inserted into the endoplasmic reticulum and transported through the Golgi and the trans-Golgi to the plasma membrane . Connexiin vitro, Cx43 expression was reduced and its trafficking to cell membranes was interrupted, which resulted in altered gap junction communication and eventually cochlear cell death . β-. β-32]. HCMV targets the Wnt pathway and regulates its activity either positively or negatively in different scenarios. In colorectal cancer-derived stem cell-like cells, HCMV infection dramatically increased the gene expression of Wnt pathway components WNT11, frizzled-7, GSK3β, and β-catenin . Wnt/β-cInteraction between Wnt/β-catenin signaling and Cx43 has also been reported. Cx43 was found to partially colocalize with β-catenin at the cell membrane and it translocated to the nucleus along with β-catenin upon Wnt pathway activation . Cx43 waHes (hairy enhancer of split) and Hey (hairy/enhancer of split-related with YRPW motif) families of basic helix–loop–helix transcription factors. Activation of Notch induces the expression of Sex-determining region Y (SRY)-box2 (SOX2), a core transcriptional factor for stem cell self-renewal and pluripotency; thus SOX2 has also been considered as a direct target of Notch pathway [As an evolutionarily highly conserved signaling pathway, the Notch pathway is critical for the development of most organ systems. It plays multiple roles during the inner ear development, from the origination of the otic placode alongside the central region of the embryonic hindbrain, to the mosaic cell pattern formation of HCs and SCs through lateral inhibition. The mammalian Notch pathway mainly consists of four transmembrane Notch receptors (Notch1–4) and five DSL (Delta/Serrate/Lag-2) ligands (Jagged 1/2 and Delta-like (Dll) 1/3/4). The transmembrane Notch receptor has an extracellular domain with multiple EGF-like repeats and a Notch intracellular domain (NICD). Binding of the DSL ligands to the Notch extracellular domain (NECD) triggers sequential proteolytic cleavages of Notch by the metalloproteases of the ADAM  family and γ-secretase. This process releases the NICD from the membrane, which translocates into the nucleus and forms a transcriptional complex with CSL (CBF1/SuH/Lag-1) to regulate the expression of Notch target genes such as the  pathway . Notch e pathway ,54.In the early stages of ear development, Notch pathway is involved in the otic placode induction, which later gives rise to the entire inner ear. The Notch1 receptor, its ligands (Jag1 and Dll1) and the downstream effector Hes1 are expressed in the otic placode, induced by Wnt signaling ,55. NotcIn addition, Notch signaling has been shown to regulate both the neurogenic process and the prosensory specification . During Hes/Hey family are expressed in the developing cochlea, where they function redundantly or cooperatively to ensure the proper cell alignment, polarity and cell numbers of HCs and SCs  to mature neurons and glial cells is regulated by Notch signaling . HCMV inHearing loss has a critical adverse impact on life quality, so it is important and urgent to develop effective therapies to reverse it. Antiviral therapies have been recommended for neonates with congenitally CMV infections . InfantsConsidering the pivotal roles of Wnt and Notch signaling pathways in inner ear development and their intricate interactions with CMV, targeting these pathways may provide a new direction for therapeutic development. Activation of Wnt signaling pathway by a GSK3β inhibitor has been exploited to generate sensory HCs from cochlear SCs expressing Leucine-rich repeat containing G-protein-coupled receptor 5 . In addiGene replacement therapy is another innovative therapeutic approach for hearing loss and it has shown promising results in animal models. Conditional deletion of Cx26 in the inner ear of mouse resulted in HC loss and hearing impairment. Deliver a Cx26 replacement gene in cochlear organotypic cultures by ovine adeno-associated viral (AAV) vectors restored Cx26 protein expression and repaired gap junction coupling . FurtherThe detailed mechanism of CMV-induced hearing loss remains elusive. Previous studies were more focused on the direct cytotoxic effect and inflammatory response elicited by CMV. In this review, we highlight the significance of CMV in regulating Wnt and Notch signaling pathways during ear development. More research on these interactions in vivo will definitely yield profound insights about the mechanism of CMV-induced hearing loss, and reveal new targets for therapeutic interventions.


The NO-cGMP signal transduction pathway plays a crucial role in tone regulation in hepatic sinusoids and peripheral blood vessels. In a cirrhotic liver, the key enzymes endothelial NO synthase (eNOS), soluble guanylate cyclase (sGC), and phosphodiesterase-5 (PDE-5) are overexpressed, leading to decreased cyclic guanosine-monophosphate (cGMP). This results in constriction of hepatic sinusoids, contributing about 30% of portal pressure. In contrast, in peripheral arteries, dilation prevails with excess cGMP due to low PDE-5. Both effects eventually lead to circulatory dysfunction in progressed liver cirrhosis. The conventional view of portal hypertension (PH) pathophysiology has been described using the “NO-paradox”, referring to reduced NO availability inside the liver and elevated NO production in the peripheral systemic circulation. However, recent data suggest that an altered availability of cGMP could better elucidate the contrasting findings of intrahepatic vasoconstriction and peripheral systemic vasodilation than mere focus on NO availability. Preclinical and clinical data have demonstrated that targeting the NO-cGMP pathway in liver cirrhosis using PDE-5 inhibitors or sGC stimulators/activators decreases intrahepatic resistance through dilation of sinusoids, lowering portal pressure, and increasing portal venous blood flow. These results suggest further clinical applications in liver cirrhosis. Targeting the NO-cGMP system plays a role in possible reversal of liver fibrosis or cirrhosis. PDE-5 inhibitors may have therapeutic potential for hepatic encephalopathy. Serum/plasma levels of cGMP can be used as a non-invasive marker of clinically significant portal hypertension. This manuscript reviews new data about the role of the NO-cGMP signal transduction system in pathophysiology of cirrhotic portal hypertension and provides perspective for further studies. Portal hypertension (PH) is defined as portal venous pressure exceeding 5 mm Hg. Significant sequelae of PH occur when pressure exceeds 10–12 mmHg ,4,5,6. IAn increase in hepatic vascular resistance to portal blood flow is the main factor of intrahepatic PH. The structural component contributing about 70% to the intrahepatic vascular resistance is caused by the disturbed liver architecture, fibrotic tissue, regenerative nodules, angiogenesis, narrowing of intrahepatic blood vessels by extracellular matrix proteins, and vascular occlusion. A dynamic component accounts for about 30%. It is caused by an impaired interplay of the sinusoidal cells, i.e., hepatocytes, liver sinusoidal endothelial cells (LSECs), and hepatic stellate cells (HSCs), characterized by transformation of contractile HSCs to myofibroblasts, synthesis of extracellular matrix proteins, and capillarization of LSECs. Eventually, this leads to an increased sinusoidal tone caused by an imbalance of dilating and constricting factors ,19,20,21The main regulator of vascular and sinusoidal tone is the NO-cGMP pathway ,20,24. EThis manuscript reviews recent studies on localization and expression of the enzymes eNOS, sGC, and PDE-5, as well as the molecule cGMP in a healthy and cirrhotic liver. It proposes shifting the focus to cGMP as the key component responsible for sinusoidal constriction and peripheral vasodilation in liver cirrhosis. We discuss study recommendations on the effects of sGC modulators and PDE-5-inhibitors in liver diseases such as modulation of the NO-cGMP pathway for treatment of portal hypertension , reversaNO and eNOS: In a healthy liver, eNOS is constitutively expressed. A number of studies showed reduced activity of eNOS in a cirrhotic liver. However, it is not clear whether this reflects reduced expression or disturbed post-translational modification of the enzyme [4-induced liver cirrhosis, accompanied by PDE-5 upregulation. In hepatic arteries of human cirrhotics, however, eNOS was upregulated and PDE-5 was downregulated, while in the aortic wall of cirrhotic rats, eNOS was upregulated, and PDE-5 was downregulated.e enzyme ,38,39,40e enzyme ,42,43 fosGC: Using immunohistochemistry, Theilig et al. (2001) [. (2001)  detected. (2001) , sGC act. (2001) , Lee et . (2001) , Schwabl. (2001) ,48, and . (2001)  describe. (2001)  describe. (2001) . Schwabl. (2001) . In a hePDE-5: Perri et al. (2006) [. (2006)  describe. (2006)  found a . (2006)  in BDL-i. (2006) , on the . (2006)  stimulat. (2006) . Uschner. (2006)  confirmeAnother study by Brusilovskaya et al. (2020) investigated the effects of tadalafil (a long-acting inhibitor of PDE-5), riociguat (a sGC-stimulator), and cinaciguat (a sGC-activator) in BDL-induced liver cirrhosis . TadalafcGMP: Niederberger et al. (1995) [. (1995)  confirme. (1995) . Tahseld. (1995)  investig. (1995)  clarifieConsidering these recent findings, we propose explanations for these controversial findings and thereby offer an alternative perspective in understanding the pathophysiology of PH. We suggest a paradigm highlighting how the NO-cGMP pathway is altered in liver cirrhosis. Modulation of sGC and/or PDE-5 regulates sinusoidal cGMP availability, thus influencing sinusoidal tone, portal pressure, and portal venous blood flow .NO is generated by eNOS in sinusoidal endothelial cells and diffuses into the neighboring hepatic stellate cells, where it binds to and activates sGC. This enzyme catalyzes the conversion of GTP to cGMP. This intracellular second messenger, in turn, triggers distinct downstream signaling effects  which eventually exert vasodilation. As a negative feedback mechanism, rising cGMP concentrations initiate the activation of PDE-5, which mediates cGMP inactivation. The opposing zonation of sGC and PDE-5 may suggest regulation of sinusoidal cGMP. It is synthesized in the periphery of the sinusoids (high sGC concentration), exerts its physiological function along the sinusoids and is inactivated before it enters systemic circulation (high PDE-5 concentration in zone 3 hepatocytes). In liver cirrhosis, both eNOS and sGC are overexpressed. Their activity is overridden by the marked overexpression of PDE-5 primarily in perisinusoidal cells and the loss of the physiological zonation of PDE-5. The final dilator cGMP is converted to inactive 5′-GMP. Sinusoids persist in a constricted state. PDE-5 is markedly overexpressed in liver cirrhosis, however, its activity can be blocked by PDE-5 inhibitors. This leads to a normalization of cGMP concentrations and, consequently, sinusoidal dilation. Comparable effects are achieved if sGC activity is further enhanced by either an sGC stimulator or activator. This overrides the overexpression of PDE-5, leading to normalization of cGMP levels and sinusoidal dilation. Further studies should show whether the etiology of liver damage has an effect on these changes in the NO-cGMP pathway.Targeting the components of the NO-cGMP pathway in cirrhotic liver management using PDE-5 inhibitors or sGC modulators could lower portal pressure and increase portal perfusion. These effects might have clinical consequences.These drugs are potential therapeutic alternatives for portal hypertension.PDE-5 inhibitors or sGC modulators may be useful for reversal of liver fibrosis/cirrhosis, as shown in animal studies.PDE-5 inhibitors are a promising therapy of hepatic encephalopathy in liver cirrhosis.Serum levels of cGMP can be used as a simple non-invasive marker of clinically significant portal hypertension.The effects of PDE-5 inhibitors on portal hemodynamics in experimental models of liver damage were investigated by several authors ,48,54,55Preclinical and clinical data provide evidence that targeting sCG (stimulators or activators) or PDE-5 inhibitors in liver cirrhosis lowers portal pressure and intrahepatic resistance, thereby increasing sinusoidal blood flow. Thus, PDE-5-inhibitors and sGC stimulators/activators can be used as a novel therapy in treating portal hypertension. The data also suggest that although the effects of sGC and PDE-5 inhibitors are dependent on NO synthesis, eNOS activity it not the limiting factor. The main regulator of sinusoidal tone, cGMP, can be modulated by targeting sGC and/or PDE-5.The results of preclinical and clinical studies are summarized in Recent clinical and experimental studies suggested that chronic liver disease and resulting portal hypertension may be at least partially reversible ,65,66,67For example, regression of fibrosis/cirrhosis has been observed in alcoholic liver disease after cessation of alcohol consumption ,70, in cThe cellular key players in the development of liver fibrosis are HSCs, which differentiate into myofibroblasts. The discovery of novel pathways and mediators revealed the plasticity and complexity of HSC activation but also yielded information about potential approaches to reverse HSC activation . ReversaFurthermore, Knorr et al. (2011)  demonstrIn a NASH model investigated by Flores-Costa et al. (2018) , sCG andPreclinical data suggest that modulation of the NO-cGMP pathway may induce or accelerate reversal of fibrosis/cirrhosis.The pathogenesis of hepatic encephalopathy (HE) is a complex process involving a disturbed interplay of the gut, liver, kidneys, skeletal muscles, and brain ,91,92,93Ammonia is produced mainly from protein digestion in the gastrointestinal tract and, in part, from glutamine via glutaminase in the kidney . In healThe glutamate-NO-cGMP pathway, including N-methyl-D-aspartate (NMDA) receptors, plays important roles in function and intercellular communication. Several investigators demonstrated modifiable learning ability depending on extracellular cGMP levels in rats ,103,104.Hyperammonemic rats show impaired function of the glutamate-NO-cGMP pathway, reduced levels of extracellular cGMP in the cerebellum, and reduced ability for spatial learning and memory . TreatmeThese studies suggest that in pathological situations wherein reduced extracellular cGMP concentration is associated with reduced function of the glutamate-NO-cGMP pathway, it is possible to improve the mechanisms of such a pathway and enhance learning ability using treatments that increase cGMP levels. This may be achieved by administering phosphodiesterase inhibitors such as zaprinast or sildenafil ,106, antThe memory-enhancing effects of PDE-5 inhibition in experimental studies may possibly be related to increased blood flow and, consequently, increased glucose metabolism, as PDE-5 inhibitors are known vasodilators . BiochemThe influence of PDE-5 inhibitors on cerebral function in HE is complex. In addition to modifying the glutamate-NO-cGMP pathway, changes in cerebral blood flow may also play a role. Influencing inflammation via intracellular cGMP concentration is also conceivable. The increase in sinusoidal perfusion, decrease of portal pressure, and reduction of shunt volume might lead to an improvement in the detoxification capacity of the liver. Further clinical studies are needed to prove the effect of PDE-5 inhibitors on hepatic encephalopathy.Numerous blood tests have been established to recognize or differentiate various liver diseases ,117,118.Serum/plasma cGMP could be a potential indicator of clinically significant portal hypertension in which the pathophysiological background is based on the opposed disturbance of the NO-cGMP pathway inside (low cGMP) compared to outside the cirrhotic liver (high cGMP). Inside the cirrhotic liver, cGMP is converted into biologically inactive 5′-cGMP by overexpressed PDE-5. This results in low cGMP in sinusoids and in liver outflow . In contIn patients with progressed liver cirrhosis, similar findings were reported. Kirstetter et al. (1997)  describeThe “NO-paradox” states that NO availability inside the liver is reduced and NO production in the peripheral systemic circulation is increased, leading to vascular disturbance in liver cirrhosis. However, recent data suggest that altered availability of cGMP better elucidates the contrasting findings of intrahepatic vasoconstriction and peripheral systemic vasodilation. We suggest a focus shift from NO to cGMP and propose the alternative “cGMP-paradox”. The enzymes sGC and PDE-5 play a crucial role in the regulation of local cGMP levels. Hence, targeting these enzymes by PDE-5 inhibitors or sGC stimulators/activators could induce dilation of hepatic sinusoids, decrease intrahepatic resistance, increase portal venous blood flow, and consequently, lower portal pressure in cirrhotic portal hypertension. These effects suggest further clinical applications in liver cirrhosis. Inhibitors of PDE-5 or stimulators/activators of sGC may contribute to reversal of liver fibrosis or cirrhosis. Inhibitors of PDE-5 may have therapeutic potential for hepatic encephalopathy. Finally, plasma/serum levels of cGMP can be used as non-invasive marker of clinically significant portal hypertension.


Varicose veins are one of the most common disease; however, secondary varicose veins caused by tricuspid valve regurgitation (TVR) are rare.A patient who developed pulsating bleeding from superficial varicose veins due to TVR was successfully treated by endovenous laser ablation (EVLA) of the great saphenous vein (GSV) and repeated foam sclerotherapy of varicose veins. There were no complications, such as rebleeding or recanalization of the GSV during the 1-year follow-up period.We herein report a rare case of pulsatile hemorrhagic varicose veins caused by TVR that was successfully managed by combined treatment of EVLA and foam sclerotherapy. When pulsatile varicose veins are found, the presence of TVR should be suspected. Most varicose veins are caused by primary valvular insufficiency. It is reported that only about 5–20% of varicose veins occur secondary to conditions, such as deep vein thrombosis, pelvic tumor or arteriovenous fistula , 2. In pA 69-year-old male patient was admitted for pulsating bleeding from superficial varicose veins of the left dorsal foot. After compression hemostasis, ultrasonography revealed pulsatile regurgitation in the left GSV Fig. . He had 4a, as assessed using the clinical, etiological, anatomical and pathological (CEAP) classification. Ultrasonography revealed regurgitation in the left deep veins, from the common femoral to the popliteal, and perforators in the left lower leg, in addition to the left GSV. We clinically suspected arteriovenous fistula and the patient was admitted for a detailed hemodynamic examination. Computed tomography revealed the presence of congestive liver and inferior vena cava dilatation; however, no arteriovenous fistula was observed  under general anesthesia with tumescent local anesthesia . Subsequently, three incompetent perforating veins in the left lower leg were identified under ultrasound guidance, and then ligated and dissected. The puncture site of the introducer sheath and the incision in the lower leg bled easily; however, hemostasis could be obtained by manual compression. After the operation, the patient rested on the bed with the left lower limb compressed by an elastic bandage. Duplex sonography confirmed the success of EVLA of the left GSV and the patency of the deep vein system  and cardiac stimulants  was introduced after the bleeding event involving the varicose veins.In previous studies, some cases of pulsatile varicose veins secondary to TVR were treated by approaches, such as EVLA alone and saphenofemoral ligation with foam sclerotherapy; however, other cases were treated conservatively by compression therapy with elastic stockings, in consideration of the bleeding due to venous hypertension and cardiac risk during the operation , 8–11. ODeep vein regurgitation was also observed in our case, so even after EVLA of the GSV, regurgitation through the incompetent perforating vein and rebleeding from varicose veins may occur. Therefore, it was considered that ligation of the incompetent perforating veins and foam sclerotherapy for the superficial varicose veins were effective. Since there is not enough evidence concerning the long-term outcomes of EVLA for varicose veins caused by TVR, further follow-up will be necessary.We herein report a rare case of pulsatile hemorrhagic varicose veins caused by TVR that was successfully treated by EVLA and foam sclerotherapy. When pulsatile varicose veins are found, the presence of TVR should be suspected.


IR) on the day of hatch at a commercial hatchery or sham untreated control (C). Data collected included beak length, body weight, feed intake, feed efficiency, and mortality. Data were analyzed using a 1 or 2-way ANOVA, followed by Tukey's range test for mean separation when interactions were found. Results showed that beak length (Experiment 1 only) was significantly shorter in IR poults from 2 to 12 wk of age. In the same experiment, IR toms had lighter body weight than C toms, but IR hens were heavier than C hens from 2 to 4 wk of age. By 12 wk, IR poults were heavier than C poults, regardless of gender. In experiment 2, IR hens had lighter body weight from 2 to 4 wk of age. In conclusion, infrared beak treatment had minimal effects on feed intake, feed efficiency, or mortality over the 12-wk periods of both experiments.Controlling injurious pecking in commercial turkeys remains a significant challenge to producers and the industry. Infrared beak treatment is an effective method of controlling injurious pecking in chickens; however, the effects of infrared beak treatment on turkey performance are still largely unknown. Two experiments were conducted to determine the impact of infrared beak treatment on the beak length and performance of turkeys raised to 12 wk of age. Experiment 1 tested both toms (n = 236) and hens (n = 324), while Experiment 2 focused on hens (n = 608). Poults for each experiment were assigned to 1 of 2 beak treatments: infrared beak treated ( Beak treatment is one of the most effective management practices used in commercial poultry production to help control cannibalism and feather pecking. The practice is continually criticized from an animal welfare perspective as some beak treatment methods have been associated with acute pain , reducedOne method of beak treatment used in commercial turkey production is infrared beak treatment. The process involves placing day-of-hatch birds into a head-holding fixture and exposing their beak tips to a noncontact, high-intensity infrared light . The infWhen turkeys are beak treated using electric or hot-blade trimming, the effects on performance are variable. Research that has been conducted on infrared beak treatment thus far has been collected from egg-production pullets and hens, and there is an absence of scientific studies examining the effects of infrared beak treatment on turkeys. Therefore, the objective of this project was to determine the effect of infrared beak treatment on the beak length and production performance of turkey tom and hens raised to 12 wk of age. To the author's knowledge, this is the first study reported investigating infrared beak treatment in turkeys and its effect on performance.The protocols for these experiments were approved by the University of Saskatchewan Animal Research Ethics Board and all birds were cared for as specified in the Guide to the Care and Use of Experimental Animals by the Canadian Council of Animal Care . The impIR) or sham untreated control (C). Infrared beak treatment was applied immediately post-hatch using the Poultry Service Processor  at lamp power 35 with no mirror (which resulted in only the top beak being treated). Control poults were placed onto the same equipment as treated birds, but their beaks were not exposed to the infrared light. The poults were then transported to the research facility and randomly allocated to 16 pens (4 replicate pens per treatment). Poults were housed at a density of 32 kg/m2 based on their predicted 12-wk body weight, resulting in 27 toms or 38 hens per pen  were sexed at a commercial hatchery. All poults were then randomly allocated to one of 2 beak treatment groups: infrared beak treated . Water was provided ad libitum using a 38-cm bell drinker for the first 4 wk and 56 cm after. The temperature was set at 30°C for the initial brooding period (first week) then reduced by approximately 2°C per week to reach a final temperature of 13°C at 9 wk of age. Humidifiers were used for the first 2 wk to maintain a range of 50 to 75% RH. The light was provided using incandescent bulbs. For the first 5 d, the photoperiod was 23L:1D (40 lux). Starting at 6 d of age, the photoperiod was reduced by 1 h per day to reach a final photoperiod of 18L:6D (5 lux) at 10 d of age. This photoperiod was maintained for the remainder of the experiment. Light intensity was also reduced daily by 6 lux starting at 4 d of age.This experiment used only Nicholas Select turkey hens (n = 608). Beak treatments, husbandry, housing, and environmental conditions were identical to those used in Experiment 1. Poults were randomly allocated to 16 floor pens resulting in 8 replicate pens per treatment.During Experiment 1, the extent of sloughing was recorded from every bird in 2 replicates (76 hens and 54 toms per treatment) by visual examination from 3 d of age until sloughing was complete. Poults were individually examined, and their top beaks were identified as either 1) intact with no visible signs of sloughing, 2) partial sloughing where the epidermis had partially sloughed off, or 3) complete sloughing where the entire beak tip had sloughed off.Beak length was also determined during Experiment 1 for all birds in 2 replicates per treatment (76 hens and 54 toms) at 0, 1, 2, 4, 8, and 12 wk of age. For weeks 0, 1, 2, and 4, photographs of the beak were taken using the Nova-Tech beak scale (Nova-Tech Engineering LLC) and a Canon PowerShot SD1200IS Camera . Photographs were analyzed to calculate beak length (distance between the anterior end of the nares to the end of the upper beak) and overall growth using ImageJ analysis software . At 8 and 12 wk of age, beak photographs were taken using an Olympus OM-D E-M10 camera  and beak length was determined using a scale also present in the photo.Body weight and feed intake for both experiments were determined on a pen basis at 0, 1, 2, 3, 4, 8, and 12 wk of age. Mortality was recorded daily, and all dead or culled birds were sent to an independent diagnostic laboratory for necropsy. Turkeys from both experiments that showed minor signs of pecking (either aggressive or feather) had pine tar applied to the wounded area to discourage further pecking, while turkeys that underwent severe pecking were removed from the trial and placed in a recovery pen or euthanized at the discretion of the animal technicians. From these data, average body weight, average feed intake, feed efficiency (feed to gain ratio) with and without mortality correction, and percent mortality were calculated.P ≤ 0.05 and a trend was noted when 0.05 < P ≤ 0.10.Experiment 1 was designed as a 2 × 2 factorial arrangement of beak treatment and gender, in a completely randomized design, with 4 replicates per treatment. Experiment 2 was a one-way analysis of variance with 8 replicates per beak treatment in a completely randomized design. Due to an insufficient number of replicates for statistical analysis, beak length data is presented as observations only. Data were analyzed using PROC MIXED  with Tukey's range test to separate means. Percentage data were checked for normality using PROC UNIVARIATE  and log-transformed (data log + 1) when necessary. Differences were considered significant when During the first experiment, sloughing off the treated beak tissue was first seen at 4 d of age, with 0.80% of poults showing partial sloughing . CompletInfrared beak treatment reduced beak length from 2 to 12 wk of age in the first experiment . IR turkP = 0.07), and no differences after that. Interactions between beak treatment and gender in Experiment 1 were noted at 2 and 4 wk of age  and 4 to 8 wk (P = 0.09) compared to C hens. There were no differences in feed efficiency between IR and C turkeys during either experiment. Interactions between beak treatment and gender in Experiment 1 were noted from 0 to 1 and 3 to 4 wk of age . Infrared beak treatment also significantly reduced the percentage of live birds that needed to have a pecking deterrent applied due to injurious pecking and aggression in Experiment 1 . There were no differences in total mortality between toms and hens during Experiment 1; however, there was a tendency for a greater percentage of hens to require the application of a pecking deterrent compared to toms (P = 0.06).For both experiments, no differences in total mortality were found between IR and C turkeys over the 12-wk periods . HoweverBeak treatment is performed in many commercial poultry species in an effort to reduce the physical damage and mortality that can result from cannibalism and injurious pecking. By removing the sharp, hook-shaped beak tip, birds are less effective at grasping the feathers and tissues of other birds . The beaWhen there is a reduction in feed intake following beak treatment, there is often a corresponding reduction in body weight . ReductiLooking beyond the first 4 wk of life, previous studies conducted with laying hens and broiler breeders have suggested that infrared beak treatment does not affect final body weight . In the Larger experiments conducted with laying hens have observed significant reductions in mortality when hens are beak treated . AlthougIn conclusion, the results of this study suggest that although infrared beak treated turkeys had lower body weight and feed intake up to 4 wk post-treatment, infrared beak treatment did not have any long-term impacts on the productivity of turkey toms and hens. It is clear that the treated turkeys were able to adapt to the change in beak shape once sloughing was complete. Infrared beak treatment simultaneously improved welfare by reducing mortality due to pecking.