Hearing loss is the most common human sensory deficit, affecting normal communication. Recently, patients with hearing loss or at risk of hearing loss are increasingly turning to the online health community for health information and support. Information on health-related topics exchanged on the Internet is a useful resource to examine patients’ informational needs. The ability to understand the patients’ perspectives on hearing loss is critical for health professionals to develop a patient-centered intervention. In this paper, we apply Latent Dirichlet Allocation (LDA) on electronic patient-authored questions on social question-and-answer (Q&A) sites to identify patients’ perceptions, concerns, and needs on hearing loss. Our results reveal 21 topics, which are both representative and meaningful, and mostly correspond to sub-fields established in hearing science research. The latent topics are classified into five themes, which include “sudden hearing loss”, “tinnitus”, “noise-induced hearing loss”, “hearing aids”, “dizziness”, “curiosity about hearing loss”, “otitis media” and “complications of disease”. Our topic analysis of patients’ questions on the topic of hearing loss allows achieving a thorough understanding of patients’ perspectives, thereby leading to better development of the patient-centered intervention. Hearing loss is the most common human sensory deficit, affecting normal communication. Hearing loss is a multifactorial disorder caused by both genetic and environmental factors . AccordiDeveloping adequate healthcare and public health promotion interventions requires not only an in-depth knowledge of diseases and traits, but also a comprehensive understanding of patients’ perceptions, misconceptions, concerns, and needs about the diseases. Clinical and behavioral interventions are more effective when seeking to improve outcomes that are central to patients’ experiences and perspectives . A revieWith the advances in Internet and communication technologies, healthcare professionals and patients can easily communicate about patient-provided data. In addition, patients not only can easily generate and share their health data and concerns with others, but also look for relevant medical information from peers who have experienced a similar diagnosis, set of symptoms or treatments. Fox and Duggan  investigIt is not surprising that patients with hearing loss or hearing difficulties use social media channels and social Q&A, such as Yahoo! Answers in English, Baidu Knows in Chinese, and Naver Knowledge-IN in Korean, to exchange information to address their concerns about hearing problems. Prior research has demonstrated that a collection of questions that patients post on social Q&A provides not only interesting but also important information to health professionals ,10,11. TIn this paper, we investigate the electronic patient-authored questions on social Q&A sites by applying the natural language analytics. This study adopts a multi-component semantic and computational linguistics method to discover and analyze themes or topics from hearing loss-related health conversations in the social Q&A sphere. Computational linguistics analysis is suitable to process unstructured textual data and identify hidden patterns in the data. Notably, a probabilistic topic modeling is applied to answer our research questions—topic prevalence, topic correlation, and topic evolution: what are hearing loss-related topics being asked or communicated in the social Q&A sphere? What are the prevalent topics in the hearing loss health community? How are those topics interrelated?First, to the best of our knowledge, no prior studies have examined questions and conversations on social media Q&A as a viable source of understanding patients’ prevalent concerns on hearing loss. By applying LDA topic modeling for text analysis techniques on electronic patient-authored hearing loss questions, our present study extracts latent topics and their dominant words, which might provide useful insights for understanding patients’ perspectives and concerns on hearing loss. Second, our results reveal that patients post about the relationship between hearing loss and other diseases such as otitis media, tinnitus, and chronic kidney disease. These topic relations between categories have implications for the development of a patient-centered intervention. Lastly, our present research demonstrates evidence that topic model analysis techniques applied to electronic patient-authored questions are effective in studying patient-focused engagement strategy. The extant literature on hearing loss indicates that survey-based methods have been a primary study design to assess patients’ concerns and perceptions about hearing loss and related issues. Using this traditional engagement strategy is costly to capture and analyze a massive volume of patients’ concerns. Data analytics on patient-authored texts on social Q&A have the potential to improve patient-centered outcome research.Hearing loss is the most common sensory deficit. Among 432 million people with hearing loss, 93% of them are adults, and 54% of them are male—over 5% of the world’s population have hearing loss. Furthermore, it is estimated that the number of people with hearing loss will rise to over 900 million by 2050. Untreated hearing loss can negatively affect individuals’ communication performance and thus the quality of life in individuals and their families. Hearing loss can be reduced speech understanding, declined acoustic information, and impaired localization of sound sources . HearingHearing loss can be caused by damage to any portion of the peripheral and central auditory systems. The main causes of sensorineural hearing loss are degenerative processes associated with aging, genetic mutations, noise exposure, exposure to therapeutic drugs that have ototoxic side effects, and chronic conditions . The mosSeveral options are available for hearing loss, ranging from medical treatment to listening devices such as hearing aids and cochlear implants. Treatment depends on the cause and severity of hearing loss. For age-related and noise-induced hearing loss, hearing cannot be treated, but hearing can be restored after using hearing aids or cochlear implantation .Social Q&A is an online question-and-answer platform enabled by Internet and Web technologies. It is a community-driven platform that allows online users to exchange information by asking questions and providing answers ,29. It iAccording to the Pew Internet and American Life Project data, more than 70% of Internet users use the Internet to search for health or medical information ,31. As tA review of the literature on the electronic patient-authored text on the social Q&A community indicates that the existing research streams can be divided into content-centered  and user-centered  studies. The content-centered studies have mainly focused on three areas: (1) detection of diverse types of health-related questions and answers ,33,34; , and specify a level of severity when posting a tinnitus symptom. Tinnitus, commonly referred to as buzzing in the ears, is “often accompanied by hearing loss but not everyone with hearing loss experiences tinnitus” . HoweverTopic 15 shows the keywords involved in treatments of tinnitus. This included words such as “treatment”, “hospital”, “doctor”, “food”, “audiologist”, “pain”, and “doctor”. The topic results show that patients are in search of diverse tinnitus treatments, and specifically seek for good hospitals or doctors, and alternative treatments for tinnitus. We also found that, based on the selected keywords, effective food is a frequently occurring word, implying that tinnitus patients also search for foods to help reduce tinnitus.Topic 19 represents a cause of tinnitus with keywords specifically including “infection”, “drug”, “earwax”, “noise”, “stress”, and “medication”. The topic results show that people want to understand what causes tinnitus. Patients who are suffering from tinnitus want to know more about whether their recent illness, such as ear infection, ear wax, or stress, causes tinnitus. Additionally, patients with tinnitus post inquiries about the relationship between tinnitus and hearing loss, and particularly ask whether tinnitus can lead to hearing loss. Most importantly, the results show that many patients with hearing loss post questions whether exposure to loud noise causes tinnitus.Theme 3. Noise-Induced Hearing Loss.Topic 2 contains terms such as “loud”, “music”, “earphone”, “headset”, “cause”, “damage”, referred to as “noise-induced hearing loss”. These words imply that users want to ask about the relationship between listening to loud music through earphones or headsets with a personal listening device and hearing loss. In addition, people want to know how long listening to music is safe for not getting hearing loss per day.The authors can observe the terms “shooting”, “military”, “gun”, “explosion”, “compensation”, “degree”, and “diagnosis”, “hospital” in Topic 18. These terms imply that people who are exposed to excessive and continuous noise wonder and get the information whether and how they can get any compensation with their degree of hearing loss. Notably, South Korea has adopted a conscription system. Noise-induced hearing loss is a severe disease in the military because military personnel remain in a noisy environment for the completion of their missions. Thus, the prevalence of hearing loss and tinnitus in the military is higher than the general public .Theme 4. Hearing Aids.Topics 8, 11, and 16 were identified as hearing aids. Hearing aids are the most popular option of treating hearing loss for improving speech understanding. Topic 8 contains the words, “hearing aids”, “cochlear implant”, “handicap degree”, “disabled”, and “support”. In South Korea, the registered disabled person with hearing loss gets the subsidy of their hearing aid expense every five years. People with hearing loss or their family members want to know whether their hearing loss degree gets financial support.In Topic 11, the authors also observe the term “cochlear implant” and “surgery”. In a person with severe to profound hearing loss, hearing aids do not give many benefits. So, instead of hearing aids, cochlear implantation can help to improve speech understanding to people with severe to profound hearing loss. People want to ask about alternative interventions, such as cochlear implantation surgery, other than hearing aids.Topic 16 consists of the keywords: “hearing aids”, “recommend”, “brand”, “hospital”, and “price”. Those keywords indicate that patients post questions by asking for a specific recommendation for an excellent hearing aid with a reasonable price in social Q&A.Theme 5. Otitis media.Topics 4 and 10 include the terms related to hearing loss with symptoms of otitis media, such as “pain”, “sore throat”, “infection”, “deafen”, “headache” and “eardrum”. Otitis media is an infection of the middle ear, and it is one of the most common disease in children . The symTopic 10 also contains keywords related to the treatment of otitis media, “hospital”, “surgery”, “medication”, “test”, “after”. The results indicate that people asked about hearing loss after taking medication or undergoing surgery for otitis media. The term “hospital”, “after”, and “doctor” imply that, right after visiting doctors, users ask questions about otitis media treatment, such as drugs and surgery. Mild hearing loss can come with otitis media, and usually, hearing loss recovers after otitis media is cured. However, if otitis media occurs repeatedly, it causes permanent hearing loss .Theme 6. Dizziness.Topic 9 contains the words “dizzy”, “cause”, “headache”, “awake”, “morning”, “severe” and “sudden” referred to as “dizziness”. Topic 14 also contains the keywords “headache”, “stress”, and “dizziness” referred to as “dizziness”. One of the most common cause of dizziness is problems of the inner ear. The vestibular system, which is responsible for balance, is located within the inner ear with the auditory system. There are many diseases that affect dizziness and hearing loss, including severe cold, and bacterial or virus infections of the inner ear. In particular, Ménière’s disease is a disorder of the inner ear that leads to dizziness and sudden hearing loss. The affected ear may lead to progressive and/or permanent hearing loss . Other sTheme 7. Curiosity or general inquiry about hearing loss.Topics 5 and 20 contain a higher number of words relating to hearing loss itself. The authors could observe that users want to know about assessment results, such as the units (decibel) which are used for describing hearing loss. Additionally, the terms such as “stress”, “nerve”, “headache”, “worry” imply that users ask about their symptoms relating to hearing loss.The terms “treatment”, “hospital”, “communication” “learning” imply that people went to the hospital to have assessments of their hearing, but they did not fully understand their hearing loss and how to treat their hearing loss. In social Q&A, they want to get the information about their hearing loss.Theme 8: Complications of disease.Topic 7 and 12 represent the terms “chronic”, “anemia”, “cancer”, “thyroid”, “hepatitis”, “kidney” and “disease”. All the diseases in topic 12 are related to hearing loss. Hearing loss is a side effect of some chemotherapy drugs ,52,53,54Hearing loss subtopics indicated that users posted about the relationship between hearing loss and hearing loss-related disease. The themes of sudden deafness, noise-induced hearing loss, and otitis media, and related complications of diseases are covered by hearing loss-related disease. Sudden deafness and otitis media themes show that users searched for social Q&A about the cause of diseases, treatment options, and side effects of the medicine. These topics confirmed that people are not well-informed about their medications. Notably, sudden deafness is considered an otologic emergency. Patients with sudden deafness can recover from the hearing loss problem if they receive appropriate treatments promptly. Prior studies reported that treatment within seven days of the onset of sudden deafness is effective for better hearing recovery . The staIn the theme complications, we found several keywords are related to diseases, including diabetes, anemia, cancer, thyroid, hepatitis, and kidney disease. The medications for these diseases have side effects that can cause hearing loss. Based on our findings, health providers, such as physicians, did not give enough information about treatment and medicine. Lee et al.  indicateOn the other hand, noise-induced hearing loss is a slow-occurring hearing loss. In subtopics of noise-induced hearing loss, users post about the causes of hearing loss, such as loud noise exposure and the usage of listening devices with headphones. People wonder how much loud noise exposure causes hearing loss. Exposure to noise increases the risk of tinnitus, as well. Noise-induced hearing loss is the only preventable loss, so education on the usage of a safe listening device is necessary . For preNext, users posted the relationship between hearing loss and symptoms of hearing loss, tinnitus, and dizziness. The highest subtopics are related to tinnitus. Tinnitus is a symptom associated with ear disease, including hearing loss, but tinnitus does not cause hearing loss. More than 50 million people, with an estimated prevalence of 10–15% in adults, reported that they experienced tinnitus in the U.S. . The keyTinnitus is a symptom that people feel chronically, while dizziness is a symptom that people feel acutely. Our results reveal several keywords related to the symptoms of Ménière’s disease. Ménière’s disease is a disorder of the inner ear that leads to dizziness and sudden hearing loss. The affected ear may lead to progressive or permanent hearing loss . Other dLastly, people want to search for information about the treatment options of hearing loss, such as hearing aids and cochlear implants. Hearing aid usage is the most common treatment to reduce the adverse effects, including communication difficulties and cognitive decline, caused by hearing loss . In addiHearing loss is the most frequently occurring human sensory deficit and has many different causes. Hearing loss is also known to be related to many other health issues. Analyzing patient-authored questions can be a useful approach to better understand patients’ perceptions, concerns and needs. Traditional surveys are limited to small sample sizes. However, social Q&A offers a new environment for patients to easily share various opinions and medical experiences, so a large volume of patient-authored data can accumulate. Exploring how patients with hearing loss use social questions and answers to find health information not only helps to identify a set of critical topics and issues for various types of research but also improves communication between patients and healthcare professionals. To the best of our knowledge, this is the first analysis of patient-authored contents on the topic of hearing loss from the social Q&A community, and these results provide valuable methodological and content insights.This study provides a computational linguistic approach to perform an in-depth analysis using patient-authored data from sizeable online data sets. Our framework decodes public health views from hearing loss-related questions, which can be useful for developing adequate healthcare and public health promotion interventions. Our results reveal that those characterized topics ranging from sudden deafness to hearing aids are both representative and meaningful, and mostly correspond to sub-fields established in hearing science research.


Objective: Despite the successful implementation of newborn hearing screening (NHS), a debate is emerging as to what should be the best means of enabling timely diagnosis and intervention for preschoolers with educationally significant sensorineural or conductive hearing impairment (HI) missed at the time of NHS or occurred after birth. Our study aims to document the proportion and characteristics of HIs diagnosed in children in need of audiologic assessment, in order to outline the optimization areas of an operational framework for auditory surveillance during preschool age.Method: The referral routes and outcomes of 730 audiological assessments performed in 3 years within the framework of the early hearing identification program in Trieste  were retrospectively analyzed.Results: Among 570/595 completed evaluations, an HI was diagnosed in 114 children, 73.7% of which presenting an exclusively conductive HI due to middle ear effusion. HIs were found in 36/141 who failed NHS, and 60/385 preschoolers who were referred by the primary care pediatrician's surveillance activity during well-child visits, with diagnostic yield of 25.5 and 15.5%, respectively.Conclusion: Ongoing preschool surveillance in primary care setting integrated into a NHS program is feasible to conduct and may effectively identify HIs that missed NHS or were related with a risk factor. New triage instruments and protocols for immediate audiology referral could allow to obtain the diagnosis of educationally significant conductive and sensorineural HIs ahead of the development concern and in the same way reduce patient mobility, thus optimizing timing efficiency and economic impact of the program. Auditory deprivation that follows undetected hearing impairments (HI) is responsible of delays in language competence, academic achievements and social and emotional development . These cEarly intervention has demonstrated measurable benefit yet requires attaining a prompt access to the audiological evaluation in case of suspected HI. Even though newborn hearing screening (NHS) has proved to be an effective means to reducing the identification age of congenital HI, delays and loss to follow-up after failed NHS are common .Moreover, concerns have been expressed regarding HIs that are not identified by the NHS  and a deWith the aim of outlining the optimization areas of an operational framework for auditory surveillance during preschool age, we retrospectively analyzed the outcomes and diagnostic yield of the comprehensive audiological assessments performed at as part of the early hearing identification program in Trieste area, Italy. The program is characterized by an integration of screening levels  with the diagnostic audiologic level throughout preschool age.All children referred to the Pediatric Audiology Service (PAS) over three sample years  for a full audiological assessment were included in the study. The PAS, located at the “Burlo Garofolo” Institute in Trieste , is the referral center for three hospital-based NHSs and for the postnatal hearing surveillance run by roughly 60 FPs working in the territory. The annual live births in the population studied were 2,386 in 2013, 2276 in 2015, and 2276 in 2017. The regional program for the early identification of childhood HI, which includes the universal NHS and the hearing surveillance activity during preschool age, has been established since April 2012 (Neonates are screened by nurses with a two-stage procedure: the first transient otoacoustic emission (TEOAE) screening is followed by automated auditory brainstem response (A-ABR) for infants who fail TEOAE; both tests are performed in at-risk infants. The NHS coverage was 95.7% in 2013, 96.8% in 2015, and 97.2% in 2017 with a referral rate of 3.9, 2.8, and 2.0%.The FP, granted by the National Health System and deployed throughout the territory, is entrusted with the task of postnatal hearing surveillance performed at the regular health checks carried out at 1–3–6–9–12–18–36 months of age. Furthermore, the FP verifies the NHS completion, checks age-related auditory and language milestones, and monitors HI risk indicators.Comprehensive audiological evaluations are provided at the PAS by trained audiologists, possibly in a single session. Objective and subjective evaluations include otoscopy, diagnostic TEOAE, tympanometry, air- and bone-conduction click-ABR for threshold measurement, and age-appropriate behavioral audiometry, when feasible.NHS-fail); missed or uncompleted NHS process (NHS-miss); passed NHS testing, but referred for congenital or postnatal risk-factor presence, as defined by the Joint Committee on Infant Hearing (JCIH) (NHS-pass with JCIH risk); and passed NHS testing, but referred for other reasons, without presenting a risk factor as defined by JCIH (NHS-pass without JCIH risk).Reasons for PAS admission were defined as follows: NHS failed testing for one or both ears (g (JCIH)  (NHS-pasThe HI degree was defined in decibels (dB) hearing level (HL) as mild (>20– ≤ 40), moderate–severe (>41– ≤ 79), and profound (>80 HL) by averaging the hearing threshold at 500, 1,000, and 2,000 Hertz (Hz).Normal hearing ; 2. Conductive HI due to middle-ear effusion ; 3. Sensorineural-mixed HI ; and 4. Not completed. .Results of audiometric tests performed at the PAS appointment were cross-checked and summed up in four auditory statuses: 1. Within the analyzed years, the PAS registered 730 requests for audiological evaluation, involving 595 children (371 boys and 224 girls) with an average age of 31.3 months .In the case of multiple accesses of the same child, the hearing profile was defined only by the first completed PAS assessment, and the results of subsequent evaluations were excluded from the data analysis.P-values < 0.05 were considered significant. Data were analyzed using Excel (version 16.23) for IOS 10.14.6.The comparisons of proportion were made using 2020 MedCalc Software Ltd. P < 0.0001). Regarding the reasons for PAS admission, there is a decreasing trend in the proportion of children who failed or missed NHS, without however achieving statistical significance along the analyzed years. An HI was identified in 114 children, with mostly bilateral involvement (78.9%). In 73.7% of HI cases, the deficit resulted to be exclusively due to middle-ear effusion  of mild or moderate degree, with a large majority (79.7%) presenting only a mild threshold involvement. The sensorineural-mixed HI represented 26.3% of the identified HIs . In 10/30 children, the sensorineural-mixed HI was unilateral.The audiological assessments were brought to completion in 570/595 children referred to the PAS within the analyzed years. There was a significant reduction in the number of children who requested 2 or more evaluations from 2013 to 2017  increased from 2013 to 2017, in parallel with sensorineural HI decreasing proportion. NHS pass with risk) was the most frequent reason for PAS admission, attributed to 56.5% of children that were fully evaluated (322/570), with a yield of 48 (15%) cases with conductive and 4 (1.3%) with sensorineural/mixed HI. The single most reported risk factor was “caregiver concern regarding hearing, speech, language, or developmental delay” (169/595), which represented the referral reason of 39 hearing impaired children, 35 of which presented a conductive HI. Other reported risk factors included hospitalization in neonatal intensive care unit for more than 5 days and/or use of ototoxic medications (127/595); family history of permanent childhood HI (72/595); in utero infections, such as CMV (27/595); craniofacial anomalies (21/595); neurodegenerative disorders or syndromes associated with HI (18/595); postnatal infections associated with sensorineural hearing loss (11/595); head trauma (2/595); and chemotherapy (2/595).Overall, the presence of at least one JCIH risk factor  and 5/63 (7.9%), respectively.NHS fail referrals, 16/20 (80%) of sensorineural/mixed HIs resulted within the JCIH benchmark of 3 months of life for HI diagnosis. Differently, the mean age of sensorineural/mixed HI identification for NHS miss referrals (5 cases) was 15.8 months .The ages at which the sensorineural/mixed HI was identified were segregated by reason of access . Within Ongoing surveillance of infants and toddlers in primary care settings is feasible to conduct and can effectively overcome the barriers to follow-up in childhood hearing deficits described by other reports , 8. NHS There are some interesting remarks gathered from the present data that could become useful in the phases following the implementation of an integrated service. Firstly, the number of referrals and assessed children has halved over the years in our program, offering diverse interpretations. The variation cannot be explained solely by the drop in the birth rate, which decreased by not more than 6.8% from 2013 to 2017 in the area . A more NHS fail referrals were evaluated by the PAS within 3 months of age in our program. The percentage reaches 87.8% if we included 8 of the 25 late evaluated infants who had a history of prematurity that were nevertheless evaluated within 3 months of corrected age. Although overall PAS coverage for NHS fail cases does not reach the benchmarks indicated by JCIH  of 15/139 of by JCIH . RegardiA third comment regards the fact that positive audiological evaluations are overloaded by conductive HIs linked to middle-ear effusions (OME). An HI related to OME can be a major concern as it may impair speech and language input for young children at their most sensitive age for language acquisition . The oveThe reported numbers should alert pediatric health organizations not to overload the PASs with assessments that could be managed and resolved already in primary care, without interfering with the workload of second-level audiological services. It is the belief of the authors that an effective means to increasing the power of suspected-oriented level of audiological referral would be favored by providing pediatric primary care with effective self-help hearing screening objective equipment. An ongoing program during preschool age could in fact result in additional public health benefits: it would allow a reduction of family mobility in accessing to more expensive audiologic evaluations. Moreover, a self-help diagnosis would favor a more aware and appropriate prescription of antibiotic therapy in case of otitis media , possiblAs for the limits of this work, our data are descriptive and based on PAS outcomes without follow-up of children who did not present a risk indicator, i.e., not all children born and living in the area have been re-screened for hearing at a later age. The yield of the program may have been consequently overestimated.Regarding permanent  HI, Watkin and Baldwin conducted a cohort study over a 10-year period in Great Britain, after initiation of NHS . They reIn the near future, further research should be addressed to confirm the strength of an ongoing hearing prevention service during preschool age. Studies should be designed to include the use of an objective hearing screening tool to be implemented already at primary care level. In addition to defining the organizational and economic sustainability of the system, data analyses should also be set up with a view and aim of promoting the quality of primary care provided as well as economic and time saving for public health organizations.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the institutional review board (research project 17/17) and by the Italian Ministry of Health-CCM (project 12/2013). Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.EO and AF: conceived and designed the experiment. AF, GP, and RM: collected the data. LT, GP, and LM: analyzed the data. EO: wrote the paper. LT and EM: provided critical review of the paper. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


There is a growing body of evidence for the utility of eosinophil-derived neurotoxin (EDN) as a biomarker in asthma, including association with eosinophilic airway inflammation, assessment of disease severity and potential for predicting pathogenic risks, including exacerbations. However, to interpret any biomarker data with confidence, it is first important to understand the preanalytical factors and biological variation that may affect its reliable measurement and results interpretation. In this study we defined the healthy serum EDN reference range for men and women as 1.98 to 26.10 ng/mL, with no significant gender differences. Smoking did not impact the mean EDN levels and no circadian rhythm was identified for EDN, unlike blood eosinophils (EOS) where levels peaked at 00:00h. EDN expression in different cell types was investigated and shown to occur primarily in eosinophils, indicating they are likely to be the main cellular repository for EDN. We also confirm that the quantification of serum EDN is not influenced by the type of storage tube used, and it is stable at ambient temperature or when refrigerated for at least 7 days and for up to one year when frozen at -20°C or -80°C. In summary, EDN is a stable biomarker that may prove useful in precision medicine approaches by enabling the identification of a subpopulation of asthma patients with activated eosinophils and a more severe form of the disease. In 2015, the global number of asthma sufferers was estimated to be 352 million people, an increase of ten percent over a decade . This heEosinophilic inflammation is a common feature in many asthma patients, and is associated with a higher risk of a more severe disease , where eA number of studies have looked at the role of EDN and its use as a clinical biomarker for the diagnosis and monitoring of asthma. Serum EDN correlates with asthma disease severity  and withEDN is potentially an analytically attractive biomarker that can be reliably quantified, unlike other eosinophil granule proteins, which are inherently sticky due their strong polycationic properties , 18. QuaThe EDN serum reference interval was established using 120 healthy volunteer samples from Bioreclamation, USA. For the temporal, smoking and atopy studies we recruited additional subjects, males or females aged between 18–75 years, from Medicines Evaluation Unit, Manchester University NHS Foundation Trust (MFT), UK. Written informed consent was obtained from all participants  and the study was conducted in accordance with the UK Human Tissue Act (2004) and the 1964 Declaration of Helsinki.Healthy subjects had no history of hyper-eosinophilic disease  and any subject receiving oral corticosteroids or anti-eosinophilic therapies within the past 1 and 6 months, respectively, was excluded. Non-smokers had a pack year smoking history of <1 year and smokers had a history of ≥10 pack-years. Atopic subjects had a positive skin prick test, with a ≥3 mm wheal diameter to at least 1 of 3 common allergens .Asthma patients had a physician diagnosis of asthma, requiring treatment with: (i) short-acting β2 adrenergic agonist alone or low dose inhaled corticosteroid (ICS)  and a reliever medication or (ii) low dose ICS  plus long-acting β2 adrenergic agonist ± theophylline, montelukast OR medium dose ICS  and a reliever medication (mild and moderate asthma patients respectively), for at least 12 months prior to the study.g for 10 minutes, at 4°C and serum stored in aliquots at -20°C and -80°C.For serum preparation a venous whole blood sample was drawn into BD SST Vacutainers  then allowed to clot at room temperature (22°C) for 30–60 minutes. Clotted blood was removed by centrifugation at 1500EDN in whole blood and serum was measured with a commercial EDN ELISA  according to the supplier’s instructions. The microtitre plate, coated with capture anti-EDN monoclonal antibody, was washed 5 times with 250 μL of wash buffer in each well. After the final washing step, the residual buffer was removed by tapping the plate onto absorbent paper. Lyophilized calibration curve standards and controls were reconstituted in 500 μL ultrapure water. 100 μL of the calibration curve standards (0.25–16 ng/mL), controls (C1:[0.55 ng/mL] and C2:[2.63 ng/mL]) and samples  were added in duplicate to the plate wells. The plate was covered tightly and incubated for 1 hour at room temperature (18–26°C) on a plate shaker. The contents of each well were then discarded and the plate washed as before. Residual buffer was removed and 100 μL of the detection anti-EDN peroxidase conjugated rabbit polyclonal antibody was added to each well and incubated for 1 hour. 100 μL substrate (tetramethylbenzidine) was added into each well and the plate was incubated for 15 minutes, at room temperature, in the dark. 100 μL acidic stop solution was added and the plate was read on a SpectraMax reader  at 450 nm against 620 nm as a reference. The EDN concentration of unknown samples were calculated from interpolation of the standard curve via a 4-parameter logistic fit using Softmax Pro GxP v5.0 software .Blood eosinophils were quantified as part of a complete blood cell count performed on a Sysmex XN-10 automated haematology analyser at MFT clinical laboratory . Cell counts were measured and reported to two decimal places.Measurement of EDN recovery was conducted using five commercially available polypropylene tubes . 2 mL of 5 donor serum samples, covering the range 30–100 ng/mL EDN, were incubated in each tube type at room temperature for 2 hours.2-EDTA anti-coagulated venous blood from 3 healthy subjects was sourced from a commercial supplier . Whole blood samples were left at room temperature on a tube roller until an aliquot was removed for EDN measurement at 0, 4, 24, 48 and 72 hours using the EDN immunoassay. Short term stability of serum EDN was assessed using seven serum samples at ambient temperature measured 1, 2, 3, 4 and 7 days after harvesting. Long term serum stability was assessed at baseline, 2 and 3 months, and then every 3 months for up to 1 year, at -20°C and -80°C. Freeze/thaw stability of human EDN in serum was determined at -20°C and -80°C after 1, 2 and 3 consecutive freeze/thaw cycles.Human KQuantification of matched circadian eosinophil and EDN variation in healthy volunteers (n = 10) and asthma patients  was based on blood samples collected at time-points 16:00, 20:00, 00:00, 04:00, 08:00 and 12:00 hours.TM  as per the manufacturer’s instructions. In brief, the blood was layered onto an equal volume of LymphoprepTM and then centrifuged at 850g for 20 minutes at room temperature. The PBMC fraction was transferred to a new tube and washed once with buffer ) before isolation of monocytes. The granulocyte pellet was kept on ice and resuspended into 0.5 mL of cold PBS and 6.0 mL of water added to lyse the remaining RBCs. The lysis reaction was terminated after 15 seconds with stopping buffer .Donor blood  was diluted with an equal volume of 2% Dextran  in phosphate buffered saline pH7.4  and incubated until red blood cells (RBCs) had sedimented. Granulocytes and peripheral blood mononuclear cells (PBMCs) were isolated from the phase above the red blood cells by density gradient centrifugation using Lymphoprepg for 10 minutes at 4⁰C and then diluted to 20 million cells/mL in PBS. 10–15 million cells were stained with anti-human CD16 AlexaFluor® 647  and anti-human CDw125 PE  for one hour at 4⁰C. Cells were washed with PBS (as previously described), diluted to 15 million cells/mL in PBS and sorted on a SH800S Cell Sorter (SONY Biotechnology) with 100 μm microfluidic sorting chip. Eosinophil  and neutrophil fractions  were collected. The purity of sorted cell fractions was assessed with flow cytometry on a FACS Fortessa instrument  for 15 minutes at room temperature. Cells were again washed with 4 volumes of cold PBS  and tubes spun at 350Monocytes were enriched to high purity from PBMCs using magnetic cell sorting anti-CD14 coated beads as per manufacturer instructions . Purity was assessed with flow cytometry on a FACS Fortessa instrument (BD Bioscience). Isolated cells were spun down, lysed in buffer  and kept at -80⁰C until determination of EDN content with the ALPCO immunoassay. Purity was assessed with flow cytometry on a FACS Fortessa instrument (BD Bioscience). The data were analyzed using FlowJo software  were thawed and washed in CHRM medium  before being plated in INVITROGRO CP Medium (BioIVT). Cells were rested for 4 hours and then lysed in buffer . Lysates were kept at -80⁰C until analysis of EDN content with the ALPCO immunoassay.2. The next day cells were lysed in buffer  and kept at -80⁰C until analysis of EDN content with the ALPCO immunoassay.Alveolar macrophages were isolated from lung tissue obtained distal to tumour from patients undergoing lung resection, under informed consent and with ethical approval number 1026–15. Cells were flushed out from the tissue with PBS, collected by centrifugation and resuspended in Xvivo 10 medium . Then cells were plated and allowed to attach for 1 hour before being washed to remove erythrocytes and incubated overnight at 37°C and 5% COth and 97.5th percentile. Temporal changes in EDN and eosinophils were analysed using a mixed model for repeated measurements, with log of EDN and log of eosinophils as response variables, timepoint and cohort  as factors with interaction, and subject as a random effect to account for within-subject correlation.Statistical evaluations  were based on log transformed EDN measurements, or log transformed eosinophil counts, due to the log-normal characteristic of this type of data. Presented group means and confidence intervals are back-transformed to linear scale. The reference interval was determined according to the Clinical Laboratory Standards Institutes guidance . The ref80 healthy volunteers were enrolled into the smoker and atopic study. The non-smoker non-atopic subjects were 20–70 years (mean 46 years), 8 males and 12 females, 19 white and 1 mixed race; non-smoker atopic subjects were 21–62 years (mean 39 years), 9 males and 11 females, 17 white, 1 black and 2 mixed race; smoker non-atopic subjects were 41–70 years (mean 57 years), 6 males and 14 females, 19 white and 1 mixed race; smoker atopic subjects were 33–69 years (mean 52 years), 14 males and 6 females, 18 white, 1 black and 1 mixed race.Healthy volunteers enrolled in the circadian study were aged between 24–67 years, 9 males and 1 female, all subjects were white and atopy negative; asthmatic subjects (50% mild and 50% moderate asthma) were aged 25–64 years and consisted of 13 males and 7 females, 16 white, 2 black and 2 mixed race, and 18 atopy positive. All asthma subjects had no exacerbations for the 12 months prior to or during the study. The mean Asthma Control Questionnaire (ACQ6) score was 0.62.P<0.001). Conversely, ambient temperature serum EDN levels showed no significant changes from a mean value of 26.5 ng/mL (SD ± 11.0) at baseline to 26.0 ng/mL (SD ± 10.1) at day 7 . A strong Pearson correlation coefficient (r) was observed between eosinophil and EDN levels  in healthy subjects who were not smokers, whether without or with atopy; r = 0.85, 95% CI: 0.65,0.94 (P<0.0001) and 0.82, 95% CI: 0.60,0.93 (P<0.0001), respectively. Conversely, there was a weak to moderate correlation seen with smokers without or with atopy, r = 0.46, 95% CI: 0.03,0.75 (P = 0.03) and 0.35, 95% CI: 0.11,0.68 (P = 0.13), respectively . Healthy subjects also displayed a time of day difference in EOS but with a smaller relative ratio at 00:00h of 1.35, 95% CI: 1.05,1.73 (P = 0.018). There was no clearly discernible EDN circadian rhythm in either asthma or healthy subjects, except for an increased mean in the asthma cohort at 04:00h relative to 12:00h in healthy subjects (P = 0.027).To assess possible time of day differences in blood eosinophils and serum EDN levels we sampled blood from subjects every four hours over a 24 hour period. For mild/moderate asthma patients, blood eosinophil levels showed a circadian rhythm, with a significant increase during the night and early morning . The flusubjects  of 1.22,in-silico using transcriptomic datasets . Based on these data and published information we chose cell types, in addition to eosinophils, that could be a possible EDN source contributing to serum levels. EDN protein measured in isolated cells as means ± SD are: eosinophils 2437.1 ± 407.9 ng/106 cells; neutrophils 13.4 ± 2.1 ng/106 cells; monocytes 3.8 ± 4.7 ng/106 cells; hepatocytes 0.3 ± 0.2 ng/106 cells; alveolar macrophages 8.3. ± 2.3 ng/106 cells , while a strong correlation with eosinophil counts in non-smokers was demonstrated. Furthermore, the diurnal variation observed for blood eosinophil counts in asthma patients was less marked for serum EDN measurements.As part of our body of evidence, we first considered the possibility of non-specific binding of EDN to different polypropylene storage tubes, a well-known phenomenon for protein and peptide biomarkers and one that can distort data comparison . We obseNext, we considered the stability of EDN in whole blood and serum. In short-term stability studies, serum samples were stable at ambient temperature and when refrigerated for at least seven days. This was the maximum timepoint we measured as this seemed a practicable duration for conducting laboratory experiments. However, it is likely that short term stability extends beyond this period. At ambient temperature, whole blood EDN levels were stable for up to 24 hours, after which the levels increased approximately fivefold. This increase may be caused by granulocyte degranulation or cytolysis and concomitant release of intracellular EDN. The whole blood stability profile is likely to be important when considering the time to transport and process venous blood into serum or plasma during clinical investigations, although cooling the sample may aid further control of sample degradation. For long-term storage, we found serum EDN was stable for at least a year when frozen and also through repeated freeze/thaw cycles. Further serum stability timepoints are ongoing to up to 2 years. These stability data should always be taken into account when analysing historical samples and special care needs to be taken to ensure they are measured within the known sample stability time frame.To better understand where elevated and potentially pathophysiological levels of EDN may start we determined the reference interval for serum EDN in healthy individuals. Using the ALPCO immunoassay there were no significant gender differences in EDN levels measured, for men it was 2.10 to 26.10 ng/mL and 1.98 to 25.71 ng/mL for women. As far as we can ascertain this is the first published healthy reference gender data for EDN. However, we also recommend that each laboratory should establish their own matrix specific reference interval, especially when using alternative immunoassays, due to assay commutability , 12. A fWe identified a circadian rhythm in eosinophil levels in subjects with asthma, with a minimum at midday and a maximum at midnight. These observations are broadly in line with those of Durrington et al.  who obseIn-silico transcript profiling identified neutrophils, monocytes, hepatocytes and macrophages as potential sources of EDN. The EDN levels we measured from purified blood eosinophils were consistent with those previously reported [Lastly, we considered the role that different cellular expression patterns could have on the utility of EDN as a biomarker of activated eosinophils. reported . EosinopIn conclusion, our results suggest that EDN is an analytically attractive biomarker that can be reliably quantified and is robust enough to store long term. Additionally, the biomarker does not suffer from significant temporal biological changes that could affect the determination of possible thresholds for the diagnosis of eosinophilic driven diseases, estimation of disease severity or the determination of drug responses. Further studies using EDN as a biomarker in eosinophil associated diseases including asthma are warranted.S1 Fig+/CD16- eosinophils, 99.5% pure; CDw125-/CD16+ neutrophils, 99.8% pure; CD14+ monocytes, 97.0% pure.Samples of sorted eosinophils, neutrophils monocytes were stained with antibodies for cell surface markers and analysed by flow cytometry on a Fortessa FACS instrument. Single cells in the cell gate of the FSC-H vs SSC-H plot were gated for specific markers: CDw125(TIF)Click here for additional data file.S2 Figr = 0.85, P<0.0001 B) non-smoker atopic: r = 0.82, P<0.0001 C) smoker non-atopic: r = 0.46, P = 0.03 D) smoker atopic: r = 0.35, P = 0.13. Correlations are based on log-transformed data.A) non-smoker non-atopic: (TIF)Click here for additional data file.


Supplemental Digital Content is available in the text Colorectal cancer has become a major chronic and difficult disease endangering human health. After thousands of years of precipitation, traditional Chinese medicine in China is now also being applied in clinical treatment, with its unique advantages in the treatment of cancer. However, the efficacy of traditional Chinese medicine in the treatment of advanced colorectal cancer still cannot reach consensus in the world. Therefore, the aim of this study was to provide a scheme to evaluate the efficacy and safety of traditional Chinese medicine decoction in the treatment of advanced colorectal cancer, thus providing clinical decision-making.The systematic review and meta-analysis will be conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. The following 8databases will be searched: China National Knowledge Infrastructure (CNKI), China Biology Medicine (CBM), Wan Fang Data, the Chinese Science and Technology Periodical Database (VIP), PubMed, Cochrane Library, Embase, and Web of Science. Relevant data will be performed by Revman 5.3 software provided (Cochrane Collaboration) and Stata 14.0 statistical software.The results of this systematic review and meta-analysis will be published in a peer-reviewed journal.INPLASY202080102. For such patients, prolonging survival time and alleviating pain are the treatment goals. Chemotherapy plays an important role in the treatment of advanced colorectal cancer. The commonly used chemotherapy regimens include m FOLFOX6, FOLFIRI, Cape OX and capecitabine.–10Although the mortality of colorectal cancer is decreasing, it is still a digestive tract malignant tumor which seriously threatens human health.,12 which is consistent with prolonging the survival period and alleviating the pain of patients. Through long-term treatment, traditional Chinese medicine can achieve the effect of overall regulation. At present, studies have shown the anticancer mechanism of the commonly used Chinese herbal decoction for colorectal cancer.,14 Jianpi Xiaoai recipe can up regulate E-cadherin and down regulate vimentin table by mediating TGF–β. Jianpi Jiedu recipe inhibits the expression of snail / E-cadherin in colorectal cancer induced by transforming growth factor (TGF -) and EMT-β/ Smad.Traditional Chinese medicine, as a treasure of China, believes that the treatment of advanced colorectal cancer should be strengthening the body and attacking pathogenic factors,Although some researchers seem to have achieved a certain effect in the treatment of advanced colorectal cancer with traditional Chinese medicine decoction combined with chemotherapy, the research design is not strictly in accordance with the randomized controlled trials, the evaluation standards of curative effect are inconsistent, and the research conclusions obtained are not repeatable and reliable. In order to evaluate the efficacy of traditional Chinese medicine decoction in the treatment of advanced colorectal cancer more objectively, the meta-analysis of evidence-based medicine by systematically reviewing the existing literature is helpful to improve the reliability of traditional Chinese medicine decoction in the treatment of advanced colorectal cancer.22.1https://www.doi.org). This protocol of meta-analysis will be reported in accordance with the preferred reporting items of the system review and meta analysis (PRISMA) statement guidelines.,18The protocol has been registered on the INPLASY register. The registration number is INPLASY202080102 , China Biology Medicine (CBM), Wan Fang Data, the Chinese Science and Technology Periodical Database (VIP), PubMed, Cochrane Library, Embase, and Web of Science.2.32.3.1We will include all randomized controlled trials of decoction combined with chemotherapy in the treatment of advanced colorectal cancer without language and blind restrictions.2.3.2All included cases (over 18 years old) must be confirmed as advanced colorectal cancer by pathology or cytology. There will be no restriction on gender, race, or nation. Patients with non primary colorectal cancer or other tumors were excluded.2.3.3The RCTs that used traditional Chinese medicine decoction combined with chemotherapy will be included. There will be no restrictions on the types of traditional Chinese medicine decoction and chemotherapy.2.3.4In the same original study, the chemotherapy regimen in the control group of colorectal cancer patients is the same as that in the experimental group of colorectal cancer patients. The dosage and course of treatment are not limited.2.4The primary outcome will be an important basis for judging the curative effect after treatment. It will include:1.DCR;2.OS and FPS.The secondary outcomes will include:1.The quality of life (which is assessed according to the Kamofsky score);2.Immune function assessment ;3.Evaluation of adverse drug reactions was evaluated according to NCI CTCAE version 4.0 .2.5Any one of the following articles can be excluded:1.The subjects had other primary tumors2.Observational studies, animal experiments, case reports, reviews and other non randomized controlled trials or self-control study or random method error research investigate3.Traditional Chinese medicine decoction combined with other treatments except chemotherapy4.For the repetitive articles, only those with the latest publication year, large sample size and comprehensive information are retained5.The full text cannot be obtained6.Study on non oral administration of traditional Chinese medicine decoction.2.6https://kdocs.cn/l/soruAsZWisne).The 2 authors will search the following databases : PubMed, the Cochrane Library, Embase, Web of Science, China Biology Medicine (CBM), China National Knowledge infrastructure (CNKI), Wan Fang Data, the Chinese Science, and Technology Periodical Database (VIP). The group of search words was a combination of Colorectal Neoplasm  and traditional Chinese medicine. Take PubMed as an example to list the retrieval strategy, which will be attached as Annex 1  will be used for dichotomy results with 95% confidence intervals, and mean difference (MD) or normalized mean difference (SMD) will be used for continuous variables with 95% confidence intervals.2.10.1If the corresponding data cannot be obtained in the end, this kind of research will be eliminated. If the data cannot be obtained in the end, such research will be excluded.2.11I2 will be used to evaluate the heterogeneity. If there is no heterogeneity , fixed effect model will be used in meta-analysis. Otherwise, we will choose sensitivity analysis, subgroup analysis or meta regression to explore the causes of heterogeneity. If the cause cannot be found and the degree of heterogeneity is acceptable, the random effect will be selected.The choice of random effect model or fixed effect model depends on the heterogeneity of the original research. In this study, the Cochrane Q test will be used to analyze the heterogeneity between studies, and 2.11.1Sensitivity analysis is to explore the impact of individual studies on aggregate results, which will be judged by the method of excluding studies one by one, so as to check the robustness of the comprehensive results.2.11.2In order to further study the heterogeneity, subgroup analysis and meta-analysis may be used to investigate the heterogeneity from age, gender, chemotherapy regimen, Chinese herbal decoction, sample sizes,2.12Funnel plot, Begg tests, Egger test will be used to investigate whether there is publication bias in this study. If the funnel plot is asymmetric, we will continue to process the asymmetric funnel plot through the shear compensation method, so as to ensure the symmetry of the funnel plot and eliminate publication bias.2.13,20Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system will be used to evaluate the quality of evidence for the outcomes, Comprehensive results caused by 5 factors  affect the quality of evidence, which is divided into 4 levels: high level, medium level, low level, very low level.2.14No ethical approval is required, as SR will be based on published research. According to the PRISMA guidelines, SR's results will be published in a peer-reviewed scientific journal.3As a disease endangering human health and life, colorectal cancer should be paid more attention. As a treasure of China, traditional Chinese medicine is also widely used in the treatment of tumors. However, there is still a lack of effective evidence that traditional Chinese medicine decoction is effective and safe in the treatment of colorectal cancer. Therefore, our study will evaluate the safety and effectiveness of TCM Decoction in the treatment of colorectal cancer through meta-analysis and Sr, so as to provide more reliable basis for clinical treatment of colorectal cancer.We would like to thank the members who have devoted themselves to this research.Conceptualization: Yan Yang.Methodology: Xue-li Jia, Yu-xiang Sun.Supervision: Si-miao Gong, Min Li.Writing – original draft: Shu-fan Liao.


The article describes a multi-sensory dataset related to the Activities of Daily Living (ADL). These are the activities that contribute to an assessment of the overall status of elderly or people with special needs, possibly suffering from mild cognitive impairments. Typical basic ADLs include walking, such postural transitions as getting up or sitting down, as well as behaviours related to feeding, such as drinking or eating with knife and fork, or personal hygiene, e.g., teeth brushing. The collection process adopted for building this dataset considers nine ADL-related activities, which have been performed in different locations and involving the usage of both left and right arms. The dataset acquisition involved 10 volunteers performing 186 ADL instances, for a grand total of over 1860 examples. The dataset contains data from six 9-axis Inertial Measurement Units (IMUs), worn by each volunteer . The dataset features an accurate data labelling done via manual annotation performed thanks to videos recorded by an RGB camera. The videos recorded during the experiments have been used only for labelling purposes, and they are not published. Specifications Table•The multi-sensory dataset allows for grounding ADL-related studies, including the development of data-driven techniques for the recognition of ADL in assistive scenarios.The multi-sensory dataset can be used by researchers in machine learning as a benchmark for ADL recognition, and by physicians to use motion models of heathy subjects as a benchmark for motion analysis.The high number of considered ADL classes, the number of subjects, considering ADL execution with both arms and the different order followed by the subjects to execute the various actions guarantee a high variety of the dataset.1Walk activity that has been performed 40 times, in different sequences and alternating the hand wearing the IMUs. The dataset published on MendeleyData•“BothArms” is used when all instances of each activity are labelled independently of which arm has been employed;•Walk, Sit Down or the Stand Up activities;“RightArm” is used for those activity instances using only the right arm, or in case they belong to the •Walk, Sit Down or the Stand Up activities;“LeftArm” is used for those activity instances using only the left arm, or in case they belong to the •Walk, Sit Down and Stand Up.“Locomotion” is a scope labelling only the instances of In this article, we present a multi-sensory dataset concerning the execution of actions related to the Activities of Daily Living (ADL) Finally, the last two columns report a session identification (ID). There are four different sessions characterised by the order in which the activities are performed, the used arm see also , and whe22.1In our experiment 6 IMUs . All the subjects participated voluntarily and gave their written, informed consent.The authors declare that they have no known competing financial interests or personal relationships which have, or could be perceived to have, influenced the work reported in this article.


The relationship between autoimmune disease and sensorineural loss is well documented in literature. Immune mediated sudden hearing loss is asymmetric, bilateral and rapidly progressive but responds well to steroid therapy. However association of cranial nerve neuropathies with sudden hearing loss is rare.A 41 year old female presented with sudden mixed hearing loss and developed multiple cranial nerve palsies within a month. Blood and Cerebrospinal fluid analysis revealed an undiagnosed rheumatoid arthritis. She responded well to definitive therapy with cyclophosphamide and azathioprine. If sudden hearing loss is associated with cranial neuropathy, an autoimmune work-up is highly recommended. The relationship between autoimmune diseases and hearing loss has been well documented. Immune-mediated sensorineural hearing losses (SNHL) occur in women in their thirties and forties; they are usually bilateral, asymmetric and rapidly progressive . The temAutoimmune disorders causing both sudden SNHL and multiple cranial nerve palsies are extremely rare. Here we report one such case, and highlight the challenges we faced in the diagnosis and management of the patient who presented with this unusual combination of symptoms.A 41 years old South Asian female of Indian descent, a homemaker by occupation, presented to the Otorhinolaryngology outpatient department with bilateral hearing loss for one month. The hearing loss was sudden and occurred within two days. The hearing loss was preceded by an episode of upper respiratory tract infection. There was no history of diabetes mellitus, hypertension or tuberculosis. She was taking hormone supplementation for hypothyroidism. There was no relevant family history. On examination of the ear, the tympanic membrane was retracted bilaterally. An audiogram revealed moderate to profound sloping mixed hearing loss on the right and moderate to severe sloping mixed hearing loss on the left with bilateral “B” type tympanogram Her routine blood investigations were unremarkable except for an erythrocyte sedimentation rate of 42 mm. Ultra-sonogram of the neck showed bulky thyroid gland with nodules in the right lobe. She was treated with systemic steroids (Prednisolone 1mg/kg body weight) for 10 days, which was tapered over 16 days. At the time of discharge, her hearing had dramatically improved .Two weeks later, she again presented with decreased hearing in both ears. An audiogram revealed mild to moderately severe mixed hearing loss with bilateral “C” type of tympanogram. On myringotomy, thin serous fluid was present in both middle ears and grommets were inserted bilaterally. Diagnostic nasal endoscopy and blind biopsy of the fossa of Rosenmuller on both sides was also done. Histopathology was reported as normal with no evidence of malignancy. After 10 days she presented with facial weakness on the right side and difficulties in speech and swallowing in addition to hearing loss, tinnitus and vertigo. Vertigo was mild, rotatory and brought about by sudden changes in posture. It was not associated with vomiting or sweating. Tinnitus was bilateral, continuous and resembled a whistling tone. Audiology revealed moderate to severe mixed hearing loss on the right and mild SNHL on the left. The impedance on the right side was the ‘Cs’ curve and the ‘A’ curve on the left. She was restarted on steroids (Tab. Prednisolone 1mg/kg body weight). On examination, she had right-sided seventh and left-sided tenth and twelfth cranial nerve palsies. The neurologist opined that there was no peripheral neuropathy. On Functional endoscopic assessment of swallowing there was the presence of pooling of secretions in bilateral pyriform fossae with aspiration. th and 8th nerve complex on the right side. The CSF analysis was normal with no evidence of malignant cells or paraneoplastic neuronal antibodies.P-Anti-neutrophil cytoplasmic antibody (ANCA) and rheumatoid factor (RF)  were reported positive on analysis of blood. Anti-myeloperoxidase (MPO) autoantibodies were reported as highly positive with a value of 10 IU/ml . Anti PR3 autoantibodies were negative. Anti-cyclic citrullinated peptide (anti-CCP) was 50.7 RU/ml . Hence a diagnosis of RA induced mononeuritis multiplex was established. She was given an option of further treatment with cyclophosphamide or rituximab. Due to financial reasons, she opted for treatment with Cyclophosphamide (IV Cyclophosphamide 1g every 3 weeks for 10 doses). The patient tolerated the treatment well and at her last follow up she showed complete recovery from cranial nerve palsies and hearing loss. On the advice of the Neurologist, autoimmune and paraneoplastic workup was ordered, in addition to radiology and Cerebrospinal fluid (CSF) analysis. Magnetic resonance imaging (MRI) of the brain with contrast showed hyperintensity in bilateral mastoid air cells and middle ear, suggestive of otomastoiditis. There was thickening with diffuse homogenous post-contrast enhancement in posterior and bilateral lateral walls of the nasopharynx. Enhancement was also noted in the 7Hughes et al classified inner ear disease associated with autoimmunity into primary and secondary autoimmune inner ear disease (AIED); in the former, the immune response is limited to the ear and in the latter, it is associated with systemic pathologies . Associath and 8th nerve complex on the right side, we assume that it is autoimmune vasculitis that caused cranial nerve palsies in our patient. Cranial nerve palsies are rare in RA; peripheral nerve involvement due to entrapment neuropathies, rheumatoid nodules, swollen synonovium, bony exostosis and inflammatory pannus is common in RA. Rapidly progressive vasculitic neuropathy like the one seen in our patient was the 7th, 8th, 10th and 12th nerves were affected in a short period have not been reported before. In this patient, there were no systemic features of an autoimmune disease. On the autoimmune panel, she had a positive anti-cyclic citrullinated peptide (anti-CCP) value with an elevated RF which pointed towards the autoimmune disease, RA. Anti-Myeloperoxidase (MPO) was mildly elevated which ruled out an antineutrophil cytoplasmic antibody-associated (ANCA) vasculitis. Hence, by investigation and clinical presentation, the final diagnosis of mononeuritis multiplex secondary to vasculitis due to RA was made.The conductive component in association with sensorineural loss has been demonstrated in a few autoimmune diseases. Polyangiitis causes granulations and effusions, while relapsing polychondritis causes Eustachian tube dysfunction . RA can The patient had all features of sudden sensory neural loss, though with a conductive component. With the appearance of multiple cranial nerve palsies in the patient, meningitis with CSF analysis and MRI was ruled out. Workup for systemic pathologies, which led to the diagnosis of RA. Autoimmune disease manifesting as a sudden sensorineural loss with multiple cranial nerve palsies is highly unusual.


The practice of beak trimming in laying hens limits the negative consequences of injurious pecking, but could be prohibited by future regulations. We addressed in this study the question of how to prevent or minimize injurious pecking and its consequences, especially when beak trimming is not carried out. We found that a combination of different management strategies applied from rearing to laying stages improved to some extent the welfare of non-beak trimmed birds . Fiber supplementation in the feed did not provide any benefit on pecking-related problems. We suggest practical solutions to limit the consequences of injurious pecking where non-beak-trimmed animals are reared in barn system and transferred to furnished cages, while preserving good welfare, health and productivity.Beak trimming in laying hens limits the negative consequences of injurious pecking, but could be prohibited by future regulations. This study assessed a combination of management strategies during the rearing period  and laying period  to raise non-beak-trimmed animals. The welfare and laying performances of beak-trimmed (T) and non-beak-trimmed (NT) ISA Brown birds were compared between groups with (E) or without (NE) these strategies, with or without fiber supplementation in the diet during laying period. Fiber supplementation did not provide any benefit on pecking-related problems. In comparison with NT-NE birds, NT-E birds had lower mortality, were less fearful of a novel object, and had a better feather cover, without a negative impact on productivity . Although this study showed advantages of beak trimming , it highlighted related problems . This study proposes practical solutions to limit the consequences of injurious pecking in non-beak-trimmed animals. Worldwide, the seven billion laying hens raised every year are mainly housed in cages . In EuroCurrently, the most effective and reliable method of reducing the damage caused by IP is beak trimming, consisting in most cases of infra-red radiation applied in day-old chicks at commercial hatcheries. The use of this method has become widespread, in a prophylactic manner on all flocks. The procedure appears to be efficient, because IP problems are more common and feather condition is worse in birds with intact beaks, in comparison to beak-trimmed birds . HoweverIn egg production, day-old chicks are transferred from the hatchery to a rearing farm, and then transferred around 18 weeks of age (WOA) to a variety of layer housing systems. It is recommended that laying hens be reared according to their later housing conditions for optimal welfare and productivity of layers . GeneralSeveral reviews ,12,21 haAlthough the literature on the causes of IP and potential solutions is abundant, it is sometimes difficult to apply the findings to the current French situation. Most research on non-beak-trimmed hens focusses on free-range or other cage free birds. In cage housing systems, introducing enrichment and renew it is challenging because of financial costs and time demands, even though it may be more important given the relatively barren environment of a cage . TherefoThe goal of this study was to measure the effect of a combination of several management strategies from rearing to laying stages that have proven to be individually efficient to control IP. The different management strategies were chosen taking into account the potential benefit for the animals, feasibility and cost for farm implementation. The objective was first to decrease reactivity , and to decrease animal fear of humans . A second objective was to promote more natural behaviors with an extra environmental enrichment. Concurrently, the enrichment should be feasible, robust and inexpensive for commercial application. Thus, during rearing period, objects were renewed in contrast to the laying period, where objects were deliberately left until the end of the experiment, without being renewed to mimic commercial conditions. A last objective was to increase the time spent eating, by fiber supplementation in the diet during laying period. The hypothesis was that the combination of the different management strategies altogether leads to a decrease of IP and resulting problems related to body status, fear and laying performance. As IP is found in non-beak-trimmed but also in beak-trimmed flocks, comparisons of effectiveness of such management strategies on these two situations were carried out.n = 4656) were obtained (May 2016) from a commercial supplier: half of them had infra-red beak treatment. Both beak-trimmed (T) and non-beak-trimmed (NT) chicks were randomly allocated to two separate rooms at the experimental facilities of ANSES Ploufragan (France), and reared in groups of 388 in floor pens (surface 30 m2) until 17 WOA. In each room, there were six identical pens: three housing T pullets, and three housing NT pullets. In both rooms, pullets had ad libitum access to the same commercial rearing feed and water, and wood shavings as litter. They were all reared following standard commercial specifications for temperature, lighting (20 lx), and vaccinations.ISA Brown day-old chicks (The birds in the two separate rooms were subjected to different rearing treatments. In one room—the “enriched” room (E)—a combination of seven management strategies was provided, and these strategies were absent in the other room—the “unenriched” room (NE). These management strategies are grouped in the following paper as “enrichment” even if they did not include exclusively environmental enrichments. They consisted of:(1) a total of 8 cm/animal of wooden perches: one perch rack in the middle of the pen , another at the rear of the pen, close to the back wall , and 4 additional low perch bars (H × W: 0.2 m × 2 m). They were provided continuously.(2) the continuous presence of plywood boards (l × L = 1 m × 0.35 m) placed under the two perch racks and maintained vertically as a barrier, allowing animals to retreat.2) or suspended items  or items suspended using nets .(3) five objects that were renewed every 15 days, from 2 until 17 WOA, with different object combinations . The same combination of 5 different objects per pen were present at the same time in each pen. These objects were placed on the ground: PVC pipes , jerricans , a sand box (1 m(4) sound enrichment: music playing during lighting hours (radio mixing music and voices) around 30 dB.(5) an alert system for anyone entering the enriched room: knocking on the door.(6) lights switched on and off gradually (20 min duration).(7) additional human passages, several times a week: a human entered the pen, crossed the pen while making regular stops, at the same speed and for the same duration in each pen and came out of the pen.n = 4200) were transferred in groups of 60 hens for the laying period up to 73 WOA to furnished cages, according to rearing and beak treatments: E pullets were transferred to E cages, and conversely. The 70 cages were all arranged in a single room at the experimental facilities , and distributed into three battery blocks with each three tiers (and aisles in-between). Treatments were allocated equally to each battery and tier.At 17 WOA, birds (2/hen) contained a nest  and perches (15 cm/hen). In E cages, a combination of two enrichment strategies was provided, these were absent in the NE cages:Each E and NE cage (750 cm2/hen),(1) an artificial turf mat for pecking and scratching in an area of the cage free of perches (67 cm(2) ten different objects hooked onto the cage facade: small mobile and colored objects (5 to 10 cm) hung by a metallic cable, plastic transparent pots (H × W: 10 × 5 cm) filled with colored rings for poultry and plastic chain links (5 cm).For the experimental purpose, the housing conditions for NE birds did not fulfil European minimum standards regarding the pecking and scratching area, as no mat was provided in the area free of perches in NE cages.ad libitum access to water and feed automatically delivered 3 times per day: at 7 am, 3 pm and 8 pm. Two types of diet were provided. As automatic distribution of feed can only be implemented per full battery, one battery (23 cages) received a standard commercial diet , while the others two batteries (47 cages) received a diet with 5.16% cellulose .All hens had For all cages, the lights (bulbs on 2 levels) were arranged facing the scratching area, opposite the nests (luminosity measured facing the nests: 3 lx and facing the scratching area: 19 lx). Lights were switched on and off gradually (20 min duration) from 6 am to 10 pm from 21 WOA.During the rearing and laying periods, mortalities were recorded daily. For ethical reasons, birds that were severely cannibalized were culled and recorded as dead.During the rearing period, at days 1, 3, 6, 11, 21, 28, 35, 49, 63, 105 and 119 of age: 50 pullets per pen were weighed in all pens . Pullets were randomly selected in each pen; and for each weighing individuals could be different or identical each time. At 16 WOA, feather cover, beak status and skin damage were assessed on 16 pullets randomly selected in each pen .During the laying period, at 31, 35, 41 and 61 WOA: feather cover was assessed for all cages on 8 hens randomly selected per cage, and observed in situ from the corridor (without handling) by a single observer. Individuals could be different or identical each time. At 71 WOA: 8 hens randomly selected in each cage were removed from their cages and evaluated ex situ for feather cover, beak status, skin damage and body weight. Numbers of assessed hens were equally distributed between beak and enrichment modalities (140 hens in each B × E treatments). This represented 326 F hens and 234 C hens.Feather cover was scored on three areas  using a three-point scale: 0%–20% of the surface area affected by plumage damage (score 0); 20%–50% of the surface area affected by plumage damage and visibly defeathered parts (score 1); 50%–100% of the surface area affected by plumage damage and visibly defeathered parts (score 2). The scores for the three body areas were added together for each hen, with a total score between 0 and six points (6 representing the worst feather degradation).Beak morphologies were assessed visually to classify them as having a defect: shovel beaks (bottom beak longer than top), split (beaks with a visible crack on the top and/or bottom beak), crossed (bottom on top beaks in two different directions) or not .Skin damage was recorded as no skin lesion over 1 cm long on the whole body area (score 0), or at least one skin lesion over 1 cm long on the whole body area (score 1).2 tests showed no difference between the scores they gave: p = 0.23 for feather cover score, beak status and skin damage at 16 WOA, and p = 0.47, 0.61 and 0.25 for feather cover score, beak status and skin damage at 71 WOA.Feather cover, beak status and skin damage were assessed ex situ by three observers firstly trained to do it on 25 birds in common. They assessed the same number of birds in each treatment. The χFear or exploratory motivation towards an object and fear or attraction towards an unfamiliar human were assessed using tests in the home environment  was performed at 10 WOA in all pens, between 8 and 11.30 am, by a single observer. The NOT followed the procedures of the Welfare Quality poultry . The novDuring the laying period, the NOT was performed at 62 WOA between 8 and 11.30 am, by a single observer, in cages from the medium and bottom tiers (upper tier was more difficult to observe directly without disturbing the test) . After 3 min in the presence of the observer who remained immobile 4 m away from the cage, the observer counted hens with their heads out of the cage façade or immediately behind the façade, by scan sampling at 10-s intervals, over a 2-min period . Then, NO was hung on the façade of the cage (same NO as during the rearing period). Immediately thereafter, the observer remained on the corridor 4 m away from the cage, and observed the same parameters than before NO presence, adding the number of hens pecking the object, by scan sampling at 10-s intervals, over a 2-min period (12 scans per cage).In both tests (during the rearing and laying periods), the numbers were related to the initial situation (average of the 12 scans after the NO placement compared to the 12 scans before) to assess the hens’ reactivity to the NO.During the rearing period, an avoidance distance test (ADT) was performed at 9, 14 and 15 WOA in all pens by a single observer  between 4 and 6 pm. The observer walked around the pen for 2 min then sat on the floor and waited 3 min for the pullets to become accustomed to the human presence. Then, the observer noted the number of pullets within an arm’s length, tried to gently touch birds and noted the number of pullets touched, the number of pullets pecking at the observer, and the latency of the first peck at the observer.During the laying period, an ADT was performed at 31, 41 and 53 WOA in cages from the medium and bottom tiers (same sample as the NOT), by a single observer (who was not involved in caretaking), between 4 and 6 pm. The observer walked gently down the corridor along the wall or opposite the battery with one hand held in front of the body, and the other hand held at the side, the body not facing the cage. The observer focused on any hen with its head out of the cage façade, and gently moved forward at the level of the hen (with the hand remaining in front). Then, the observer turned towards the hen and approached her at a speed of one-step per second before withdrawal. A score from 1 to 4 (1: distant (2 m), 4: very close (10 cm)), reflecting the distance between the hand and hen’s feet was noted when the hen put her head back in the cage. If the hen pulled her head in before this step, the observer skipped to a different hen. If more than three hens were skipped, or if no hens had their head out before the test, a score of 0 was given for the cage.When the hens were 24, 36, 42, 50, 64, 68 and 72 WOA, the eggs laid on 2 consecutive days were counted per cage for 5 to 7 cages per treatment. Cages were selected randomly at 23 WOA and the same cages were used for the following measures. The eggs from each cage were visually examined to record the number of cracked and dirty eggs. The normal eggs produced per cage (neither dirty nor cracked) were weighed to determine the mean egg weight. Hen-day egg production (eggs laid per cage × 100/number of hens housed per cage at the time of recording) and the percentages of dirty and cracked eggs per cage were calculated, as well as the percentage of eggs laid into the nest. From a practical point of view, egg laying location was determined by delimiting the nest with wedges placed on the egg belt; an egg was supposed to be laid in the area in front of which it had rolled out of the cage. At 13 pm on the day previous to the measure days, all eggs blocked in the cages were gathered and the wedges were placed on the egg belt. The egg belts were stopped. At 8 am and 13 pm on the two following days, eggs were manually gathered and counted separately for the two parts of each cage.During the rearing period, the experiment was designed as a 2 × 2 factorial, with beak treatment (infra-red trimmed (T) or not trimmed (NT)) and “enrichment” (enrichment (E) or no enrichment (NE)) as the two main factors, creating 4 treatments of each 3 pens with 388 birds see .During the laying period, the experiment was designed as a 2 × 2 × 2 factorial, with beak treatment (T or NT), enrichment (E or NE) and diet (with extra fiber cellulose (F) or control (C)) as the three main factors, creating 8 treatments of various numbers of cages see . The treThe observational unit was the pen or the cage for ADT and NOT data and for laying data, while the single bird was considered the observational unit for body weights, feather cover data and the occurrence of beak defects and skin damage. Statistical analysis was conducted in R Studio , separately for the rearing and laying periods.lm) was used to analyze the main and interactive effects of beak (trimmed or not), enrichment (presence or absence) and feed (with or without fiber supplementation) as fixed factors.For the ratio of hens after/before NO placement during the laying period, a linear model , due to the low number of replicates. Two distinct analyses were applied with one factor: beak, enrichment.For NOT data (number of pullets next to the object after/before NO placement) during rearing, non-parametric testing was applied in the form of a Kruskal–Wallis test  was used for variance analysis of the data. Beak, enrichment and feed were fixed effects, while cage was the random effect. Main and interactive effects were analyzed.For ex situ feather score data and body weight during laying period, the multilevel linear model (art) to analyze the main and interactive effects of enrichment, beak and feed during laying period as fixed factors, while cages or pens and ages were the random effects.For ADT data , the non-parametric testing was applied after rank transformation of data .The occurrence of mortality at the end of the rearing and laying periods, the frequency distribution of beak defects and skin damage were analyzed using a Chi-square test  No. 016 at the French Ministry for Education, Higher Education and Research before the start of data collection (number APAFIS#4703-201603251170251167 v5). All efforts were made to minimize the number of animals used and their suffering.A total of 190 pullets died during the rearing period, none related to pecking disorders consequences. More than 80% of the mortality occurred in the first two weeks (156 out of 190). The results of a comparison between the treatments are shown in p < 0.001). For NT pullets only, enrichment reduced mortality: 10 pullets died in E pens (7 in the first 2 weeks), vs. 23 in NE pens, spread out in 3 pens each (9 died in the first 2 weeks).Mortality of T pullets was higher than that of NT pullets . Beak x age interaction was significant (p = 0.014): NT pullets were heavier than T pullets from 3 to 21 days (after post-hoc adjustment), without differences thereafter.Between 1 and 119 days of age, body weights were not different depending on enrichment (p < 0.001), without a difference between E and NE pullets .At 16 WOA, feather cover was scored as 0 for all pullets of the sample, and no skin damage was observed. The beak was noted as having a defect for 1.9% of NT pullets and for 38.5% of T pullets . The number of pullets observed pecking at the NO was low: only 1 hen was observed pecking at the NO in 4 pens, 3 in another pen, and 0 in all the others, across the various treatment groups. This could not be subjected to further statistical analyses.The percentage of pullets approaching the NO was 24.6%, without difference between treatments (T vs. NT: p = 0.060). Similarly, the latency of the first peck tended to be shorter in E pens (p = 0.054). Number of pullets around the observer and touched by the observer were not different between E and NE pens (p = 0.690 and p = 0.245).Beak condition did not significantly affect the results of the ADTs. The number of pullets pecking at the observer tended to be higher in E pens than in NE pens . For NT hens, enrichment reduced mortality; this was not the case for T hens. Mortality varied greatly between cages within the same group, especially for NT hens (0 to 26 dead hens per cage recorded over the laying period). From 31 to 35 WOA, there was one IP episode: 21 cages were affected by mortality, including 16 due to IP: 91 hens died , particularly in six NT cages with 74 hens dying, including 32 euthanized. During the entire laying period (18 to 72 WOA), seven cages showed no mortality at all .Mortality of T hens was lower than NT hens: 2.55% for T hens vs. 8.89% for NT hens , for T hens, enrichment had no effect on feather score. Skin damage was more frequent in NT hens than in T hens at 71 WOA. More T hens displayed beak defects than NT hens. The majority of defects were shovel beak (25% of the T hens), split beak (19%) and crossed beak (7%).Trimmed hens were heavier than NT hens at 71 WOA, with a difference of 158 g, which is 8% more. The feather score was lower for T hens compared to NT hens (in and ex situ). The interaction beak treatment x enrichment was significant in situ: for NT hens, feather score was lower for E than for NE treatments (p < 0.001), without a difference between beak treatments (p = 0.390).No hens pecked at the NO during the 2-min period of observation. The proportion of hens close to the NO  after NO placement in comparison to before NO placement was higher in E cages than in NE cages , beak (p = 0.162) nor interaction beak × enrichment (p = 0.644) on ADT was detected in this test.No effect of enrichment . The percentage of nest laying was higher for T compared to NT hens. Enrichment increased the percentage of eggs laid in the nest, and tended to increase the laying rate. There was no difference between treatments on egg weight, and percentages of cracked and dirty eggs.Laying rate of NT hens were lower than those of T hens, with interaction with age: NT hens lay less eggs at 50, 59, 64 and 68 WOA  towards a novel object during the laying period and to a lesser extent tended to be less fearful towards an unfamiliar human (or more attracted) during the rearing period. This suggests that E birds would have a lower risk to experience stress than NE animals, and shows the effectiveness of using multiple sources of management strategies, from the very beginning of the rearing period, from physical objects, sounds, lights and human sources. This is consistent with , who fouAn interesting result was that mortality in NT pullets was rare, but even lower in E pens. The difference in mortality appeared after the first two weeks, and was not directly linked to IP related problems. This may be associated with an overall decrease in stress, and/or increase in positive emotions with secondary effects on health. In fact, enriched housing environments can have positive impacts on immunocompetence (reviewed by ).Enrichment in the cage, like the artificial turf mat in the pecking and scratching area of the cage, did not relocate egg laying to this area. On the contrary, the percentage of egg laying into the nest was higher in E cages, showing better distribution of resources and a better use of the cage areas by the hens. In the same way, T hens better used the nest for egg laying than NT hens. In NE and NT cages, hens may have used the nest as an escape from peckers, making it less available for egg laying. The better use of nest for laying can partly explain the better laying rates in E (tendency) and in T cages.The management strategies provided in the rearing up to laying stages have therefore shown their value for the welfare of animals, without a negative impact on productivity. However, this approach still showed some limitations and can be improved.The E treatments limited feather cover damage for NT hens during the laying period, but at 71 WOA it was no longer sufficient: all hens showed severe damage of the feather cover. This shows some difficulties for field application in comparison with the beak trimming procedure. Also, during the IP episode in the laying period, NE hens were far more affected than E hens, but mortality varied greatly between cages within the same group treatment, especially for NT hens. The causes of this IP episode were unknown and probably multifactorial . This shows the complexity of the problem and how difficult it is to control on the farm.Applying a similar environment between the rearing and laying periods would probably play a role in decreasing the risk of IP. Our experimental setup limited the implementation of certain management strategies: one single room housed E and NE cages with the same environmental conditions for all cages. However, on commercial farms, solutions can be added during the laying period as provided during the rearing period such as music playing, warning of human arrival and improving the human-animal relationship. Altogether, this would probably further increase the effectiveness of management strategies on IP consequences reduction.Moreover in our study, the effects of management strategies during the laying phase could be long-term effects of the rearing treatment. Indeed, in , where eOur study proposed various management strategies, both at the rearing and laying stages, based on the existing literature but also on the practical and economic feasibility of installing such enrichments in commercial farms in barn system and in furnished cages. The objects provided were simple, easily obtained directly on farms or inexpensive if purchased. In barn systems, the farmer can easily renew them. However in furnished cages, we decided not to renew the objects in order to propose the simplest situation for farmers . It is thus possible that the management strategies provided in our study could be even more effective if objects were renewed during the laying period. The farmer could do this several times during the laying period, during hens’ presence as objects are placed on the façade of the cage.Although precautions have been taken to avoid observer bias in body condition assesment, inter-observer reliability testing should be added for future studies in order to improve methodology.Unsurprisingly, beak trimming considerably limited the consequences of IP during the laying period: lower mortality, better feather cover and lower skin damage. These results are similar to those reported in previous studies that have been conducted on commercial farms ,44 in baHowever, negative consequences of beak-trimming were highlighted in our study. More than a third of T pullets were affected by beak defects at the end of the rearing period . This demonstrates poor treatment of the beak and regrowth problems. This is in line with field results ,14,47, aThis study investigated practical solutions in the situation where non-beak-trimmed animals are reared in a barn system and transferred to furnished cages. Fiber supplementation in feed did not provide any added value, but different combinations of management strategies from the rearing to laying stages increased animal welfare, especially for animals with intact beaks, without negative impacts on productivity. These management strategies improved animal welfare in terms of decreased fear, mortality and improved feather cover, while remaining realistic and feasible with easy procurement of inexpensive and simple objects on the farm.As beak trimming is increasingly coming under scrutiny, such management strategies should be reinforced on farms even before any ban on beak trimming. This process should involve pullet flocks, in addition to laying hen flocks, as they are often not included in the debates around IP. Although these enrichment solutions can be improved, they achieved their goal: decreasing IP consequences when hens were not beak-trimmed. However, this study also shows the complexity of resolving the multifactorial IP problem entirely. Despite improved housing and flock management, the risk of IP cannot be completely eliminated. If still used, the infra-red beak trimming technique needs to be better controlled.