Mucormycosis has become increasingly associated with COVID-19, leading to the use of the term “COVID-19 associated mucormycosis (CAM)”. Treatment of CAM is challenging due to factors such as resistance to many antifungals and underlying co-morbidities. India is particularly at risk for this disease due to the large number of patients with COVID-19 carrying comorbidities that predispose them to the development of mucormycosis. Additionally, mucormycosis treatment is complicated due to the atypical symptoms and delayed presentation after the resolution of COVID-19. Since this disease is associated with increased morbidity and mortality, early identification and diagnosis are desirable to initiate a suitable combination of therapies and control the disease. At present, the first-line treatment involves Amphotericin B and surgical debridement. To overcome limitations associated with surgery  and amphotericin B , additional therapies can be utilized as adjuncts or alternatives to reduce treatment duration and improve prognosis. This review discusses the challenges associated with treating CAM and the critical aspects for controlling this invasive fungal infection—early diagnosis and initiation of therapy, reversal of risk factors, and adoption of a multipronged treatment strategy. It also details the various therapeutic options  that have been used for the treatment of CAM.  Mucorales and include genera such as Rhizopus, Rhizomucor, Mucor, Lichtheimia, Cunninghamella and Saksenaea. These fungi are commonly present in the environment. Although they are well recognized to cause opportunistic infections in immunocompromised patients, 19% of mucormycosis has been reported in immunocompetent patients [Mucormycosis is a life-threatening invasive fungal infection (IFI), which, although once considered rare, has become increasingly prevalent in patients affected by SARS-CoV-2 . The funpatients . A main patients . Depending on varying factors, mucormycosis infection is classified into five major types: rhino-orbital/rhino-cerebral/rhino-orbital cerebral mucormycosis (ROM/RCM/ROCM), pulmonary mucormycosis, cutaneous mucormycosis, disseminated mucormycosis and gastric mucormycosis. Various rare forms of mucormycosis are osteomyelitis, renal, peritonitis and cardiac . This reSince early 2021, IFIs such as COVID-19-associated pulmonary aspergillosis (CAPA) and COVID-19-associated mucormycosis (CAM) have been increasingly found. CAPA, also called white fungus infection, primarily affects the lungs, and severely impacts the kidney, mouth, skin and brain. CAM, also called black fungus infection, primarily affects the nose and sinuses associated with COVID-19 but can also affect other areas depending on the sub-type . AlthougRhizopus, commonly CotH3 for ROCM. In pulmonary mucormycosis, invasion and infection are facilitated by fungal CotH7 with integrin-β1 (with heterodimer formation with integrin-α3) [Mucormycosis invasion occurs through glucose-regulated proteins (GRPs), which are molecular chaperones of the Hsp70 family (70 KDa Heat Shock Proteins) . Althouggrin-α3) , which egrin-α3) . Mucoricgrin-α3) ,22. Apargrin-α3) . The mecThe atypical clinical presentation of mucormycosis leads to increased disease spread, and hence early diagnosis is crucial and is the main target of current research. Direct examination, culture, and histopathology are the cornerstones of diagnosing mucormycosis, but they are time-consuming and lack sensitivity. Newer molecular diagnostic techniques, such as in situ hybridization and Polymerase Chain Reaction (PCR), offer an alternative that may lead to earlier diagnosis and prompt initiation of treatment . Since mTreatment of CAM is also complicated because early initiation of therapy is required to control the disease, but it should also be ensured that any empirical treatments for COVID-19 do not amplify the underlying co-morbidities, thus increasing the severity of the disease  . AdditioThe probability of acquiring mucormycosis is associated with various risk factors, of which the most important ones are DM (with or without ketoacidosis) and conditions causing immunocompromised status . The priOne of mucormycosis’s primary and most common risk factors is uncontrolled DM . DM increases the severity of SARS-CoV-2 and the risk of mucormycosis , especiaDiabetes may be pre-existing or associated with COVID-19 infection (corticosteroid therapy for COVID-19 or other infectious diseases predisposes patients to mucormycosis) . DiabeteThe virus affects angiotensin-converting enzyme 2 (ACE2) producing cells (including beta cells of the pancreas), leading to the decreased breakdown of angiotensin II. This causes insulin resistance and upregulation of the sodium and hydrogen exchanger (NHE). NHE can increase damage to the pancreas due to its role in insulin release . NHE affMucorales are present generally in the environment [Fungi of ironment . They arironment . Howeverironment . Rhizopus is increased and tissue necrosis is observed [Mucorales infections [Further, the favorable environment for fungal growth  created by DKA is responsible for increased expression of glucose-regulator protein 78 (GRP-78) on the surface of endothelium cells . It is aobserved . DKA alsfections .Prolonged administration of corticosteroid therapy or immunomodulatory drugs to patients with COVID-19 and pre-existing comorbidities can increase their risk of developing CAM. It was found that immunocompromised patients who crossed a threshold of 600 mg of prednisone (cumulative dose) or 2–7 g methyl prednisone  are at higher risk of mucormycosis infection. In a study conducted by Patel et al. 2021, it was found that for the majority of the patients, the cumulative glucocorticoid dose administered vastly exceeded the recommended dosage. However, shorter courses of corticosteroid treatment of even 5–14 days have been found to predispose diabetic patients to mucormycosis ,39. AddiIt has been hypothesized that COVID-19-mediated ACE2 dysregulation creates a cascade that results in an environment suitable for fungal growth through its effects on the pancreas, lungs, colon, ileum, esophagus, cardiovascular and cardiovascular tissues . ACE2 isCOVID-19 is also associated with a reduction in phagocytosis, thrombosis and endothelialitis . EndotheMucormycosis may also be associated with nosocomial sources, especially during prolonged hospitalization . Non-steIn the case of a heart transplant patient who did not demonstrate any of the usual risk factors associated with CAM, it was suggested that COVID-19 was responsible for lymphocytopenia and the resultant immunosuppression, which led to fungal infection . IntubatMucorales fungi [Mucorales fungi, leading to mucormycosis [In general, treatment for COVID-19 with various antibiotics and immunosuppressive therapies such as monoclonal antibodies and steroids can cause dysbiosis of the human microbiome and damage epithelial linings, which aids the development of IFIs. One such treatment for COVID-19 is zinc, since it is known to have antiviral effects . Howeveres fungi . Additiormycosis . In addirmycosis . Early diagnosis and intensive, multidisciplinary treatment and management of the disease are critical for a better prognosis. Intracranial extension was associated with a poor prognosis . Hence eSince early diagnosis is essential for a higher chance of patient survival, clinical examination plays a vital role in identifying clinical manifestations of patients with COVID-19 at moderate to increased risk of developing mucormycosis. This involves ocular examination as well as examination for sinus tenderness. The ocular examination involves testing for visual acuity, pupil and ocular motility, extraocular abnormalities, and examination of the fundus and biomicroscopy ,57. AbnoImaging may not always be specific or diagnostic and the presentation may vary with the severity of mucormycosis. Computerized Tomography scan (CT), Magnetic Resonance Imaging  and endoscopy are the standard imaging modalities used to assess the extent of involvement in mucormycosis. Staging is usually done based on sinus and cerebral involvement. Radiological imaging usually can be done by CT or MRI, with or without contrast. CT and MRI have been used to ascertain the extent of the fungal invasion and intracranial extension and, thus, the disease progression of mucormycosis. For this purpose, brain MRI is required as it helps ascertain brain, orbit and sinus involvement. MRI of orbits or paranasal sinuses may also be used to diagnose mucormycosis ,63. MRI CT imaging may be performed for the paranasal sinus, nose, orbits, brain or chest for diagnosis. Bone destruction is generally observed using CT imaging of the paranasal sinus and brain. The presence of mucormycosis may be identified in CT at early stages using features such as a reverse halo often seen in the periphery of the lung. This might also be visualized as central necrosis and an air crescent sign ,64. DiagEndoscopy can be performed alone or in combination with other procedures for diagnostic purposes, and may be rhinoscopy, sinonasal endoscopy or bronchoscopy for ROCM. Bronchoscopy detects tissue masses that obstruct the bronchus . FurtherMucorales structures [Histopathology is the best approach for diagnosing mucormycosis due to its sensitivity and specificity . Histopaructures . Pauci-sructures ,47,58,60The microscopic examination of the exact fungi and the fungal hyphae can be done using culture. A nasal swab is usually used for a sample collection from suspected mucormycosis patients. This sample is viewed under a microscope by preparing a direct smear with 10% KOH to detect fungal colonies and hyaline mycelium ,38. HoweFungal colonies are usually detected based on morphological features such as color , but more specific tests such as DNA-sequencing can also be carried out. This may involve sequencing rRNA or 18S, 28S, internal transcribed spacer (ITS), and other barcode genes. MALDI-TOF spectrometry can also be used for confirmatory tests. Owing to fungal colonization, fungal DNA may be detected in various clinical samples such as tissue and serum. However, this approach requires further standardization .Mucorales fungi. qPCR-based detection designed by Million et al., 2006 was found to aid in early diagnosis by detecting Mucorales DNA at least three days before diagnosis of mucormycosis in over 90% of the study patients [Mucorales genera such as Mucor, Rhizopus, Lichtheimia, and Rhizomucor have been detected using in-house assays. Since the use of these non-invasive methods for detection aid in early diagnosis and improved survival rate, qPCR result is also considered in addition to the reverse halo in the CT for diagnosis [Mucorales and the resultant amplicon can be sequenced [®, developed by Pathonostics , is an easy-to-use multiplex PCR assay for detecting Cunninghamella spp. in addition to the above clinically relevant Mucorales in BAL and serum [Other non-invasive diagnostic techniques include quantitative multiplex polymerase chain reaction (qPCR) of blood serum targeting 18S rRNA of patients ,67. Commiagnosis . DNA canequenced . Additiond serum . Alternand serum .Mucorales specific antigens have not been found in the blood serum of mucormycosis patients. So, unlike most IFIs, antigen tests such as the galactomannan test and detection of -b-D-glucan (BDG) are not used for the detection of mucormycosis [Mucorales fungi are not detected in the cerebrospinal fluid culture of ROCM patients. However, T-cells such as CD4+ and CD8+ are seen explicitly in invasive mucormycosis and have been suggested as a possible non-invasive diagnostic test for mucormycosis. These T-cells may be detected using enzyme-linked immunospot  [Biomarkers such as rmycosis . MoreoveELISpot) . Once thELISpot) .CAM displays a high degree of angio-invasiveness. As a result, a multi-pronged approach is required to control the disease and prevent a recurrence. The treatment strategy for CAM is similar to that of mucormycosis. It primarily involves three aspects: addressing risk factors and co-morbidities, surgical debridement of infected tissue and administration of antifungals to control the spread of infection ,70. AdjuReversal of risk factors involves reversing hyperglycemic, immunosuppressed states and other risk factors that perpetuate mucormycosis in patients with COVID-19. The immunosuppressed condition may be changed by tapering or discontinuing immunosuppressants such as corticosteroids, antimetabolites, and calcineurin inhibitors. In the case of CAM-affected transplant patients, this might not be possible, and so the patient is treated with corticosteroid monotherapy and cessation of all other drugs . GlucoseThe surgical part of the treatment involves otorhinolaryngology, ophthalmology, neurosurgery, oral and maxillofacial surgery . HoeniglMucorales are resistant to many antifungals, the current first-line therapy against mucormycosis involves polyenes such as intravenous liposomal Amphotericin B (LAmB) (polyene). In contrast, salvage therapy includes IV posaconazole and isavuconazole (triazoles). However, systemic antifungal therapy is considered an adjunct to surgical debridement [Since ridement . Cytokinridement .Mucorales. The duration of first-line treatment must be adjusted as per the co-morbidities and response of the patient, assessed by diagnostic tests. As amphotericin B is a fungistatic agent, the treatment duration is protracted compared to fungicidal agents. Polyenes such as LAmB have also been combined with echinocandins (which have low activity when used as monotherapy) such as caspofungin or micafungin and iron chelators such as deferasirox that control angioinvasion and pathogenesis and improve survival [Amphotericin B deoxycholate and Amphotericin lipid complex (ABLC) have also been used. LAmB is preferred due to its reduced nephrotoxicity , improved CNS penetration and results in a murine model . Amphotesurvival . These cMucorales fungi but demonstrated poor activity against M. circinelloides-infected mice [A double-blind placebo-controlled study by Spellberg et al., 2012 found that deferasirox was associated with higher mortality and lower success rate. Still, they could not draw generalized conclusions due to imbalances in the populations of deferasirox and placebo arms . Amphoteted mice . It prevted mice ,77. It ited mice . It has ted mice ,78. Isavuconazole, administered intravenously or orally, is an extended-spectrum antifungal, which is the reason for its use in the treatment of invasive mucormycosis . It is uSaksenaea, Lichtheimia and Rhizomucor [Itraconazole has also been limited activity and therapeutic effect against mucormycosis, acting primarily against izomucor ,80. Flucizomucor . The effIn some patients, hyperbaric oxygen therapy (HBOT) or hyperbaric chamber therapy is used as adjunctive therapy to other conventional therapies to improve survival rates. The humidifiers for oxygen therapy must use sterile distilled water. HBOT involves the patient’s exposure to 100% oxygen at pressures above one atmosphere  for multiple treatments. This increases the oxygen transport capacity of the blood by increasing the alveolar partial pressure of oxygen, thereby causing revascularization and tissue oxygenation, thus reversing hypoxia. Theoretically, this could increase the oxygen concentration to a fungicidal level. However, hyperbaric oxygen is usually found to be fungistatic . On the These includes drugs such as calcineurin inhibitors (CNIs) and CNI alternatives such as sirolimus . CNIs acTacrolimus is a CNI used for transplant patients affected with Mucormycosis or CAM . A studyM. circinelloides with improved survival rates  in a study conducted by Bastidas et al. 2012 [M. circinelloides homologs of FKBP12 (FK506-binding protein) and Tor (Target of Rapamycin) proteins. FKBP12 was critical for the inhibition of Tor (Rapamycin (sirolimus) is an immunosuppressant drug that demonstrated in vitro and in vivo activity against al. 2012 . They idn of Tor C. FKBP12Mucorales fungi. Consequently, sequestration of iron can be a strategy used to treat mucormycosis. Deferasirox is an iron chelator administered orally and may be fungistatic or fungicidal. It acts by affecting the iron availability to the pathogen, generating an iron-starvation response which terminates in metacaspase dependent apoptosis and cell death , thus affecting cell membrane synthesis . It exhibited an inhibitory effect against various fungi apart from Rhizopus and is non-toxic. Although the targets of haemofungin were highly similar to the corresponding human protein, the authors suggest that this can be overcome, as the azoles currently in use as antifungals share 40% identity with a human protein [Haemofungin is an antifungal compound identified to affect cell wall synthesis leading to swelling and death. It targets HemH/ferrochelatase, thus preventing the final step of haem biosynthesis, leading to the accumulation of toxic intermediates, which also cause death C. It is  protein .Mucorales like Rhizopus oryzae, Rhizomucor pusillus, Mucor circinelloides and Lichtheimia corymbifera. It was found to have good activity in vitro against these fungi, where it demonstrated lower MICs compared to voriconazole and posaconazole. Additionally, it also shows rapid cellular permeation and persistence of action. The latter was observed when administered before inoculation in Aspergillus fumigatus, suggesting that it can be used for prophylaxis. It is proposed to act by inhibiting cell wall synthesis through inhibition of fungal sterol 14α-demethylase (CYP51A1)  B. This srequired .The host epidermal growth factor receptor (EGFR) is phosphorylated, activated, and colocalized with Mucorales fungi during infection. EGFR activation is critical for fungal invasion. As a result, network analysis identified EGFR as a potential drug target. Gefitinib (a drug) and Cetuximab (an antibody) are inhibitors of EGFR which were associated with lowered ability to invade fungi and more prolonged survival in mice with pulmonary mucormycosis. The response of EGFR to fungal infections is also reduced by gefitinib treatment .Various drugs have exhibited different interactions with existing medications to treat mucormycosis and therefore could potentially be used as combination therapies for CAM. These drugs and their activities have been described in detail. A study conducted by Ben-Ami et al., 2010 found that colistin had modest activity against mucormycosis . It was Mucor and Rhizopus fungi. Combination therapy was associated with synergy even in azoles to which these fungi are innately resistant (such as fluconazole). These effects are due to the suppression of Hos2 transcriptional complexes associated with resistance toward azoles.Pfaller et al., 2009 studied the effects of MGCD290, a Hos2 fungal histone deacetylase (HDAC) inhibitor, as monotherapy and in combination with triazoles . MonotheMiltefosine, a membrane phosphatidylcholine analogue, was tested for activity against fungal pathogens as a monotherapy and in combination with voriconazole or posaconazole. The monotherapy exhibited high MICs, but in vitro synergy was observed with both azoles, as demonstrated by lowered MICs. Although it is known that Miltefosine targets fungal phospholipase B1 enzymes, the mechanism of synergy is unknown. Further in vivo studies are required .Rhizopus and Mucor spp. in vitro. Synergy was observed with voriconazole against mucormycosis-infected models of Drosophila. However, studying the pharmacodynamics and pharmacokinetics of orally absorbed drugs is complex in Drosophila [Lovastatin was found to be active against mammalian and fungal cells by generating apoptosis-like responses. In mouse models, it was found to act by inhibiting prenylation of signaling molecules such as Ras. In fungi, it led to morphology that resembled apoptotic cells, DNA degradation and loss of cell viability. However, it was ineffective in the spherical stage of fungal growth, possibly due to differences in metabolism from polarized growth . It was osophila . R. oryzae [A study by Naeimi Eshkaleti et al., 2019 demonstrated that the combinations of Atorvastatin (synthetic statin) and Lovastatin  with Amphotericin B led to a reduction of Amphotericin B MICs against . oryzae . AtorvasRhizopus species in vitro. No significant effect was observed with Rifampin alone. This synergy was also observed in a patient with Rhizopus pneumonia. It is proposed to act by increasing cell permeability to Rifampin due to Amphotericin B binding with ergosterol. Rifampin entry results in DNA-dependent RNA polymerases inhibition, inhibiting fungal growth [In combination with Amphotericin B, Rifampin demonstrated synergy against l growth . Rhizopus, Rhizomucor and Mucor species combined with amphotericin B and voriconazole [Terbinafine is an antifungal that inhibits fungal sterol synthesis, thus affecting ergosterol synthesis and cell wall synthesis. Terbinafine exhibited synergistic and additive effects against conazole . The effconazole . Quinolones are a class of bactericidal drugs that inhibit bacterial DNA replication by interfering with topoisomerase activity. Sugar and Liu, 2000 tested the effect of the Quinolone-Amphotericin B combination on pulmonary mucormycosis in a mouse model. The combination of fluconazole and trovafloxacin (a quinolone) was found to have improved median survival time (MST) compared to control and fluconazole monotherapy. Varieties of Amphotericin B-trovafloxacin and Amphotericin B-trovafloxacin-fluconazole were associated with longer MST than all other treatments . Still, there was no significant difference in MSTs between these two treatments. Similar MST was also observed when the mice were administered fluconazole-ciprofloxacin treatment .Anti-CotH3 binds to the receptor GRP78 and facilitates invasion. A predicted highly immunogenic and conserved domain present in the GRP78 binding domain of CotH3 was targeted using polyclonal antibodies. This was found to prevent invasion, angioinvasion and dissemination to the brain in DKA and neutropenic mice. It acts by multiple mechanisms, including increased phagocytic recruitment, higher phagolysosome acidification and increased ROS (Reactive Oxygen Species) production. Opsonophagocytosis helps in reducing the fungal burden. It might have a role in improving the fungicidal role of macrophages, further favouring its use in neutropenic patients .Candida or Aspergillus. This suggested the relevance of blocking GRP78 to treat mucormycosis. Liu et al., 2010 demonstrated that blocking GRP78 using antibodies effectively prevented infection in mice with DKA . MucormyThis includes interferon-γ (IFN-γ), granulocyte-colony stimulating factor (G-CSF), granulocyte macrophage-colony-stimulating factor and macrophage-colony stimulating factor (M-CSF). G-CSF and IFN-γ, in combination with GM-CSF, favour immune response by polymorphonuclear leukocytes (PMNs) and M-CSF promote the destructive activity of monocytes and macrophages. These are active against various invasive fungi in vitro and humans. Some combinations of cytokines act synergistically. IFN-γ is active against the broadest range of organisms . IFN-γ, Rhizopus. Pre-treatment with LED and methylene blue was observed to lower the MICs of existing antifungals used for mucormycosis treatment, such as itraconazole, posaconazole and amphotericin B. It is proposed as an alternative or adjunctive to surgical debridement owing to its high tissue transmission, localization to tissues with PS accumulation, non-invasiveness, low cost and convenience. Additionally, it can lower antifungal dosage and side effects, thus increasing patient compliance [Antimicrobial photodynamic therapy (aPDT) involves using a photosensitizer (PS), which sensitizes pathogenic fungi to the wavelength of light produced by an LED, resulting in a phototoxic reaction that produces reactive oxygen species, killing the fungi. This has been found to be useful for many pathogenic fungi, including mpliance .R. oryzae [Shirazi et al., 2013 conducted an in vitro study on the effects of hyperthermia on the activity of CNIs (tacrolimus) and triazoles (itraconazole and posaconazole) against . oryzae . It was A study by Jain et al., 2013 identified six potential targets based on sequence differences in humans. Out of these, three were shortlisted due to the presence of just one copy . These aThis review discusses the risk factors and diagnosis associated with mucormycosis. Some possible links between COVID-19 and mucormycosis are also explored. Although only a few treatments are currently recommended to manage mucormycosis, other treatments must be explored due to the development of resistance to mucormycosis. Several therapies have been tested at various levels and have proved successful in treating mucormycosis. These treatments require further evaluation for administration to humans and treatment of CAM.


Background: Both in 5v5 and 3x3 basketball, the goal of the players is to score more points than the opponent. However, the differences in rules between two basketball disciplines can affect thinking, behaviour, and decisions of the players. A core difference between two disciplines is the value of the shots. In 5v5, long-range shots are worth three points and close-range two, while in 3x3, their values are two and one points, respectively. As the value ratio of the close and long-range shots is greater in 3x3, we assume that players make different decisions about their shot selection in 3x3 than in 5v5, which can affect offensive efficiency. Methods: We analysed game statistics of the 2019 men’s 5v5 and 3x3 Basketball World Cups. Besides regular statistical indicators, we applied relative offensive rating to be able to compare the two disciplines. Results: The analysis of relative offensive rating showed that offences are more effective in 5v5 than in 3x3. We also found significant difference in shot selection and efficiency. In 3x3, there is a higher proportion of the shots than in 5v5, but long-range shots are more successful in 5v5. Conclusions: For rule differences that affect player’s shot selection and affect offensive efficiency, their decisions are characterized by ecological dynamics and naturalistic decision-making. This new sport became immediately widespread over the world and gained immense popularity, and 3x3 has already become part of the Olympic program in Tokyo 2020.Three on three (3x3) basketball officially debuted at the Singapore Youth Olympics in 2010  . The 3x3Due to the 3x3 rules, the attacker–defender role can change continuously within a few seconds, which requires players to maintain constant concentration. The immediate role changing can change the behaviour and thinking of the players in 3x3 as it does in 5v5. All of these suggest players’ decision making is different in a 3x3 game than in 5v5, which may be interesting for this kind of comparison of the two forms of basketball.In terms of shot selection and effectiveness, previous studies ,4 found Basketball is often considered to have an unpredictable environment , as are To understand the decision mechanisms, three perspectives have emerged information processing, ecological dynamics, and naturalistic decision-making. Information processing is determined by cognitive abilities during the decision-making process and revolves around player’s access to memory representations. From information-processing stores, players make decisions through the process of selecting formalized responses . AccordiThese approaches show that the decision-making process depends on factors such as complexity, typicality, available time, and available contextual priorities in the game situation .Research ,2,5,6 coAnother research study  found thThe 3x3 games specifically require high-speed inertial movement within a limited distance, resulting in a relatively high physiological response , so playThe statistical system applied during basketball games, due to the nature of modern sports, fulfils the interest of media and spectators and helps in performance evaluation of both individual players and teams . In sporIn addition to common game statistical indicators, like shooting efficiency, Oliver’s  ball-posOfficial game statistics record data mostly on offense; the most frequently used parameter is effective field goal percentage (eFG%) (Equation (1)) :(1)eFG%=According to Oliver , while sFor analysing key game statistical performance indicators in 5v5, games can be classified into three categories  based on their outcome ,37. WinnIn 5v5 game statistics, shooting efficiency, rebounds, turnovers, and other objective data are used to compare teams. Better performance can theoretically be explained by the offensive and defensive efficiency ratings, both of which are based on ball possession . This meBall possession can end in a basketball game in three ways: a shot, a lost ball (turnover), or a penalty shot. Considering a shot, players decide the value of the shot to be taken depending on the team’s strategy, tactics, and the given situation. A long-range shot has a higher value but lower rate of success, whilst a close shot is worth less but comes with greater probability of success.In certain game situations, players may think differently at different times in the match. In contrast to the model of perfectly rational decisions, the phenomenon of loss aversion  has beenBased on the statistical data of the analysis of 5v5 basketball games, it can be clearly stated that due to the 1.5 ratio of two- and three-point shots, the number of attempts and successes of three-point shots have become a determining factor . This isPlayers prefer multi-point shooting whenever it is possible because, like all competitive athletes, they strive to maximize their own performance by optimizing everything , be it mThe player’s decisions with the ball are influenced by the number of times the player is in a decision-making position. Compared to 5v5, there is significantly more ball possession per player in 3x3 . In 5v5,According to previous comparative-intensity and decision-making studies ,3,4,5,6,During the game, three and two points can be scored per ball possession in 5v5, two and one points in 3x3, and the shot clock is 24 seconds in 5v5 and 12 seconds in 3x3. Based on these rule differences, we assumed that offensive efficiency and shot efficiency differ between the two basketball disciplines. Regarding the selection of shots, we assume that the larger point difference achieved in 3x3  affects the player’s decision mechanism. Furthermore, we assumed that due to the difference in the rules between the disciplines, the different ratio of points available per ball possession results in a difference in the ratio of close- and distant-shot attempts. Finally, we assumed the relative-offensive-value difference between 3x3 and 5v5, from which we can conclude the decision-making mechanism of the players, shows which aspects characterize them.Data of the 2019 men’s Basketball World Cups (WC), both the 3x3 and 5v5 disciplines, were collected from the official basketball website FIBA and by 3x3 WC video analysis.From the 3x3 WC, data of 20 teams in 48 games were collected, while from the 5v5 WC, data of 32 teams in 92 games were available. Teams in each discipline were coded separately; for instance, team USA had different codes in 3x3 and 5v5, appearing as different teams. Games were grouped based on the score difference  and the The following variables were calculated from the raw dataset: possession, points per possession, relative points per possession, shooting percentages for both the close- and long-range shots, and the ratios of close- and long-range-shot attempts to all field-goal attempts. For 5v5 and 3x3 basketball, possession (P) (Equation (2)) was calculated with Oliver’s formula , which iFinally, we compared the relative offensive rating (Equation (4)) of the two disciplines, which is the ratio of the points scored per ball possession to maximum points achievable per ball possession. It can be calculated as follows: In the case of 3x3 basketball, all games were manually analysed. Thus, in the previous equation, the exact number of possessions related to FTA was available. Points per possession and relative points per possession (Equation (4)) were further calculated.p-value correction. The level of significance was set at α = 0.05 in all cases.Statistical analysis was carried out in the R open-source  environment. Descriptive statistics are given in mean and standard error of mean (SEM) . DiffereThe parameters used during the analysis are presented in p = 0.002). In the 5v5 WC, the relative offensive rating was greater than that of the 3x3 WC, with an average of 7.1% higher (95% CI: 4.8%–9.3%)  = 36.8, 8%–9.3%) .p < 0.001) and the interaction of range and discipline  = 41.6, p < 0.001) but not discipline alone  = 3.3, p = 0.094). Pairwise comparison revealed that overall shooting efficiency did not differ between the disciplines (p < 0.001) (p = 0.131) between the two disciplines, while long-range shots were 8.6% better in the 5v5 discipline than in the 3x3 one   = 619.3, ciplines A. Howeve< 0.001) B. In the< 0.001) C.p < 0.001) and the interaction of range and discipline  = 60.6, p < 0.001). The overall percentage of close–mid-range shots was (52% ± 0.7%) higher than long range shots, with an average of 21.3% higher  (p < 0.001)  = 459.2, < 0.001) A. In the< 0.001) B.The innovation of our study is the comparison of the two types of basketball (3x3 and 5v5) from a whole new perspective. One of the aims of our study is to reveal whether there is a difference between 5v5 and 3x3 in the players’ shot selection and efficiency. The other aim of our study is to investigate whether the different value ratios yield different proportions of close- and long-range-shot attempts. Through these results, the offensive efficiency and relative offensive value of the two disciplines was determined, which made the two basketball forms comparable in terms of offensive efficiency. Due to the differences in the rules, we assumed that the difference in the maximum point value per possession affects the players’ shot selection. We examined the areas of study from which the two basketball forms can be compared. The analysis of the variables revealed important game statistics regarding the players’ decision-making and the change in their behaviour when the game rules, conditions, and environment change.For our research, we used basketball-game statistical indicators and examined ball possession and points scored, the ratio of relative offensive rating, shooting efficiency, shot selection, and long-range and close shots in the two disciplines.The maximum points that can be scored during an offense are three points in 5v5 , while it is two points in 3x3. In our research, we applied the offensive rating (used for the effectiveness of the offenses in the 5v5 games) for 3x3 games as well, but for the sake of better comparison, we used the relative offensive rating based on the different scoring in the two disciplines. In 5v5, the possession of the ball was approximately 77 (76.6 ± 0.4) per game, while the average score of a team was nearly 80 points (79.5 ± 1), which shows an offensive rating of 1.04 (± 0.01) and confirms the previously measured 1.02 offensive rating ,41. In 3In terms of the effectiveness of all shots, there was no significant difference between the two basketball sports . In 3x3, the efficiency of close shots is better than in 5v5 . Based on our conclusion, the difference exists due to the fewer players and thus the larger usable area per player, as found in previous research [There was a significant difference in the effectiveness of long-range shots in the study. Confirming the results of previous studies ,4, the rConsidering the statistical data used in the previous ,4 and cuThe limitations of this study are that the comparison does not consider different court sizes, shot selections made in different periods of the games or of the shot clock, and the relative position of the defender and of the shooter during shot selection. Therefore, in terms of these, further research is suggested comparing the shots, especially long-range shots, which may explain the differences in shot selection of offensive players between 5v5 and 3x3. In addition, research can be conducted with professional female players so the genders can also be compared.Based on the results, we found that changes in game conditions and rules affect player’s thinking, behaviour, and decision-making on the court during the game. In the comparison, in terms of overall shots, we found a significant difference between 5v5 and 3x3 in the shot selection, specifically in the ratio and efficiency of long-range. In 5v5, long-range (three-point) shots have increased in number and effectiveness in basketball games over the decades . Based oConfirming previous results ,4, the eIn 3x3, the shorter shot clock and reduction in the number of players require particularly high-speed inertial movement within a limited distance, which results in a relatively high physiological response  than in


The cochlear implant electronic device is the most effective sensorial prosthesis in medical history. Indications for cochlear implants have undergone evolutionary times, all based on technological development, improvements in the surgical techniques and the training and qualification of the interdisciplinary teams involved in the process of deployment. Thistechnology can help people with varying degrees of hearing loss at different times of sensory deprivation, although it works better when indicated early on, during the first year of life.The indication of bilateral cochlear implantation has been a controversial issue and is a reality in European countries and in the USA. The British healthcare system indicates the simultaneous bilateral cochlear implants for all children with severe to profound bilateral hearing loss, for their studies have shown a high cost-benefit ratio for the health programs subsidized by the government, both individual and social. Children under 1 year of age with simultaneous bilateral cochlear implants behave like normal hearing listeners at 4 years of age, with better use of hearing in quiet and in noisy environments, better development in understanding and speech production, social behavior of normal-hearing children, as well as school achievement and school interaction as normal-hearing children without having to resort to lip reading and sign language.The unilateral cochlear implant provides hearing, but limits the localization and discrimination of sounds in noisy environments, making it hard for the individual to follow the conversation.The bilateral cochlear implant rapidly promotes a homogeneous and organized cortical activity measured by the compound auditory evoked potential (CAEP). Its stimulation promotes P1-wave latency and amplitude similar to normal-hearing children of the same age range, proving a symmetrical bilateral development of the central auditory pathways. Spoken language acquisition is faster within the first year after bilateral cochlear implant compared to the unilateral implant and children who receive the second cochlear implant closer to the first have better speech perception with the use of the second implant.The relatives of patients using two cochlear implants reported improvement in their children's overall behavior, with better speech intelligibility, better school performance and better speech perception after the second implant.Thus, the indication of bilateral cochlear implant is a reality and is being considered by regulatory agencies of private healthcare insurance companies; and in due time it will be indicated to patients from the public healthcare system. Age must be considered when one thinks aboutthe possibility of cochlear implants in children, for it may independently affect hearing development.head-shadow effect occurs by head obstruction and the sound arriving at the stimulated ear, improving the signal-to-noise ratio (SNR). The binaural summation is the result of central auditory processing, and it shows the capacity the central nervous auditory system has to integrate and use information from both ears. The Squelch effect is the auditory system'sability to use the information from both ears when speech and noise are spatially separated.The best performance in terms of sound localization in bilateral cochlear implant users depends on the head-shadow, the “squelch” and the binaural summation effects. These effects are important for understanding speech in noisy environments, timely locating the sound reaching each implanted ear. The In order to indicate bilateral cochlear implant, an important condition to consider is the critical period for binaural auditory development, which favors early simultaneous implant. The central auditory pathways' plasticity, soon after early bilateral implantation is favorable in children implanted bilaterally, and sequentially to a second implant performed in a time interval shorter than 1 year. The short time between sequential implants and simultaneous cochlear implantation in children should be considered favorable to rehabilitation with greater opportunity for speech and language development. In adults, simultaneous or sequential bilateral cochlear implantsenhancelistening comfort, to be able to listen through both ears, with the benefit of sound localization.When considering bilateral cochlear implants in children two paramount issues are:the hearing loss duration before the first surgery, which interferes with the development of oral language and language skills, and the interval between surgeries, which affects the development of the binaural auditory processing.The timing of the indication and age to undergo surgery should be thoroughly discussed with the cochlear implant program team, which will aim at early intervention and better overall hearing, seeking to reduce existing difficulties, and providing auditory benefits, pursuing respect and social inclusion.International studies have shown that if money is not the problem, bilateral cochlear implant would benefit all children with profound bilateral sensorineural hearing loss, and both ears must meet the pediatric audiological criteria.Contraindications for the bilateral cochlear implant are children weighing less than 6kg and lack of family support. In the case of adults the contraindication is related to the duration of sound deprivation without the use of individual hearing aids.To wait and reserve a non-implanted ear to a new technology or future treatment should be considered and one must not forget that there is a critical period for cortical development. Therefore, waiting for a new technology can be harmful, because the cerebral cortex would not take advantage of this new technology or new treatment. Despite delays in incorporating these technologies to healthcare in Brazil, on July 28, 2011 the National Agency of Supplemental Health (ANS) through its Normative Resolution - RN No. 261 - requires that health insurance companies should add as of January, 2012 in their lists of procedures, the cochlear implants, facilitating the access of patients insured by health plans to this important benefit that is already a reality in the Brazilian Public Healthcare System (SUS), not requiring court orders for theunilateral or bilateral cochlear implant surgery. Now, patients enrolled in the SUS must wait for when the Federal Government will provide the technology bilaterally, which is already a reality in many countries.


This not only impacts on individual sufferers, but also on clinicians who can offer little in the way of support. Animal studies using invasive methodologies have developed solid evidence for a range of pathologies underlying this hidden hearing loss (HHL), including cochlear synaptopathy, auditory nerve demyelination, elevated central gain, and neural mal-adaptation. Despite progress in pre-clinical models, evidence supporting the existence of HHL in humans remains inconclusive, and clinicians lack any non-invasive biomarkers sensitive to HHL, as well as a standardized protocol to manage hearing problems in the absence of elevated hearing thresholds. Here, we review animal models of HHL as well as the ongoing research for tools with which to diagnose and manage hearing difficulties associated with HHL. We also discuss new research opportunities facilitated by recent methodological tools that may overcome a series of barriers that have hampered meaningful progress in diagnosing and treating of HHL.Many individuals experience hearing problems that are  The World Health Organization (WHO), in its “2021 World Report on Hearing,” estimates that half the global population is at risk of developing hearing loss due to unsafe listening practices , includihidden because it is not possible to diagnose using best-practice clinical tools, such as the audiogram , and discuss perspectives and forthcoming trends enabled by emerging methodological tools and outcomes—some of them developed by our own laboratories (section “Discussion”). For clarity, this paper uses the term “HHL” according to the definition provided by the WHO—<<the condition where an individual experiences common symptoms associated with noise-related auditory damage, such as difficulty in hearing in noise, and that is undetectable on pure-tone audiometry>>  increase in neural sensitivity (or activity) in the central auditory system, arising as early as the cochlear nucleus in the brainstem  is an auditory steady-state response  has been proposed as a potential biomarker of cochlear synaptopathy due to its strong dependence on the integrity of high-threshold auditory nerve afferent fibers . Loud soDespite the large number of non-invasive candidate measures potentially sensitive to HHL in humans, there is no consensus view that the neurophysiological pathologies evident in animal models of HHL are evident in humans or that these represent the underlying cause of speech-in-noise hearing difficulties reported by individuals with normal audiograms .A possible argument explaining the differences in outcomes across studies and null results across the literature is that the human auditory structures are less susceptible to the adverse effects of noise exposure than in rodents—variations in inter-species susceptibility were reported by Interventions strategies for HHL can be classified in two categories: assistive listening devices that improve the hearing experience of their users, and emerging therapeutic interventions aimed at restoring the neurophysiological damage.n = 157) used mild-gain hearing aids as their preferred rehabilitation strategy, even though little-to-no research has been conducted to evaluate the efficacy of these technologies in adults with hearing difficulties but normal audiograms. In fact, to date, only two studies have investigated the use of a mild-gain hearing aid for this population  condition of the Listening in Spatialized Noise test   . These dA second barrier is the technical limitation imposed by standard processing methods that average several segments of the electroencephalogram to increase the signal-to-noise ratio (SNR) of the auditory evoked response. These traditional methods impose important constraints on the experimental design to meet the requirement of the inter-stimulus interval being longer than the duration of the evoked response so that the estimation of one response is not affected by adjacent responses . Overcomvalidation problem , the large inter-subject variability typically observed in neurophysiological measures such as metrics derived from the ABR or the EFR might prevent their use for diagnostic purposes —a large-scale national study conducted in the United States that uses mobile applications on the Apple Watch to assess the intensity of environmental sounds and cardiovascular metrics in order to understand the impacts of being exposed to loud sounds on hearing and cardiovascular health  to what extent these devices improve the hearing experience of their users [this will help clinicians manage the expectations of their patients]; (ii) what are the listening scenarios in which devices perform best/worse [this will help them provide adequate counseling on the capabilities of the devices]; (iii) what proportion of users benefit when using these devices in acoustically challenging situations [this will provide an estimation of the success rate of this intervention]; (iv) what are the unique features that characterize those who do benefit from these technologies [this will help clinicians anticipate which patients would benefit the most]; (v) how close do these listening devices match a prescription target [this will ensure users receive optimal audibility and that their hearing is not compromised as a consequence of any possible over-amplification]; and (vi) what are the main barriers that would discourage users from using the devices  [this will help clinicians provide informed recommendations to their patients, and may also inspire technology manufacturers in the development of the next-generation products that will close the gap between the technology features and the users’ ecologically-momentary assessment  to account for any possible placebo effect derived from device placement within the ear  that may compensate for some degree of hearing loss, and provides an acoustic advantage in noisy environments thanks to the directionality of their microphones and noise-reduction algorithms. Future research endeavors might investigate whether the acoustic benefit of these devices increases by incorporating advanced signal-processing features that have been proven successful in hearing aids and cochlear implants, including adaptive selection of the device output levels to optimally fit an individual’s hearing dynamic range , smart aOther avenues to explore include novel interventions based on attenuating (rather than amplifying) high-intensity sounds. The intention of this apparently counter-intuitive approach is to shift input sounds to a level range in which individuals with HHL are expected to have optimal sensitivity. Recent experimental animal findings see  suggest one-size-fits-all solution is not appropriate to reducing listening difficulties associated with HHL, and that different solutions are required for different segments of the HHL population. In this regard, the objective determination of the site of neurophysiological lesion might lead to the development of different strategies tailored to individual listeners. For example, technologies based on directionality or background-noise reduction might improve the hearing experience of individuals with synaptopathy; technologies that enhance binaural-hearing cues such as binaural-weighted subtraction (Finally, it could be the case that a traction  could hetraction  could heJV conceived and wrote the manuscript. AT and DM provided the conceptual framework, assisted in the literature review, and participated in the writing of the manuscript. DM proofread the English of the manuscript. All authors read and approved the final manuscript.


The Trace Amine-Associated Receptor 1 (TAAR1) is one of the six functional receptors belonging to the family of monoamine-related G protein-coupled receptors (TAAR1-TAAR9) found in humans. However, the exact biological mechanisms of TAAR1 central and peripheral action remain to be fully understood. TAAR1 is widely expressed in the prefrontal cortex and several limbic regions, interplaying with the dopamine system to modulate the reward circuitry. Recent clinical trials suggest the efficacy of TAAR1 agonists as potential novel antipsychotic agents. Here, we characterize behavioral and neurochemical phenotypes of TAAR1 knockout mice, focusing on aggression and self-grooming behavior that both strongly depend on the monoaminergic signaling and cortico-striatal and cortico-limbic circuits. Overall, we report increased aggression in these knockout mice in the resident-intruder test, accompanied by reduced self-grooming behavior in the novelty-induced grooming test, and by higher cortical serotonin (5-HT) tissue levels. Further studies are necessary to explore whether TAAR1-based therapies can become potential novel treatments for a wide range of neuropsychiatric disorders associated with aggression. Trace amines represent a group of endogenous biogenic amines, such as β-phenylethylamine, p-tyramine, tryptamine, p-octopamine and others  that, alWhile initially suggested as an animal model of schizophrenia , TAAR1 kNotably, patients with several neuropsychiatric conditions, including dementia, schizophrenia, bipolar depression and various neurodevelopmental disorders, demonstrate increased tendency toward violent behaviors ,13,14,15Self-directed grooming is a complex, patterned evolutionally-conserved behavior that is mainly mediated by dopamine transmission within the ventral striatum . Importap = 0.0271) and locomotor activity (p = 0.0061), but unaltered freezing, self-grooming, sniffing and hole exploration endpoints , a longer fighting duration and lower non-social exploration (p = 0.0152). In general, the TAAR1-KO resident mice displayed more attacks , grooming episodes, rostral and caudal bouts, as well as fewer head, body and tail grooming bouts, and fewer nose-to-head transitions among transitions within natural cephalo-caudal progression , Table 1p = 0.0021), with unaltered 5-hydroxyindoleacetic acid (5-HIAA) levels (p = 0.0146). Other neurochemical parameters in different brain structures were unaffected (As shown in ) levels b, but imaffected .Overall, the present study showed the role of TAAR1 in mouse aggressive behavior and self-grooming syntax, paralleled by dysregulation of 5-HT in the prefrontal cortex, collectively suggesting TAAR1-based therapies as a novel approach to reduce pathological aggression observed in various neuropsychiatric conditions. Indeed, while TAARs are emerging as new multimodal targets in psychopharmacotherapy, this is unsurprising because TAAR1 can modulate DA, 5-HT and glutamate signaling . A key aImportantly, aggressive behavior depends on a complex interplay between the dopaminergic and serotonergic cortico-striatal and cortico-limbic signaling , and mulThe present study found overt changes in the open field test, as the TAAR1-KO mice show higher locomotor and vertical rearing activity. However, it is possible that social isolation stress during testing exacerbated these behavioral manifestations, because such moderate hyperactivity was not consistently observed in non-isolated TAAR1-KO animals ,29. FurtOn the one hand, excessive agonist concentrations at 5-HT1A and 5-HT1B receptors in the medial prefrontal cortex or lateral septum have already been linked to mouse aggressive behavior , and altSelf-grooming represents another critical behavioral phenotype for studying a wide range of animal psychiatric models . An overOverall, the results of the grooming test here  support Interestingly, Wistar-Kyoto rats show low self-grooming activity that is recovered after exposure to serotonergic antidepressant clomipramine , supportUncontrollable violence and aggressive behavior are a critical social and medical problem. The present study demonstrated that the TAAR1 receptor may play an important role in the orchestration of aggressive reactions through altering cortical 5-HT levels and turnover. Further studies in this field are needed to better understand molecular pathways of the TAAR1-DA-5-HT regulation. Nevertheless, our research for the first time revealed neurobiological association of trace amines and their receptors with aggressive behavior. Although DA and 5-HT have long been established as major modulators of aggression, trace amines may represent another key neurobiological mechanism of aggression, clinically relevant to a wide range of psychiatric disorders. Thus, future detailed studies with TAAR1-selective pharmacological tools are necessary to further support the role of TAAR1 in aggression. Our findings also suggest potential pharmacological perspectives of TAAR1-based drugs in the context of aggressive behavior treatment. Taken together, enhanced aggression, reduced self-grooming behavior and altered 5-HT in the frontal cortex of TAAR-KO mice, such as reported here, further implicate trace amines and their receptors in central regulation of complex CNS functions and behaviors.All animal studies were performed according to the guidelines of the Ministry of Health of the Russian Federation and the principles adopted by the Federation of European Laboratory Animal Science Associations (FELASA) and the Russian Laboratory Animal Science Association (RusLASA) for the welfare of laboratory animal use. All experiments reported here were approved by the Saint Petersburg State University Ethical Committee for Animal Research . The WT (+/+) and TAAR1-KO (−/−) mice were derived by crossing (for >20 generations) heterozygous TAAR1 +/− C57BL6/129SvJ mice. Experimental adult male mice (35 ± 5 weeks old) were housed 3–5 per cage (170 × 143 × 363.5 mm) before isolation for 4 months, and maintained under standard laboratory conditions  with food  and water ad libitum. The grooming test was performed between 18:00–21:00 h during the light phase. The resident-intruder and the tube dominance tests were performed during the dark phase between 21:00–01:00 h. The mice were acclimated to the experimental room for at least 1 h prior to behavioral testing.The open field test, used here to measure mouse locomotor and exploratory activity (n = 12), was a gray plastic circular arena (67 cm in diameter) with 13 holes (1 cm in diameter) in the arena floor. The mice were individually placed at the center of the arena, and their spontaneous exploration activity was video-recorded for 10 min, scoring the locomotor activity , the number of freezing and sniffing, total duration of self-grooming (s), the number of vertical rears and holes inspected. Between the animals, the arena was cleaned with 3% hydrogen, to eliminate olfactory cues. All endpoints of recorded behavior were scored manually frame-by-frame by a highly experienced scorer blinded to the genotype.The resident-intruder paradigm was used here to evaluate territorial aggression in mice . IsolateThree days after the resident-intruder test, the same groups were tested in pairs (WT vs. TAAR1-KO) in the tube dominance test (n = 6) , scoringThe grooming test (GT) was used here to characterize both basic mouse self-grooming behavior and its complex microstructural behavioral patterns. Briefly, mice (n = 14) were individually placed into a transparent glass cylindrical jar  and their self-grooming was recorded for 10 min using an Apple iPhone SE (1st generation) video-camera . Recorded self-grooming behavior was then scored manually frame-by-frame by a highly experienced scorer blinded to genotype, assessing the number of total grooming bouts, rostral grooming bouts, caudal grooming bouts, as well as paw, face, head, body and tail grooming episodes. To further analyze self-grooming microstructure, the number of grooming transitions between different body parts  were also assessed here. Any transition between grooming stages that violated normal cephalo-caudal progression (paws > face > head > body > tail) was considered incorrect, yielding the percentage of incorrect transitions in total transitions. We also compared globally the number of transitions for each cephalo-caudal progression and generated ethograms, to better represent grooming microstructural sequential patterns according to .Monoamines examined here included NE, DA, 5-HT, 3,4-dihydroxyphenylacetic acid (DOPAC), homovanillic acid (HVA) and 5-hydroxyindoleacetic acid (5-HIAA), determined by reverse-phase high-performance liquid chromatography on a Shimadzu LC-20 Prominence chromatograph  with a Decade Elite electrochemical detector . The chromatographic system included a Rheodyne 7125 injector  with a 20 µL loop for the sample application and a Phenomenex column (4.6 × 150.0 mm) with a Sphere Clone 5 u ODS (2) sorbent . Several brain regions  were isolated from the left hemisphere and dissected on ice, frozen in liquid nitrogen and stored at −80. Tissue samples were homogenized in liquid nitrogen at −198° C with CryoMill .g at +6 °C. The supernatant was collected into clean plastic tubes and stored until analysis at a temperature of −80 °C. The samples were re-thawed on the day of analysis, after which they were centrifuged again  to avoid the possible ingress of the remaining sediment particles into the chromatographic system [The samples were then suspended in 0.1 M hydrochloric acid (HCl) as follows: samples of the striatum in 50 µL, hippocampus or olfactory tubercle in 100 µL, cortex of the cerebral hemispheres in 150 µL. They were then centrifuged for 20 min with an acceleration of 14,000× c system , and anap set at <0.005).Statistical analysis was performed with GraphPadPrism 6.0  using the non-parametric Mann–Whitney U-test to compare the WT and TAAR1-KO groups (


Colorectal cancer (CRC) is the most common gastrointestinal malignancy and is generally thought to be caused by the transformation of colorectal polyps. It has been shown that early detection and removal of colorectal polyps may reduce the mortality and morbidity of colorectal cancer.Based on the risk factors associated with colorectal polyps, an individualized clinical prediction model was built to predict and evaluate the possibility of developing colorectal polyp.A case-control study was conducted. Clinical data were collected from 475 patients who underwent colonoscopy at the Third Hospital of Hebei Medical University from 2020 to 2021. All clinical data were then divided into training sets and validation sets by using R software (7:3). A multivariate logistic analysis was performed to identify the factors associated with colorectal polyps according to the training set, and a predictive nomogram was created by R software based on the multivariate analysis. The results were internally validated by receiver operating characteristic (ROC) curves, calibration curves, and externally validated by validation sets.Multivariate logistic regression analysis showed that age , history of cystic polyp , and history of colorectal diverticulums  were independent risk factors for colorectal polyps. History of constipation  and fruit consumption  were protective factors for colorectal polyps. The nomogram demonstrated good accuracy for predicting colorectal polyps, with both C index and AUC being 0.747 (95% CI = 0.692–0.801). The calibration curves showed good agreement between the predicted risk by the nomogram and real outcomes. Both internal and external validation of the model showed good results.In our study, the nomogram prediction model is reliable and accurate, which can help early clinical screening of patients with high-risk colorectal polyps, improve polyp detection rate, and reduce the incidence of colorectal cancer (CRC). Colorectal polyps are a general term for all neoplasm that protrudes from the intestine. The CP has a high incidence worldwide, with a detection rate of 10%–20% through colonoscopy .The majoIn most cases, colorectal polyps are asymptomatic Most of the patients seek medical attention due to the corresponding symptoms or abnormal physical examination results , and polyps are later revealed by colonoscopy. Colonoscopy is the most effective method for detecting colorectal cancers and polyps . In addiThus, it is necessary to correctly identify the high-risk population of colorectal polyps and promote colonoscopy in a wider range of potential patients, which can improve screening efficiency, reduce medical costs and save medical resources. In our study, risk factors for colorectal polyp incidence would be analyzed in order to establish a nomogram that can evaluate the risk of colorectal polyp incidence. With this model, we manage to assess the patients' risk of colon polyps objectively, screen for colorectal polyps in high-risk populations, with an individual and intuitive solution, as well as educate the public about colorectal polyps.We conducted a case-control study in this research. Clinical data of patients who underwent colonoscopy at the Gastrointestinal Surgery Department of the Third Hospital of Hebei Medical University from January 2020 to September 2021 were collected as subjects. The data collected from clinical studies were retrospectively analyzed. The following criteria were used to collect clinical case information: inclusion criteria: (1) Patient undergoing colorectal polypectomy and electronic colonoscopy at the Third Hospital of Hebei Medical University. (2) Colonoscopy can access to the ileocaecal region. (3)Intestinal preparation was perfect, and mucosal observation was unaffected after endoscopy. (4) Patients who had an indication for a colonoscopy. (5) Patients who were able to receive telephone follow-up were included. On the other hand, the exclusion criteria were as follows: (1) with symptoms of mental illness. (2) Patients who were not compliant or refused to participate in the study were excluded. (3) Patients with pathologically confirmed or previous colorectal cancer. (4) Patients who had previously undergone colorectal resection. This study adhered to the principles and ethical requirements of the Helsinki Declaration. Due to the retrospective nature of the study, the requirement for informed patient consent was waived.Based on the criteria above, data were collected from 475 patients, in which including 298 patients with colorectal polyps (CP group) and 177 patients with normal endoscopic and inflammatory lesions (control group). Polyploidy lesions were found during endoscopic surgery, and the pathology was non-neoplastic lesions, while in the control group, there were normal or inflammatory lesions. Data included family history, relative diseases, personal diet habits, and pathological results were collected.Colonoscopy was performed by 2 experienced gastroenterologists who performed at least 1000 colonoscopies per year and were blinded to the bowel preparation regimens the patients received. Endoscopic diagnosis of colorectal polyps would be based on Classification and Digestive Neoplasm (2019 edition) . The patThe data was processed and statistical analyses were conducted using SPSS 25.0 , and R software (version 4.0.1) with the ‘rms’ package. The quantitative data that conform to the normal distribution were expressed as means ± standard deviation, and the difference between groups was checked by an independent sample t-test. Comparisons between groups that did not obey the normal distribution were done using the nonparametric test. Data from the enumeration process were expressed as percentages and cases, and the Chi-square test was used to determine whether groups differed.P ≤ 0.2 were selected  curves were used to measure the discrimination of the nomogram, and the calibration curve between the predicted and observed probabilities was used to evaluate the calibration. Last but not least, the validation set data was applied to validate the model externally. A nomogram chart's clinical application value was assessed by evaluating its sensitivity, specificity, predictive value, and likelihood ratio of the optimal cut-off. The optimal cut-off value was determined by the Youden index. Statistically significant differences were considered to exist when the P > 0.05). The detailed results were shown in In the training set and the validation set, there were no significant differences found in baseline characters (n = 204) and control (n = 128) groups Univariate logistic regression analysis showed that the occurrence of colorectal polyps may be correlated with gender, age, BMI, blood glucose, blood pressure, occupational habits , family genetic history, history of depression, history of cystic polyps, history of the colorectal diverticulum, history of diabetes, history of Non-Steroidal Anti-inflammatory Drugs (NSAIDs) drugs, and consumption of fruits and vegetables (P ≤ 0.2). The results were shown in As part of the training set, 332 subjects were classified into the case , history of cystic polyp  and history of the colorectal diverticulum  were independent risk factors for colorectal polyps. History of constipation  and fruit consumption  were a protective factor for colorectal polyps. The detailed results were shown in Due to the desire to analyze the factors related to the occurrence of colorectal polyps as much as possible, the index Based on the 5 independent predictors examined by multivariate logistic regression analysis, a risk nomogram for colorectal polyps was built : Points Internally, the nomogram was verified by repeating sampling 1000 times using the Bootstrap method in R software, and verification sets from external sources served as the data for external verification. The nomogram had good segmentation and calibration in predicting colorectal polyps, with C index and AUC both of which was 0.747 (95% CI = 0.692 −0.801) . There wIn the validation set, external validation of the model was conducted. In the validation set, the graph also performed well in agreement and calibration, both C index and AUC were 0.782 (95% CI = 0.703–0.861) . A good The optimal cut-off value of the training set's nomogram's total score was calculated based on the Youden index as about 93.8 points in order to determine the clinical significance of the model. Those whose overall score exceeded or equaled 93.8 were considered high-risk subjects, and those whose score was less than 93.8 were considered low-risk subjects. Under the cut-off value, sensitivity and specificity were 70.3% and 71.1% in the training set and 71.4% and 78.7% in the verification set.A colorectal polyp is an abnormal growth that sticks out from the colorectal surface. Generally, CRC develops from colorectal polyps (CP) when an adenoma-carcinoma sequence is initiated , 17. A cAge and history of colorectal diverticulums were independent risk factors for colorectal cancer development in the study. Furthermore, constipation (Dehydrated stool and reduced frequency of stools) and vegetable consumption (eat vegetables regularly) were protective factors for colorectal polyps. In the Asia Pacific Colorectal Screening Scoring System  and its In our study, a history of gallbladder polyps' disease was shown as an independent risk factor for developing CP. In a previous study performed in a Japanese case-control study, the prevalence of CP in patients with biliary tract disease was significantly higher than that of controls. The presence of biliary tract disease is an independent risk factor for colon polyps  . One posP < 0.05)  . Neverth < 0.05) .Further, our study found that the consumption of fruit and a history of constipation were protective factors for CPs. Previous studies have shown that smoking, alcohol consumption, high-fat diet, red meat, and low-fiber diets increase the risk of colorectal polyps –28. SmokMany researches focuses on the development of clinical models of disease risk, and many related risk models are available, including those for coronary heart disease and colorectal cancer , 33. CurA nomogram was constructed based on the predictors screened by statistical analysis. In this study, a nomogram could predict risk with 0.703 accuracies, and 0.711 accuracies for the validation set. This nomogram can provide a certain reference value for medical workers to intuitively analyze individual risk, as well as for patients at high risk of colorectal polyps to be screened. Depending on the predicted risk, a reasonable evil screening procedure can be designed.There are still some limitations in this study. The enrolled population selected in this study was a group of people who visited our hospital for colorectal examination at one time, and the bias of admission rate was inevitable in the selection of the population. Due to the different medical conditions of the population and the uneven understanding of colorectal polyps, the proportion of patients in the positive group may be too high. And the study sample was relatively small; it was only conducted retrospectively over one year at one hospital. In addition, the established model had a weaker generalization ability and transferability than the space test. It is still necessary to carry out large-scale research with multiple centers in order to verify this. Also screen the high-risk population for colorectal polyps, so as to achieve the goal of early detection, prevention, and treatment of colorectal polyps, as well as to serve as a reference for further prevention and treatment.In our study, the nomogram predictive model is reliable and accurate, which helps early clinical screening of patients with high-risk colorectal polyps, improves polyp detection rate, and reduces the incidence of colorectal cancer (CRC).


Sudden hearing loss is described as a sensorineural hearing loss starting at 30 decibels (dB) in three of more contiguous frequencies, which can be severe and irreversible, which onset happens suddenly along 3 days. Auditory involvement is usually unilateral in 98%-99% of the casesFor the sudden hearing loss diagnosis, besides the detailed anamneses and physical exam, a complete audiometric evaluation is paramount, brainstem evoked-response audiometry (BERA), vestibular tests and trigeminal nerve assessment, as well as MRI with gadolinium and other tests in the pursue of the etiologyM.T.T.A., female, an 82 year-old retiree, coming from Maceió - AL, was seen in the ENT ward, where she complained of tinnitus and sudden hearing loss in her right ear for about 12 years, at the time she was diagnosed with acoustic neuroma by means of an MRI . she alsThe case hereby reported is rare, it is a bilateral sudden hearing loss, of non-simultaneous occurrence, suggested by the tonal audiometry testThe present report points to the likelihood of non-simultaneous sudden bilateral hearing loss, due to the participation of numerous etiological factors which, added together, may cause severe loss to the bearer. Thus, we stress the importance of the early diagnosis of hearing involvement and the control of pathologies, especially vascular ones, which may cause sudden hearing loss, as in this clinical case and thus have a negative repercussion in the quality of life of the elderly.


During an investigation in October 2018, two people with diarrhoea, mild abdominal pain, and mild arthralgia symptoms in Guangxi, China, were identified as infected by H9N2 avian influenza virus (AIV). Four H9N2 AIVs were isolated from one of two patients, a pet cat, and a dead chicken (two respective isolates from its lung and kidney tissues) bred by the patients at a backyard farm. Epidemiological investigation indicated that the newly bought chicken died first, and clinical syndromes appeared subsequently in the two owners and one cat. Furthermore, the two individuals possessed high H9N2-specific hemagglutination inhibition and microneutralization antibodies. Shared nucleotide sequence identity (99.9% – 100%) for all genes was detected in the four H9N2 isolates, and hemagglutinin (HA) T138A located on the receptor binding domain (RBD), resulted from nucleotide polymorphisms that were exclusively found in the isolate from the female patient. Moreover, HA K137N on the RBD was found in isolates from these three host species. Importantly, these four H9N2 isolates presented an exclusive binding preference for the human-type receptor (α2-6-SA), and could replicate and cause pathological changes in mice. Phylogenetic analyses showed that these four isolates clustered together and belonged to clade C1.2, lineage Y280. In addition, H9N2 viruses of human origin are genetically divergent and interspersed with the widespread poultry-origin H9N2 AIVs. All these results indicate a high risk of H9N2 AIVs in public health, and effective prevention and control measures against H9N2 AIVs should be considered and performed for both animal and human health. The A/H9N2 (hereafter referred to as H9N2) low-pathogenicity avian influenza virus (LPAIV) is of great global concern since its worldwide circulation and even long-term endemicity in the poultry populations of countries in Asia, Africa, and the Middle East . Based ohttps://www.who.int/teams/global-influenza-programme/avian-influenza/monthly-risk-assessment-summary) [https://www.who.int/teams/global-influenza-programme/avian-influenza/monthly-risk-assessment-summary) [Occasional cross-species transmission of H9N2 AIVs from poultry to mammals, especially humans, has been reported ,9–11. Sisummary) . Typicalsummary) ,16. Furtsummary) . The novsummary) . The facIn the present study, we report a cluster of H9N2 infections among two humans, one pet cat, and several chickens at a backyard farm in Guangxi Province in October 2018. An epidemiological investigation and hemagglutination inhibition (HI) and microneutralization (MN) assays were performed to determine the disease progression of H9N2 human infections on the farm. Molecular characteristics analyses and the receptor-binding and virulence-related assays were also employed to understand the infective features and to explore the potential transmission routes of the H9N2 virus among chickens, humans, and cats. The findings of our study further uncover the public health risks of H9N2 and support the development of targeted prevention and control strategies.Animal studies were conducted according to the recommendations of the Guide for the Care and Use of Laboratory Animals of the Ministry of Science and Technology, China. In this study, the animal experiments were approved by the Research Ethics Committee of the Institute of Microbiology, Chinese Academy of Sciences (APIMCAS2018014).Ten-day-old specific pathogen-free (SPF) embryonated chicken eggs were obtained from Beijing Vital River Laboratory Animal Technology Company (China) and used for virus isolation at 37 °C and 80% humidity.Lung and kidney samples of the dead chicken were collected on October 15, 2018. Throat swabs from the two patients were collected on October 19. On the same day, the diseased cat was euthanized, and heart, liver, spleen, kidney, lung, and larynx samples were collected. The supernatants of the swabs and tissue homogenates were inoculated into 10-day-old specific pathogen-free chicken embryos through the allantoic cavity inoculation route, as previously described [Viral RNA was extracted from the allantoic fluid of the AIV-positive samples, including throat samples from the female patient, heart samples from the cat, and lung and kidney samples of the dead chicken, using the MagaBio plus Virus RNA Purification Kit . The whole genome of the AIV isolates was sequenced using next-generation sequencing (NGS). Specifically, viral RNAs were used for RT-PCR, and DNA synthesis was conducted as previously described ,2. SequeSequencing reads generated by NGS were processed and assembled to obtain sequence information on H9N2 AIVs. First, the low-quality reads , adaptor-contaminated reads (> 5 bp matched to the adaptor sequence in either of the paired reads), poly-Ns (with 8Ns), and duplicated reads were discarded from the raw read data using SOAP2 v2.21 . The clehttps://nmdc.cn; accession number: NMDCN0001181 – NMDCN0001190) and the EpiFlu database of GISAID .The four H9N2 isolates were named A/Guangxi/NN10.19T-NGS/2018, A/cat/Guangxi/NN10.19H-NGS/2018, A/chicken/Guangxi/NN10.19L1-NGS/2018, and A/chicken/Guangxi/NN10.19K2-NGS/2018. The corresponding gene sequences obtained in this study are deposited in the National Microbiology Data Center  and α2,6 sialic acid receptor  as described previously [To further confirm virus receptor-binding specificity, we performed hemagglutination assays according to the manual from the World Health Organization (WHO) using 1% chicken red blood cells , 1% resialylated cRBCs (α2-6-SA receptors), and 1% sheep red blood cells  ,28. The Plasma samples collected from the two patients were treated with the receptor-destroying enzyme (RDE). We tested the plasma samples for antibodies against the H9N2 isolate (A/Guangxi/NN10.19T-NGS/2018), and representatives of influenza A virus, namely, A/H1N1 (A/Brisbane/02/2018), A/H3N2 (A/Kansas/14/2017), and A/H5N6 (A/Shenzhen/TH002/2015), as well as influenza B viruses, B/Colorado/06/2017 (belonging to B/Victoria/2/87 lineage labelled as Bv hereafter) and B/Phuket/3073/2013 (belonging to B/Yamagata/16/88 lineage labelled as By hereafter), using HI and MN assays, respectively, according to the manual provided by the WHO  and a pr6 EID50 of H9N2 viruses isolated from the chicken (A/chicken/Guangxi/NN10.19L1-NGS/2018), cat (A/cat/Guangxi/NN10.19H-NGS/2018), and human (A/Guangxi/NN10.19T-NGS/2018), respectively. One control group of mice was intranasally inoculated with PBS. Three mice in each group were euthanized on 3, 5, and 7 days post-infection (dpi). The lungs of the euthanized mice were harvested and homogenized to detect viral titres  using qRT-PCR. The lung index (ratio of lung weight to body weight) was also calculated for each euthanized mouse. In addition, five mice in each group were monitored for bodyweight changes until 14 dpi. The percent bodyweight change was calculated as the ratio of bodyweight to initial bodyweight on day 0.Four groups of fourteen 7- to 8-week-old female BALB/c mice  were used to examine the pathogenicity of H9N2 viruses identified in this study. Three groups of BALB/c mice were intranasally inoculated with 10For histopathological examinations, the left lungs collected from euthanized mice at 5 dpi were immersed in 4% paraformaldehyde. The fixed lung tissues were dehydrated, embedded in paraffin, cut into 4-μm-thick sections, and stained with haematoxylin and eosin (H&E) staining.To uncover the genetic divergence of H9N2 viruses isolated from the chicken, cat, and human at the backyard farm, we first calculated the percent identity between each H9N2 virus based on consensus nucleotide sequences. Next, we analysed the single nucleotide polymorphisms (SNPs) and amino acid substitutions resulting from the nucleotide polymorphisms in H9N2 virus populations isolated from the different hosts. We also analysed the key amino acid sites in the HA, NA, PB2, PA, and M genes to understand the potential biological features of H9N2 viruses, including the receptor-binding preference, replication, virulence, and antiviral drug susceptibility. Subsequently, we inferred the structure of the ectodomain of HA molecule of A/Guangxi/NN10.19T-NGS/2018, using the homology modelling method with A/swine/Hong Kong/9/98  as a template in the SWISS-model . The thrhttps://www.ncbi.nlm.nih.gov/genomes/FLU/Database/nph-select.cgi#mainform) and the EpiFlu database of the GISAID as of November 22, 2020. Additionally, we downloaded the nucleotide sequences of H9N2 AIVs isolated from humans in China. Based on previous studies, we also gathered the representative strains for H9N2 lineage classification: the BJ/94 lineage (represented by A/chicken/Beijing/1/1994), Y280 lineage (A/duck/Hong Kong/Y280/1997), G1 lineage (A/quail/Hong Kong/G1/1997), and Y439 lineage (A/duck/Hong Kong/Y439/1997) [The nucleotide sequences of eight gene segments of H9N2 AIVs isolated in mainland China were downloaded from the influenza virus database hosted by the National Center for Biotechnology Information NCBI; 39/1997) . We remo39/1997) . We cons39/1997) . Limited39/1997) . To unde997 . We During our surveillance on AIVs, two farmers presented some syndromes who bred chickens in their backyard, so we collected samples from them and their cats and chickens for the identification of pathogens. And we collected demographic characteristics  of the two humans living on the farm, and the geographic location. We also recorded the clinical symptoms, onset dates, course of disease development in the humans, cat, and chickens and their exposure and contact history.On October 6, 2018, seventy 120-day-old chicks were imported into a backyard farm that already had two chickens . Three dThe H9N2 AIVs were isolated from the throat swab of the female patient, heart sample from the pet cat, and lung and kidney samples from the dead chicken after 1–3 consecutive passages.The levels of HI and MN antibodies against the H9N2 and other influenza viruses  in the plasma samples of the two recovered humans were detected . The plaTo understand the potential mechanism behind the interspecies transmission of H9N2 AIVs on the same farm, we performed solid-phase receptor-binding detection and hemagglutination assay using the red blood cells with different types of sialic acid receptors to test the receptor-binding properties of the H9N2 isolates. In the solid-phase receptor-binding assay, the H9N2 viruses isolated from the human, cat, and chicken showed an exclusive binding preference for the human-type receptor (α2-6-SA) rather than the avian-type receptor (α2-3-SA) . The samp-value < 0.05 given Student’s T-test) higher than those of mice infected with PBS in the control group at 7 dpi. H&E staining revealed the pathological changes in the lungs  of mice challenged with the H9N2 viruses.Mice infected with H9N2 viruses isolated from the cat and human showed non-negligible body weight losses from 3 dpi to 9 dpi compared to mice inoculated with PBS or H9N2 virus from the chicken . The lunConsidering the consensus nucleotide sequences, the percent sequence identities between each pair of H9N2 AIVs isolated in this study were over 99.9% for each of the eight genes: HA (99.94% – 100%), NA (99.93% – 100%), PB2 (99.96% – 100%), PB1 (100%), PA (99.95% – 100%), MP (99.90% – 100%), NP (100%), and NS (100%).To further uncover the genetic diversity of the virus populations, we found ten nucleotide polymorphisms specific to H9N2 isolated from the human and cat in comparison with those from the chicken given the NGS data . Three oFurthermore, all four H9N2 AIVs isolated in this study possessed 226L, 155 T, and 183N in the HA gene sequences  circulating in poultry farms and live poultry markets. Surveillance of human H9N2 infections, especially in workers occupationally exposed to poultry, should be enhanced to monitor the emergence of human-adapted H9N2 viruses and provide early warning of a potential outbreak or pandemic.Click here for additional data file.