Chiropractors are a particular subset of health care professionals that reportedly suffer occupational musculoskeletal disorders (MSDs), yet they have received minimal attention to date regarding mitigating risks of occupational injury. Our study determined the prevalence of occupationally-related MSDs in the preceding year, their bodily distribution, severity, and practice-related changes in practicing chiropractors in the province of Ontario.We conducted a cross-sectional survey of chiropractors who were members of the Ontario Chiropractic Association (OCA) from January to March 2019. A three-part online survey was developed to ask chiropractors about specific details of MSDs they experienced in the past year and any practice-related changes they made as a result. Responses from participants provided both quantitative and qualitative data. Prevalence estimates were derived for quantitative data. Qualitative data were stratified by themes that were further divided into categories and subcategories. Demographic variables of the respondents and OCA membership were compared to determine representativeness.From the 432 responses (11.8% response rate), 59.1% reported experiencing an occupationally-related MSD in the past year. Survey respondents were demographically representative of the OCA membership. MSDs were most commonly reported for the lower back (38.3%), wrists/hands (38.1%) and neck (37.4%). Positioning/performing manipulation was the most common occupational activity for MSD of the upper extremity (53.1%) and lower back (34.8%). Chiropractors largely reported their MSDs did not prevent them from doing their normal work (77.4%), despite the fact that 43.2% reported experiencing their MSDs for more than 30 days in the previous year. Common reported work modifications were grouped under themes of practice and physical changes. Practice changes included reducing patient volume, hiring personnel and scheduling. Physical changes included using different office equipment, selecting different techniques requiring lower force and altering their hand contacts or body position when treating patients.One-year prevalence of occupational MSDs from this study are comparable to previously reported estimates in chiropractors. These data suggest that chiropractors continue with their regular workload despite their MSDs, thereby increasing their chances of presenteeism. Chiropractors changing technique or technique parameters due to their MSDs provides direction for future research to reduce exposure to occupational MSD risk factors. Private health care workers in the United States continue to have an incidence rate for occupational injuries and illnesses that is comparable to workers in other physically demanding occupations, such as construction and manufacturing, and account for the highest total number of annual cases . This peMior and Diakow  publisheDespite the high prevalence of occupational MSDs in chiropractors, previous surveys have reported that only between 21 to 30% of chiropractors with musculoskeletal complaints have taken time away from work as a result of their MSDs , 7, 9. TThe aforementioned findings suggest that chiropractors sustain occupational MSDs consistent with overexertion and/or cumulative trauma mechanisms. Since the most recent survey of Canadian chiropractors was conducted over 30-years ago, our primary objective was to investigate the prevalence of occupational MSDs in the previous 12 months (i.e. year) amongst practicing chiropractors in the province of Ontario. Secondly, we sought to evaluate the bodily distribution, and severity  of these work-related MSDs. Previous evidence also suggests that injured chiropractors modify their techniques for administering spinal manipulative therapy to accommodate their MSDs; however, no information exists that describes either the specific nature of these modifications or other practice-related changes. A final objective was to identify specific technique modifications and practice-related changes made by practicing chiropractors in response to their MSDs.Chiropractors who were members of the Ontario Chiropractic Association (OCA) between January to March 2019 were invited to participate in the study. We used a modified tailored design method to approach practitioners and optimize participation . This apTo ensure participant privacy and anonymity, all recruitment materials were electronically distributed by the OCA. Upon opening the survey link, participants were presented with an information letter that outlined details for the study. Participants clicked on the tab at the end of the letter to provide their consent and begin the survey. All procedures and materials for this project were approved by the Research Ethics Board at the Canadian Memorial Chiropractic College (CMCC) prior to beginning recruitment and data collection (REB #1809B01).At the time of data collection, there were 3655 registered members of the OCA. Mior and Diakow’s previous study 1987) surveyed chiropractors across Canada and achieved a 60% response rate, but survey burden in general has increased in recent years. Based on the 42.2% response rate from Holm and Rose’s study [87 surveyN = 1462, the confidence interval (CI) width for a prevalence estimate of 50% would be +/− 1.3%.The primary purpose of our survey was to describe the burden of work-related musculoskeletal injury/symptoms among practicing chiropractors, which was expressed as prevalence  or the proportion of respondents that reported injuries and/or symptoms related to their work as a chiropractor. With a sample size of Each consenting participant anonymously completed a custom-designed online survey that was implemented in SurveyMonkey . The online survey included both closed-ended and open-ended questions and combined elements from the survey used by Holm and Rose  and the Demographic data were closed-ended questions related to personal characteristics  and practice characteristics .Next, a single question asked participants if they had experienced a MSD related to their practice as a chiropractor in the previous year. Chiropractors who answered “No” were taken to the end of the survey and thanked for their participation Fig. . Those aIn the last section of the survey, we asked two open-ended questions on MSD history. The first asked about particular activities to which chiropractors attributed the onset of their condition(s). And the second probed specific practice changes made by chiropractors to accommodate their MSDs .We calculated averages and standard deviations to describe participant demographics . De-identified demographic data  that is routinely collected by the OCA from their members was used to evaluate non-responder bias. We compared respondents with the target population using histograms of these demographic variables to assess the representativeness of our sample. Composition for each bin in a histogram was expressed as a percentage of either all respondents (our study) or all members (OCA members).General prevalence of work-related MSDs (i.e. answering “Yes” to the question about having experienced a MSD related to their practice as a chiropractor in the previous year) was quantified as a percentage of all participants and presented with a 95% confidence interval (CI). Prevalence over the previous year for specific areas of the body was also quantified as a percentage of all participants with 95%CI.Responses to the open-ended questions related to modifications in response to a MSD were reviewed. We employed qualitative content methodology using manifest analysis to describe what participants actually said . Each paA total of 432 responses were received, which equated to a response rate of 11.8%. Demographics of the sample are summarised in Tables Diversified technique  was commonly used by nearly all respondents, and 81.3% reported this as their single most frequently used technique Table . ActivatHistograms graphically demonstrated that our respondents were similar to the target population for the four demographic variables  that were used to assess representativeness Fig. .Fig. 3HN = 428) who provided information related to experiencing any MSD in the previous year, had a prevalence of 59.1% with 95%CI (56.8–61.4%). The three most common areas of work-related MSDs were the lower back, wrists/hands, and neck . Others noted increasingly using table sections that drop or distract, as a means of decreasing the stress and discomfort experienced when using Diversified technique. Participants described the use of mobile stools and ergonomic office equipment to allow for improved posture and limit fatigue. Participants also reflected on personal reasons for making changes, including either work-related or sport-related injuries and physical health problems, such as:“Right shoulder is primary concern and I find I’m constantly trying to avoid aggravating it with working positions, especially lumbar side-lying SMT.” (ID#276) and.“I had to ultimately go back to school for another career. I am a small female and my physical problems with chiropractic began almost immediately after finishing chiropractic college.” (ID#323).Two themes emerged from their responses to our two opened ended questions, physical and practice factors. Physical factors captured attributes categorized as personal, technique specific and office equipment. Participants identified changes to different office equipment they used in the delivery of patient care. In particular, the use of hydraulic technique tables allowing for improved or less stressful body postures, in particular when utilizing different interventions. For example, one participant noted, ““Using a little more care and attention to my own body mechanics and posture.” (ID 333) Others altered forces used during the delivery of an adjustment/manipulation or soft tissue therapy: “Less force/pressure when preforming deep tissue massage.” (ID#1) Whilst others reported changing their technique, relying more on mechanically assisted techniques or other modalities requiring less force than Diversified high-velocity low-amplitude manipulation, as noted in the following quotes:The one physical factor commonly cited by participants related to technique-specific problems and changes. Participants described how they modified their contact, body position or posture to reduce physical stress or forces impacting their body: “Moved from manual to instrument adjusting.” (ID#317).“Reduced side posture low back adjusting and relied more heavily on activator and drop table techniques.” (ID#425).“Less ART, transitioned to more stretching, traction, Graston, acupuncture.” (ID#384).“I try to be efficient with my administrative tasks, we’ve hired an office manager to handle the majority of billing issues and I spread my computer time.” (ID#350) and “Hired doctor to adjust some patients.” (ID#362).The second emergent theme related to practice factors that addressed strategies related to work, time and office administration. Participants reported making administrative changes to improve office processes and functions. Such changes included hiring associateships, changing office location and having staff assist with work, as noted by a couple of participants:“We try to schedule our day so we’re not working any longer than 4 hours straight, to have a little “body break”. (ID#378).Others modified their workday, reducing office hours or introducing more breaks during the day, and scheduling holidays to ensure improved work-life balance. For example, “Focusing more on pediatrics rather than adult injuries.” (ID#248),“Selected patient population that required less SMT and more mobilization. Self-selected less lower back pain patients.” (ID#175) and,“Reduced 2 full days of practice. Also trying to use more acupuncture to reduce pain and preserve longevity of ability to practice. Trying to aim to market to females and less elite athletes, as I am smaller individual and have less strength now to work on ‘large body types. (ID#396).Work-related aspects of practice factors focused not only on patient volume but also patient type. Participants reported focusing on a different patient population as a strategy to overcome their conditions or limiting stresses on their self. For example, a participant noted,“Decreased patients seen per day, use more acupuncture techniques than adjustments and activator methods more often.” (ID#46).But in response to conditions and dealing with MSD, participants tended to change the volume of patients seen and decrease physical demands resulting from long hours of work, for example, The current study reported on the prevalence of work-related MSDs in practicing chiropractors in the previous one-year period. Our findings indicated that almost 3/5 practicing chiropractors reported a work-related MSD in the previous year with the most commonly affected parts of the body being the lower back, wrists/hands and neck. The combination of preparing the patient for manipulation or performing a manipulation, particularly directed toward the lower back, was the most frequent occupational duty attributed to MSDs of the upper extremities and lower back. Nearly two thirds of respondents claimed to have altered their manipulation technique or technique parameters to accommodate for their MSDs. These prevalence data and specific information on work modification(s) are critical for future targeted investigations evaluating the biomechanics of these modifications and mitigating strategies for reducing the physical risk of MSDs experienced by chiropractors and other health care professionals that use manual therapies.Data from the current study adds to the growing epidemiology of work-related MSDs reported by chiropractors. Our prevalence estimate for any work-related MSD over the previous year 59.1%) was similar to the estimate provided by a recent study of MSDs in Danish chiropractors 60.8%) 9.1% was . Interes% 9.1% waOur prevalence estimates by body part differ from those reported in previous studies. However, the three main affected areas of the body identified in the current study  have been consistently ranked among the top three parts of the body that chiropractors report experiencing occupational MSDs , 7–9. InBiomechanical data that documents postures adopted by, and loads induced on the shoulders and lower back of clinicians performing these maneuvers has yet to be established. These data would be useful in determining physical exposure and mitigation strategies. Interestingly, chiropractors who attributed their hand/wrist MSDs to positioning or performing manipulation were equally divided in terms of the patient’s posture . This is somewhat different from data reported by Hansen and colleagues  that shoPrevious studies have been limited in their reporting of the severity of MSDs in chiropractors. Severity in these studies has often been quantified in terms of time away from work, as well as physical (e.g. technique modification) and practice changes (e.g. reduced hours). Qualitative responses to the open-ended questions in our survey identified themes of physical and practice factors modified by chiropractors as a result of their MSDs. Specific practice factors identified in our study included reduced patient volumes, targeting different patient demographics and hiring an associate or office manager, factors reported in previous studies , 8. PrioA novel contribution of our study was the application of the SNMQ to assess the yearly duration that chiropractors suffer from work-related MSDs. These data found that nearly 50% of those chiropractors with MSDs of the shoulder or hand/wrist reportedly experienced these troubles for more than 1 month in the previous year. This is particularly troubling for a chiropractor given the extent to which the upper extremities are involved in their delivery of manual care to patients. Yet despite this reported finding, our findings suggest that chiropractors largely did not reduce their working activities as a result of their MSDs. Evidence among nurses suggests that those working with musculoskeletal pain and/or depression report increased errors in patient medications and occurrence of patient falls along with diminished quality of care, as examples of “presenteeism” . Future Our study had limitations. First, the response rate for this survey was only 11.8%. This was lower than the response rates for the five previous studies investigating work-related MSDs in chiropractors (average response rate of 53%) . HoweverOur study found the prevalence of work-related MSDs in practicing chiropractors in Ontario was approximately 60% over the previous year, which was consistent with data reported from other parts of the world. Positioning patients for and performing a manipulation were commonly attributed causes of MSDs of the lower back, shoulders and hands/wrists. Future biomechanical work should investigate strategies to mitigate physical risk factors for MSDs in chiropractors such as posture and force.Additional file 1.Survey of MSDs in Ontario chiropractors. Survey instrument used for online implementation. (PDF 56 kb)


It is established that normal calcium and vitamin D concentrations are maintained in the body through parathyroid hormone (PTH), a signaling molecule secreted from parathyroid glands. A massive role is played by PTH in increasing calcium levels when they are extremely low in the body through different mechanisms. The dysregulation of this hormone is due to either over functioning of the gland (hyperparathyroidism) or compromised functioning in hypoparathyroidism. A detailed review was done to identify if any changes are happening in the cerebrospinal fluid (CSF) due to any pathology causing the parathormone to be dysregulated enough to, in turn, cause any further pathology in the nervous system. This may then lead to various disabling neuropsychiatric features. The calcium and vitamin D abnormalities are both directly and indirectly connected to psychiatric features like delusions, schizophrenia, disabled cognition, psychosis, coma, mania, and depression of all kinds.Moreover, their irregularities are also linked to Alzheimer's. During these manifestations, the CSF is altered concentration-wise, where elevated calcium levels inside are observed during different studies. Despite PTH's indirect connection to the CSF modifications, their association hasn't been potently proven yet, considering more observational studies should be conducted in humans and for a more extended period, along with bigger and greater numbers of CSF samples. Suppose there is a possibility of the link of CSF alterations to PTH. In that case, we can consider a pronounced increase of CSF calcium or PTH as a risk factor for debilitating neuropsychiatric diseases. In this review, the possible correlation of CSF and PTH has been discussed. If you skew the endocrine system, you lose the pathways to self; when the endocrine pattern changes, it alters the way you think and feel. One shift in the pattern tends to trip another"-HILARY MANTEL"Parathyroid hormone (PTH), a signaling molecule produced by the parathyroid gland, is also called parathyrin or a parathormone and keeps the normal regulation of the calcium concentration maintained. It's one of the most vital secretory products. During calcium dysregulation, like in hypocalcemia, it increases calcium's renal absorption and calcitriol's  production, affecting the intestinal calcium absorption, thus helping in the mobilization of calcium from the bones [Elevated calcium concentrations in hypercalcemia could cause any psychiatric manifestations . There hNeurological manifestations could be a result of any alterations in the CSF. For example, the concentration of amyloid-P plaque in Alzheimer's. After years of research, it is identified that any modifications in calcium are significant to Alzheimer's pathophysiology since calcium's misregulation can be directly associated with any alterations of tau phosphorylation and amyloid precursor proteins that define Alzheimer's clinical features ,6. A radAfter subarachnoid hemorrhage, calcium's intracellular concentration and regulation in the cerebral vessels alter, and it has been hypothesized that patients have decreased apolipoproteins and high calcium levels may have vasospasm . MoreoveWhat is known about the CSF's influence on any neuropsychiatric manifestations due to a dysregulated PTH is the increased calcium concentrations and possible vitamin D concentrations that may affect a patient's neurological health. However, more exploration is required since a few studies have suggested a weak relation of PTH with calcium, but that being the case in studies with fewer patients, without any or significant faulty alteration of PTH in them.We aim to explore the possibility and the role of PTH dysregulation and, thus, calcium and calcitriol levels to be irregularly distributed, especially in the CSF, to be further causing any symptoms neurological or psychiatric.In this review article, we will assess the effects of parathyrin on the CSF and how the CSF composition post-PTH-dysregulation could be a possible reason for any symptoms or repercussions relating to the neurological system of a patient's mental health-related quality of life.In this review article, we aim to explore the possibility of any linkage between the CSF alterations due to any pathology related to the parathyroid gland, which can, in turn, serve as a cause for neuropsychological repercussions. Neurological and psychiatric symptoms, disorders, and illnesses due to primary hyperparathyroidism have been reported through case reports, case-control studies, cohort studies, and several literature reviews, including the traditional evaluation and systematic.Physiology and pathophysiology correlating with the clinical aspectDue to the imbalance of parathyrin in the body, causing disturbed calcium homeostasis in Primary hyperparathyroidism, there may be not just recurring or infrequent elevations of calcium, but rather consistent . There iA few case reports that have been published, one about a 17-year-old adolescent male and one about an 84-year-old woman ,13, provRefractory psychosis, along with excessive consumption of alcohol and seizures, in a 36-year-old man, who had his first convulsion in the first 10 years of his life, was seen with low levels of calcium, high levels of phosphate, and parathyrin levels in the upper limit . With moConsidering the recency of a study and the number of samples used, which aimed to find out a certain amount of PTHrp (parathyroid hormone-related protein) managing the calcium regulation even in the brain, it holds more significance . Nine diTo further prove, an article, after being reviewed, implied that calcium's voltage-gated channels if mutated might trigger dysfunction and certain modifications that could serve as a cause of neuropsychiatric diseases and a spectrum that includes ataxia, schizophrenic symptoms, bipolar disorder, migraines, and depressive disorders . Apart fApart from explaining parathyrin's physiology and its clinical importance in vitamin D production and calcium reabsorption from the kidneys, the pathophysiology of parathyroid hormone was also considered, that there is a marked possibility that low levels of vitamin D correlations influence neurological development ,21. ThisCase-control studies conducted along with standardized tests for determining the quality of life before and after parathyroidectomy were also favorable. Thirty patients with pHPT (primary hyperparathyroidism) were observed six months before the surgery . Then siCellular and molecular associationsOn a molecular and a cellular level, we are exploring the causative elements, mechanisms, and the changes taking place that hold significance in understanding how the parathyroid gland, when dysfunctional, can affect the hormonal irregularities and thus put an impact on neurological and psychiatric health, by altering the CSF. A case-control study done in 2011 focused on assessing the concentration of magnesium, calcium, and other minerals like copper, zinc, manganese, and iron in the CSF . one-sevAccording to cellularity, a review article of 2017 indicated the connection between vitamin D and depression through the discussion . ChangesPsychoneuroendocrinological correlationsTo associate psychoneurological manifestation and mechanisms with those of the endocrine system is vital to emphasize and investigate their associations in the human body. Adamson et al. explore the possibility of how psychotic symptoms and illnesses can be related to low vitamin D levels . This sySimilarly, an observational study from last year discussed the role of vitamin D and depression properly. It showed that vitamin D insufficiency was remarkably and often seen in those with acute stroke, and its low levels link to depression being caused in acute stroke . This waA case report in 2016 discussed an aged man with organic psychosis due to deficient functioning of the parathyroid gland due to any therapeutic or diagnostic procedures (Iatrogenic) . The repTo sum it all up, there aren't many studies discussing a direct linkage between parathormone causing CSF pathology so that it directly and as the only pathology that affects a human's neurological or psychiatric state. Despite many studies proving how calcium and vitamin D levels, along with their other forms, can cause neuropsychological manifestations, we are still unsure if their altered levels in the body are solely dependent on the parathyroid gland's functioning.Is there a possibility of Parathyroid hormone after entering the CSF to change its form in a way other than just dysregulating calcium that causes a direct pathology and abnormal modifications in the brain? That is yet to be explained and proved by empirical studies collecting huge and high CSF samples. The various qualities, objectives, types, and conclusions of studies explained in the above passage have been summarized Table  28,30-3-330-36. LimitationsRandomized controlled trials were not included in the article, and we had only gathered observational, literature, and case studies. There were not many studies that proved a direct link between the parathyroid gland and its dysfunctional parathormone regulation, which in turn can make any direct changes inside the CSF that can cause pathology or lead to any neuropathological disease solely. Additionally, not many studies included were diverse, considering we only gathered mostly those in English. There could have been a possibility of articles directly linking the two in any other language. Moreover, we mainly stuck to articles mostly from the last 20 years except one, and thus had we explored more articles despite their recency, more information could have been extracted.Our review pointed towards the parathormone's concentration and its regulation by the parathyroid gland that can disrupt the neurological and psychiatric system and function by causing any alterations in the CSF. The review was vital to clarify and give enough proofs to establish that markedly elevated and decreased calcium levels both in the serum and CSF can be responsible for affecting one's neuropsychological health. This is to be considered since calcium dysregulation of any sort due to abnormal parathormone flow can cause manifestations and illnesses like cognitive disability, delusions, schizophrenia, schizoaffective disorder, Alzheimer's disease, convulsive episodes, coma in rare cases, and most commonly, depression and other psychotic disorders, however, in some cases, it may be reversible and some mental chronic illnesses may have normal calcium levels. Moreover, it's not just calcium but also how vitamin D insufficiency can lead to depression and hamper neurological well-being. It also provided a few observational studies and analyses that are substantial to show how even parathyroidectomy in hyperparathyroidism cases can serve in improving the quality of life. However, the hypothesis that CSF changes due to parathormone's regulatory dysfunction can play a part in neuropsychological manifestations by altering the calcium or vitamin D concentrations in the body couldn't be authenticated considering we didn't find or include enough substantial studies to validate it, except a few showing increased calcium in CSF as one of the causes for neuropsychiatric features and some other pathologies in the nervous system excluding the CSF. Thus, there is a need to study this more and perform observational studies that are done for a more extended period and include many patients.


Positive and Negative Syndrome Scale total, positive, and general scores were significantly and positively correlated with CSF hepatocyte growth factor (HGF) (p < 0.01) and S100 calcium-binding protein B (S100B) (p < 0.05) levels in patients with schizophrenia. Young mania-rating scale score was significantly and positively correlated with CSF S100B level in patients with BD (p < 0.05). Hamilton Depression Rating Scale, core, sleep, activity, somatic anxiety, and delusion subscale scores were significantly and positively correlated with CSF HGF level, while sleep subscale score was positively correlated with CSF S100B and VEGF receptor 2 levels in patients with MDD (p < 0.05). Our results suggest that CSF APP, GDNF, and NCAM-1 levels are associated with psychiatric disorders, and that CSF HGF, S100B, and VEGF receptor 2 levels are related to psychiatric symptoms.To examine the role of neuroplasticity in the pathology of psychiatric disorders, we measured cerebrospinal fluid (CSF) neuroplasticity-associated protein levels. Participants were 94 patients with schizophrenia, 68 with bipolar disorder (BD), 104 with major depressive disorder (MDD), and 118 healthy controls, matched for age, sex, and ethnicity (Japanese). A multiplex immunoassay (22-plex assay) was performed to measure CSF neuroplasticity-associated protein levels. Among 22 proteins, 11 were successfully measured in the assay. CSF amyloid precursor protein (APP) and glial cell-derived neurotrophic factor (GDNF) levels were significantly lower in patients with schizophrenia, and CSF APP and neural cell adhesion molecule (NCAM)-1 levels were significantly lower in patients with BD, than in healthy controls (all  Impaired neuroplasticity has been targeted for the treatment of BD7 and MDD11. The neuroplasticity hypothesis in psychiatric disorders has been supported by animal models14; however, there is a lack of empirical data in living human individuals supporting the hypothesis.Impaired neuroplasticity, including synaptic plasticity, has been suggested in the pathophysiology of major psychiatric disorders, such as schizophrenia15 and increased protein16 levels of brain-derived neurotrophic factor (BDNF) in patients with psychiatric disorders. Concerning the living human brain, cerebrospinal fluid (CSF) is the optimal biomaterial to examine molecular status since CSF has been reported to well reflect the state of the central nervous system18. Some immunoassay studies measured CSF neuroplasticity-associated proteins, such as BDNF20, nerve growth factor (NGF)21, neurotrophin (NT)-322, and S100 calcium-binding protein B (S100B)27 levels in patients with major psychiatric disorders. Contrary to the previous studies cited above20, we could not detect mature BDNF protein in the CSF, although our western blotting assay found decreased CSF BDNF ‘pro-peptide’ levels in patients with MDD28. Furthermore, we measured CSF neural cell adhesion molecule (NCAM) level using an enzyme-linked immunosorbent assay (ELISA) and found decreased levels in psychiatric diseases, especially BD29. However, other neuroplasticity-associated proteins remain to be quantified in the CSF collected from patients with psychiatric disorders, which warrants further comprehensive immunoassays.Postmortem brain studies reported decreased mRNA30, the technique has never been applied to measure CSF neuroplasticity-associated protein levels. Among many neuroplasticity-associated proteins, 22 were chosen since they could be investigated using commercially available products. This multiplex immunoassay study aimed to measure protein levels simultaneously in a relatively large sample of CSF collected from patients with major psychiatric disorders, or healthy controls to investigate the role of neuroplasticity in the pathology of psychiatric disorders. We tested the hypothesis that CSF neuroplasticity-associated protein levels would be reduced in patients with psychiatric disorders.Although multiplex immunoassay was developed to measure multiple proteins simultaneously32. Consensus diagnosis was determined according to the criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition33, based on the information from the M.I.N.I., additional unstructured interviews and medical records, if available. The majority of patients were under psychotropic medication. Healthy controls had no history of contact with any psychiatric services. According to pre-established criteria, participants were excluded if they had a medical history of central nervous system diseases, severe head injury, substance abuse or mental retardation. After the study had been described, written informed consent was obtained from every participant. The study protocol was approved by the Ethics Committee at the NCNP and performed in accordance with the Declaration of Helsinki34.Participants were 94 patients with schizophrenia , 68 with BD , 104 with MDD , and 118 healthy controls  who were matched for age, sex, and ethnicity (Japanese). BD included both bipolar I and II disorders (n = 22 and 46). There were 83 patients with schizophrenia, 63 with BD, and 78 with MDD under any psychotropic medication. We used a total of 384 samples although their power value was not estimated based on pre-obtained effect size. All participants were recruited at the National Center of Neurology and Psychiatry (NCNP) by advertisement at the NCNP Hospital, on its website and in local free magazines. Participants were screened for psychiatric disorders by qualified psychiatrists by using the Japanese version of the Mini International Neuropsychiatric Interview (M.I.N.I.)36. The Japanese version of the Young Mania Rating Scale (YMRS) was used to evaluate manic symptoms in patients with BD37. The Japanese version of the GRID 21-item version Hamilton Depression Rating Scale (HAMD-21) was used to assess depressive symptoms in patients with BD, and those with MDD39 and 6 subscale  scores were calculated as previously described40. These symptoms were assessed by qualified psychiatrists or research psychologists who were trained before the ratings by using the Japanese version of PANSS, YMRS, and HAMD-21 training manual and digital versatile disc. Daily doses of antipsychotics were converted to chlorpromazine-equivalent doses and those of antidepressants were converted to imipramine-equivalent doses according to published guidelines41. These medication statuses were recorded at the time of lumbar puncture.The Japanese version of the Positive and Negative Syndrome Scale (PANSS) was used to evaluate symptom severity in patients with schizophreniag for 10 min) at 4 °C. The supernatant was divided into 0.5-mL aliquots and stored at −80 °C. Multiplex immunoassays were performed after a single melting and re-freezing of the sample for the preparation of 96-well plates.Lumber puncture was performed in the left lateral decubitus or sitting position during daytime (from 10:00 to 16:00). Smoking habits or fasting conditions were not controlled before the puncture. Each participant received local anaesthesia by lidocaine hydrochloride injection before puncture. CSF was withdrawn from the L3–L4 or L4–L5 interspace using an atraumatic pencil-point needle , collected in a low protein absorption tube  and immediately transferred to ice. The CSF was centrifuged (4000×r > 0.70) in the regression equations of inter-plate adjustment. According to the criteria, the results of 11 molecules  were deemed reliable in the 22-plex assay. The assays that did not meet the criteria  were deemed unreliable. The 11 CSF protein levels were represented as pg or ng/ml.CSF protein level was measured by the MAGPIX CCD imaging system  using magnetic on-bead antibody for specific proteins  based on the manufacturer’s instructions. A custom-made kit (LXSAHM-22) was used to measure neuroplasticity-associated proteins: 22-plex targeted for amyloid precursor protein (APP), BDNF, contactin-1, epidermal growth factor (EGF), ErB2, ErbB3, fibroblast growth factor (FGF) acidic, FGF basic, FGF-23, glial cell-derived neurotrophic factor (GDNF), hepatocyte growth factor (HGF), HGF receptor, NCAM-1, neuropilin-1, beta-NGF, NT-3, ROBO4, S100B, vascular endothelial growth factor (VEGF)-D, VEGF receptor 1, VEGF receptor 2, and VEGF receptor 3. CSF samples were diluted to 1:3 and a fivefold dilution series were used as standard samples (S1–7) according to the results of verification assay. The assay was performed using 384 single CSF samples to secure a large number after confirming that the mean intra- and inter-run coefficients of variance for proteins were less than 5% and 10% in the verification assay, respectively . The VIAFLO 96/384 system  was used to apply samples and reagents into 96-well plates simultaneously. To adjust the inter-assay variations between 96-well plates, 8 independently selected CSF samples  diluted to 1:3 and 2 standards were used as margin samples to fit measures of 4 plates to those of 1 standard plate that included 7 standard dilutions and 1 blank sample (each triplicate). Based on the measures of the margin samples, regression equations were calculated for each protein using two-dimensional scatter diagrams between the standard and other four plates for use in the inter-plate adjustment. Among the proteins assayed, the measurement results that satisfied the following criteria were deemed reliable: within the assay working range, less than 5.0% mean intra-run (7 standard and 1 blank sample [triplicate]) and inter-run (8 CSF and 2 standard samples [pentaplicate]) coefficients of variance, and strong Pearson’s correlation coefficients , while correlation between CSF neuroplasticity-associated protein levels and clinical variables was assessed using the Pearson’s correlation coefficient (Student’s or Welch’s t test only for sex). The correlation matrix among CSF neuroplasticity-associated protein levels was assessed with the Pearson’s partial correlation coefficient, controlling for age, sex and drug use (only for patients). Sidak and Bonferroni corrections were applied for group comparisons (corrected p < 0.05) and correlation analyses (p < 0.05/11 = 0.0045), respectively. All statistical tests were two-tailed, and p < 0.05 was deemed significant. Statistical analyses were performed using the Statistical Package for the Social Sciences version 26.0 .Categorical and continuous variables were compared between three psychiatric diagnostic groups  and the control group using the Chi-squared test and analysis of variance, respectively. We applied parametric tests for analyses of CSF neuroplasticity-associated proteins. CSF neuroplasticity-associated protein levels were compared between the 4 groups and drug-free and non-drug-free groups using multivariate analysis of covariance, controlling for age and sex, and the effect sizes were assessed with partial p = 0.001 and 0.002).The clinical characteristics of the participants are shown in Table p = 0.019 (corrected p = 0.11) and 0.035 (corrected p = 0.21)}, while CSF APP and NCAM-1 levels were significantly lower in patients with BD {p = 0.002 (corrected p = 0.011) and 0.017 (corrected p = 0.097)}, than in healthy controls  and r = 0.28, p = 0.007}. Regarding the subscales, PANSS-positive and general scores were significantly and positively correlated with CSF HGF {r = 0.34, p = 0.001 (significant even after correction) and r = 0.31, p = 0.003 (significant even after correction)} and S100B  levels {Fig. r = 0.28, p = 0.041, Fig. r = 0.27, p = 0.008; r = 0.23, p = 0.023; r = 0.21, p = 0.041; r = 0.22, p = 0.034; r = 0.25, p = 0.015; r = 0.22, p = 0.030, Fig. r = 0.22, p = 0.031 and r = 0.22, p = 0.028; Supplementary Fig. The correlations between CSF neuroplasticity-associated protein levels and symptom scores are shown in Table p = 0.021), there were no significant differences. The correlation between CSF neuroplasticity-associated protein levels and clinical variables is shown in Supplementary Tables p < 0.05, Fig. p < 0.05). Except for a significant and negative correlation between CSF GDNF and VEGF receptor 1 levels in patients with schizophrenia , there were no proteins that showed a significant and negative correlation.The comparisons of CSF neuroplasticity-associated protein levels between drug-free and non-drug-free patients are shown in Supplementary Tables CSF APP and GDNF levels were decreased in patients with schizophrenia, while CSF APP and NCAM-1 levels were decreased in patients with BD, compared with healthy controls. As for the symptoms, PANSS scores were positively correlated with CSF HGF and S100B levels in patients with schizophrenia, while YMRS and HAMD-21  scores were positively correlated with CSF S100B levels in patients with BD and CSF HGF, S100B, and VEGF receptor 2 levels in patients with MDD, respectively. These suggest that neuroplasticity-associated proteins may serve as state- and trait markers in the pathology of psychiatric disorders. Of note, the state-marker proteins promoted symptom severity, suggesting that their functions are inverse to the trait-maker proteins.3 and those with BD7. APP is one of the transmembrane proteins44 related with neuroplasticity45. Hence, the neuroplasticity hypothesis for schizophrenia and BD suggested by animal models14 may be clinically supported by this CSF study. Among APP proteins, the soluble forms are considered measurable in the CSF; however, our multiplex immunoassay could not distinguish the α- and β-forms, secreted by α- and β-secretases, respectively44, although previous ELISA46 and multiplex immunoassay47 reported these forms separately. An ELISA study reported that the CSF-soluble form of APP α, rather than -β, was significantly reduced in 39 patients with BD compared with 71 healthy controls48. It is possible that the neurotropic (non-amyloidogenic) APP-α pathway might have been more reduced in our patients, as well as the neurotoxic (amyloidogenic) APP-β pathway45.Decreased CSF APP level was observed in patients with schizophrenia and those with BD, which is consistent with previous studies reporting impaired neuroplasticity in patients with schizophrenia49. In our previous study29, we reported decreased CSF NCAM-1, particularly in BD, which is further supported by the present result that CSF NCAM-1 level was decreased, especially in patients with BD. As the aforementioned APP, soluble forms of NCAM-1 released from the cell membrane are considered measurable as previously described29. In addition, in a diagnostic group comparison, CSF GDNF level was decreased in patients with schizophrenia compared with healthy controls. To our knowledge, GDNF, a neurotropic factor51, has never been quantified using CSF samples from patients with psychiatric disorders. Although reports of GDNF are still scarce, glial dysfunction may be particularly related with the pathomechanisms of schizophrenia55.NCAM-1 is one of the cell adhesion molecules associated with neuroplasticityp = 0.041), BD: 40.9 ± 15.6 mg/dl (corrected p = 0.38), MDD 42.3 ± 16.3 mg/dl (corrected p = 0.023) and control: 37.6 ± 14.6 mg/dl}. Furthermore, our prior study showed that CSF, a neuroplasticity-associated protein BDNF ‘pro-peptide’-level change, was also downward in patients with schizophrenia and those with MDD28. These support that neuroplasticity impairment is related with the pathology of psychiatric disorders.It is very important that the directions of CSF neuroplasticity-associated protein- (including other non-significant proteins) level changes tend to be mostly downward, while we have the data that CSF total protein level was increased in patients with psychiatric disorders {schizophrenia: 42.4 ± 14.6 mg/dl , unless serious disruption occurs59. Therefore, the observed positive correlation suggests the association of astrocyte activation and BBB dysfunction with symptoms in patients with schizophrenia. CSF S100B level also shows a positive correlation with YMRS and sleep subscale scores, similarly suggesting the involvement of astrocyte activation and BBB dysfunction61 with manic symptoms in patients with BD and sleep disturbance in patients with MDD. However, as for the comparisons with healthy controls, this study showed that CSF S100B level was not altered in patients with psychiatric disorders, which is consistent with studies in 133 patients with BD26 and 31 with MDD24. However, this is inconsistent with studies reporting increased CSF S100B level in a relatively smaller number (n = 21 and 12) of patients with schizophrenia25 and 46 with MDD27.CSF S100B level showed a positive correlation with PANSS total, positive, and general scores in patients with schizophrenia. S100B has been implicated in the pathology of schizophrenia as a marker of astrocytic response and BBB dysfunction63, suggesting that the function is associated with sleep disturbance in patients with MDD.In addition, CSF VEGF receptor 2 showed a positive correlation with sleep subscale score in patients with MDD. VEGF receptor 2 is a subtype of receptor involved in VEGF signaling20, NGF21, and NT-322, our multiplex immunoassay concluded that CSF BDNF, beta-NGF, and NT-3 levels were lower than the assay’s working range. In contrast, CSF S100B level was able to be measured in this study and this is somewhat comparable to an electrochemiluminescence immunoassay24, although incomparable to immunoluminometric assays27 and an electrochemiluminescence immunoassay26, suggesting that the different immunoassays may have somehow influenced inconsistency regarding concentration.Inconsistent with previous ELISA studies regarding BDNF29. Ageing-related processes probably promoted the increased CSF neuroplasticity-associated protein levels; however, the mechanisms remain unclear. Third, relatively lower mean symptom  scores indicate that milder forms of the illness were overrepresented in our patients, which may have minimized the difference in CSF neuroplasticity-associated protein levels between the patients and controls, as well as their correlation with symptom scores. Fourth, the cross-sectional nature precludes determination of the causality. Fifth, a substantial proportion of ‘significant' results became non-significant after correcting for multiple testing; however, we chose to discuss our results based on nominal p values to avoid type 2 errors rather than to decrease the possibility of type 1 errors. Sixth, there may be other trait- or state biomarkers than those presented here, as all kinds of neuroplasticity-associated protein levels were not measured in this study. Finally, it cannot be determined whether the alteration of expression, processing or clearance of significant proteins  results in the association with psychiatric disorders. Postmortem brain studies may be useful to further elucidate the pathomechanisms as previously reported16. Furthermore, we would like to examine the relationship of CSF neuroplasticity-associated protein levels with brain structure and cognitive function in the future.Our study has the following limitations. First, the majority of patients  had been under psychiatric medication, although most CSF neuroplasticity-associated protein levels were not different between drug-free and non-drug-free patients. Second, CSF neuroplasticity-associated protein levels showed a positive correlation with age in all diagnostic groups, which was consistent with our study on NCAM-1In conclusion, our data suggest the involvement of state-  and trait  markers associated with neuroplasticity in the pathology of psychiatric disorders. Recovery from impaired neuroplasticity may be a treatment target in patients with these psychiatric disorders.Supplementary Figure 1Supplementary Table 1Supplementary Table 2Supplementary Table 3Supplementary Table 4Supplementary Table 5Supplementary Table 6Supplementary Table 7Supplementary Table 8Supplementary Table 9Supplementary Table 10Supplementary Table 11


The aims of this study were to compare the efficacy of different androgens measured by liquid chromatography-mass spectrometry (LC-MS/MS) in representing hyperandrogenemia and to evaluate adrenal-origin androgens with a dexamethasone suppression test in patients with polycystic ovary syndrome (PCOS).One hundred and two patients with PCOS and 41 healthy volunteers were recruited and total serum testosterone (TT), androstenedione (AD), dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEA-S) were measured by LC-MS/MS. ROC analysis was performed to compare the efficacy of different androgens in representing hyperandrogenemia. Dexamethasone suppression test was performed in 51 patients with PCOS and above indicators were measured after dexamethasone administration. The prediction efficacy of DHEA and DHEA-S at baseline in the dexamethasone suppression test was evaluated with ROC analysis.. A total of 27.5% (14/51) of patients had DHEA-S excess, but only 1 of 9 patients who had a significant decrease in TT had elevated level of DHEA-S at baseline.The AUCs of TT, AD, free androgen index (FAI) and DHEA-S in ROC analysis for representing hyperandrogenemia were 0.816, 0.842, 0.937 and 0.678, respectively. The optimal cutoff value of TT was 0.337 ng/ml, with a sensitivity of 72.0% and specificity of 82.93%. The optimal cutoff value for AD was 1.309 ng/ml, with a sensitivity of 81.0% and specificity of 73.17%. The optimal cutoff value of the FAI was 2.50, with a sensitivity of 87.0% and specificity of 92.68%. Alternatively, AD or FAI more than the optimal cutoff values as evidence of hyperandrogenemia had the highest sensitivity of 91.18%. The levels of cortisol, DHEA and DHEA-S were all suppressed to narrow ranges after dexamethasone administration. Nine and 8 of 51 patients with PCOS had significant decreases in TT and AD, respectively. DHEA can be used as a indicator for predicting significant decrease of TT in dexamethasone suppression test with cutoff value of 13.28 ng/mlAD measured by LC-MS/MS can represent hyperandrogenemia in PCOS patients and, combined with TT or FAI, can improve the screening efficiency of hyperandrogenemia. Seventeen percent of PCOS patients had adrenal-origin androgen dominance, with TT significantly decreasing after 2 days of dexamethasone administration. Adrenal-origin androgen dominance was not parallel with DHEA-S excess in patients with PCOS. Polycystic ovary syndrome (PCOS), with a prevalence ranging from 6 to 20%, is the most common endocrine disorder that causes infertility in reproductive-aged women, and it is characterized by hyperandrogenemia, chronic anovulation, and polycystic ovary morphology , 2. AndrThe adrenals and ovaries share similar basic steroidogenic enzymatic machinery, and it is difficult to identify androgen from different origins by blood biochemical tests. However, ovarian androgen synthesis is regulated by luteinizing hormone (LH), whereas adrenal androgen synthesis is regulated by adrenocorticotropin (ACTH). Dexamethasone administration can suppress androgen secretion originating from the adrenal gland, and a significant decrease in androgen may represent circulating androgen dominantly originating from the adrenal gland. Dehydroepiandrosterone sulfate (DHEA-S), after peripheral conversion to dehydroepiandrosterone (DHEA), is further converted to AD and contributes indirectly to increased extraovarian testosterone formation . DHEA-S The aims of this study were to compare the efficacy of different androgens measured by LC-MS/MS in representing hyperandrogenemia and to evaluate adrenal-originated androgens with a dexamethasone suppression test in patients with PCOS.The study was approved by the Ethics Committee of the First Affiliated Hospital Shantou University Medical College according to the Council for International Organizations of Medical Sciences. All participants were recruited from the Department of Endocrinology at the First Affiliated Hospital Shantou University Medical College between September 2018 and July 2019. Written informed consent was obtained from all participants. Women with PCOS were diagnosed according to the 2003 Rotterdam criteria, which require the presence of at least two of the following: (1) oligo-ovulation and/or anovulation; (2) clinical and/or biochemical signs of hyperandrogenism; and (3) ultrasound findings of polycystic ovaries in 1 or 2 ovaries, ≥12 follicles measuring 2 to 9 mm in diameter, and/or ovarian volume ≥ 10 ml. Diagnoses of PCOS were made after the exclusion of other etiologies for hyperandrogenemia or ovulatory dysfunction  . All indThe healthy volunteers were recruited via local advertisement from the general community. These healthy volunteers had regular menstrual cycles and normal ovarian morphology. Regular menstrual cycle was defined as menstrual flow occur every 21 to 35 days and last 2 to 7 days. Transvaginal or transrectal ultrasonography was used to assess uterine and ovarian morphology on day 2–5 days of the menstrual cycle and individuals with polycystic ovarian changes were excluded. Individuals who had clinical features of androgen excess, and who were breastfeeding or pregnant within the past year were also excluded from the study. In order to exclude the possible effect of abnormal metabolism on androgens in control population, 41 healthy volunteers with normal blood lipid, blood glucose and BMI were included in this study.2) were calculated. Blood pressure was measured after at least 15 min of rest. Peripheral blood samples were collected from all subjects for TT, AD, DHEA and DHEA-S, sex hormone binding globulin (SHBG), LH, and follicle-stimulating hormone (FSH) measurement.All the participants were asked to come to our department during days 2–4 of spontaneous cycles after an overnight fast. Height, body weight and body mass index . If there was a significant decrease  in serum TT following the 2-day dexamethasone administration, then the diagnosis of hyperandrogenism of adrenal-origin dominance can be made .n = 7) were prepared with testosterone concentrations ranging from 0.01 ng/ml to 10 ng/mL, with AD concentrations ranging from 0.008 ng/ml to 10 ng/ml, with DHEA concentrations ranging from 0.03 ng/ml to 30 ng/ml and with DHEA-S concentrations ranging from 4.8 ng/ml to 4800 ng/ml, respectively. Measurement preparation began with 250 μl of sample added to glass tubes followed by the addition of 200 μl of the internal standard mixture and well vortexed. Activated SPE plate  with 1.0 ml dichloromethane, 1.0 ml acetonitrile and 1.0 ml methanol in turn, and then added 1.0 ml ultra pure water for balancing twice. All the pretreated samples were transferred to the homogenized SPE plate and passed through the column and the waste liquid was discarded. Then 500.0 μl 25% methanol were added and passed through the column. Discarded the waste liquid, and repeated once, and then completely dried the SPE column. Added 1.20 ml dichloromethane to the column to elute steroid hormones and the elute was under a nitrogen airstream. After drying, 60.0 μl 25% methanol was added into the receiving plate, vortexed for 5 min, and then centrifugated . Transferred 50.0 μl of supernatant to the sample plate and prepared for measurement. Separation was performed on a Kinetex® C18 column   which was maintained at 55 °C. The mobile phase, consisting of 1 mM ammonium acetate in water (solvent A) and 1 mM ammonium acetate in methanol (solvent B), was delivered at a flow rate of 0.80 ml/min. The solvent gradient was set as follows: initial 25% B; 40% B, 1.8 min; 70% B, 3.8 min; 95% B, 3.9 min; 95% B, 5.5 min; 25% B, 5.51 min; 25% B, 6.5 min. The mass spectrometer was operated in positive MRM mode. Parameters were as follows: IonSpray Voltage (5500 V), Curtain Gas (40 psi), Ion Source Temp (650 °C), Ion Source Gas of 1 and 2 (60 psi).A liquid chromatography  coupled to tandem mass spectrometry  system were used to quantitate TT, AD, DHEA and DHEA-S with the multiple reaction monitoring (MRM) model in BGI . Steroid hormone test kit was provided by BGI·GBI  and the internal standards included testosterone-IS, A4-IS, HDEA-IS and DHEA-S-IS. Calibrators  with intra- and total CVs of < 5.3 and < 6.6%, respectively. Levels of serum FSH, LH and cortisol were measured by radioimmunoassay . The free androgen index (FAI) was calculated with the formula FAI = TT(ng/ml)*100*3.467/SHBG (nmol/L) (1 ng/ml = 3.467 nmol/L for TT).P < 0.05 was considered statistically significant.The area under the curve (AUC) for the receiver operating characteristic (ROC) curves, the cutoff values, and the test performance characteristics were obtained from MedCalc. The optimal ratio value for each clinical condition was defined as the value on the ROC curve that was associated with the minimum Euclidean distance from the curve to the upper left corner of the graph using Youden’s index according to the formula P < 0.001), TT (P < 0.001), AD (P < 0.001), DHEA-S (P = 0.002), FAI (P < 0.001), LH (P < 0.001) and FSH (P = 0.039) and lower levels of SHBG (P < 0.001) than the control group. Age and DHEA were not significantly different between these two groups.In this study, 102 patients with PCOS and 41 healthy volunteers were recruited. Clinical and hormonal variables are described in Table P < 0.001) and DHEA  but not with DHEA-S. AD was positively correlated with DHEA  and DHEA-S . DHEA was positively correlated with DHEA-S . For the healthy volunteers, TT was positively correlated with AD  but not with DHEA and DHEA-S. AD was positively correlated with DHEA  and DHEA-S . DHEA was positively correlated with DHEA-S . All the subjects were taken into consideration, and TT, AD, DHEA and DHEA-S all had positive correlations with each other.The results of the correlation analysis among different kinds of androgen in PCOS patients and healthy volunteers are shown in Table P < 0.001), AD  and BMI  were factors influencing TT in PCOS patients, whereas SHBG  and AD  were factors influencing TT in healthy volunteers.TT was most commonly used for PCOS diagnosis according to the instructions of the PCOS guidelines . To screP < 0.001), 0.842 , 0.678  and 0.937 , respectively. The AUC of the FAI was significantly larger than that of AD, TT and DHEA-S , whereas the AUCs of AD and TT were significantly larger than that of DHEA-S . The AUCs of TT and AD were not significantly different. DHEA had no value in screening for PCOS.To compare the value of different androgens for representing hyperandrogenemia in PCOS patients, ROC analysis was performed and the results are shown in Table The optimal cutoff value of TT was 0.337 ng/ml, with a sensitivity of 72.0% (95% CI: 62.1–80.5%) and specificity of 82.93% (95% CI: 67.9–92.8%). The optimal cutoff value for AD was 1.309 ng/ml, with a sensitivity of 81.0% (95% CI: 71.9–88.2%) and specificity of 73.17% (95% CI: 57.1–85.8%). The optimal cutoff value of DHEA-S was 1887.057 ng/ml, with sensitivity 86.0% (95% CI: 77.6–92.1%) and specificity 48.78% (95% CI: 32.9–64.9%). The optimal cutoff value of the FAI was 2.50, with a sensitivity of 87.0% (95% CI: 78.8–92.9%) and specificity of 92.68% (95% CI: 80.1–98.4%).Levels of TT and AD higher than their optimal cutoff values were defined as high levels of TT and AD, respectively. Eleven patients with PCOS had elevated levels of AD but normal levels of TT, whereas only 2 patients had elevated levels of TT but normal levels of AD. The other 89 patients had the same trend in TT and AD.To improve the values of different androgens for representing hyperandrogenemia for patients with PCOS, combined androgens were used for analysis, and the results are shown in Table P < 0.05), and the optimal cutoff value of DHEA was 13.28 ng/ml, with a sensitivity of 66.67% (95% CI: 30.1–92.1%), a specificity of 84.44% (95% CI: 0.5–93.5%), a positive predictive value of 46.2% (95% CI: 19.3–74.8%) and a negative predictive value of 92.7% (95% CI: 80.1–98.4%). DHEA-S at baseline had no such predictive value for the 2-day dexamethasone suppression test.A two-day dexamethasone suppression test was performed in 51 patients with PCOS, and the results are shown in Fig. In total, 23 patients had elevated DHEA levels of more than 13.28 ng/ml in this cohort of 102 PCOS patients. According to the sensitivity of 66.67% of this index, it is predicted that 15 patients have adrenal-origin androgen dominance.DHEA-S was used as an index representing adrenal-origin androgen excess –11. In oTT has been widely used as an evaluation index of hyperandrogenemia, but there are still some problems. First, chemiluminescence is currently used for TT determination in most clinical chemistry laboratories. However, DHEA-S which is the most abundant sex hormone precursor produced by the adrenal gland, is present in 1000-fold higher concentrations than testosterone and seriously interferes with the determination of testosterone . KnudsenAD is not as widely measured in clinical departments as TT; however, the clinical value of AD is not lower than that of TT. AD and TT, but not any other androgen precursors, are key steroid hormones in obese adolescents with PCOS , and AD . The prevalence of DHEA-S excess is 10–64% in previous studies [Females have two main androgen origins: the ovary and the adrenal gland. These two glands share the same enzyme system in the process of androgen biosynthesis, and the intermediate and end products of androgen are basically the same . The mea studies , 22, 23, studies . This ex studies . O’Reill studies . WhetherDifferent androgen origins have different regulatory mechanisms. Ovarian androgen synthesis is regulated by LH, whereas adrenal androgen synthesis is regulated by ACTH . TherefoThe most important implication of determining the dominant source of androgen for PCOS patients is to assist in making the treatment plan. Vanky showed that six-month, low-dose dexamethasone treatment further reduced androgen levels in metformin-treated PCOS women . PhysiolAD measured by LC-MS/MS can represent hyperandrogenemia in PCOS patients and, combined with TT or the FAI, can improve the screening efficiency of hyperandrogenemia. Seventeen percent of patients had adrenal-origin androgen dominance, with TT significantly decreasing after 2 days of dexamethasone administration. A total of 27% of patients had DHEA-S excess, but DHEA-S excess was not parallel to adrenal-original androgen dominance in the patients of this study.


Donor conception creates families with varying genetic linkage between family members. This may have short-term as well as lifelong psychosocial consequences for all involved. Gamete donors have traditionally been anonymous to recipients and offspring, but there is a growing trend towards identity-release donor programmes that give offspring the right to obtain the donor’s identity. This review aims to provide an overview of the perspectives of donors and recipients and offspring involved in identity-release donation. The results show that both oocyte and sperm donors have primarily altruistic motives, and recipients, in particular lesbian and single women, are generally open about the donation to their offspring. The few existing studies on offspring perspectives indicate that those who are aware of their donor conception appear to be interested in contact with the donor, and most donors are open to such contact. Investigations of donors and recipients indicate a need for more counselling and support to manage family life with varying genetic linkage within and outside the family unit. This includes preparing for and managing future contact between the donor and his/her family and donor offspring and their family, as well as between donor siblings and their respective families. The desire to have a child is based both on psychological and social reasons. Assisted reproduction treatments have made it possible for many individuals/couples to have a family even when sperm and oocytes are reduced or lacking. Large numbers of children are born following donor conception, and there is an increasing demand for donor conception worldwide. Depending on legislation and regulations, treatment with donor sperm, oocytes, and embryos is available to various groups of recipients, including heterosexual couples, lesbian couples, and single women. Donor conception has traditionally been performed with anonymous donors, while it has been less common to use a donor who is ‘known’ to the recipient(s), most often a female relative who donated oocytes. There is a global trend towards programmes using donors that are identifiable to the resulting offspring at maturity, commonly labelled ‘identity-release’ or ‘open-identity’ donors. The use of identity-release donors implies that the donor is anonymous to the recipients, although they may receive some non-identifying information about the donor. Upon request from a donor-conceived child that has reached mature age, the donor’s identity is released to the child. Legislation on identity-release gamete donation was first introduced in 1985 in Sweden , the donor-conceived child, and their larger family. There is a relatively large body of research on the psychosocial aspects of anonymous donor conception, and to a lesser extent on ‘known’ donation. Systematic reviews in the field show that both oocyte and sperm donors’ psychosocial wellbeing was good throughout all donor groups  ,3, and fThe purpose of the present review is to summarize the available research on psychosocial aspects of identity-release gamete donation. Furthermore, we want to present an overview of the specific perspectives of donors, recipients, and offspring, including motivations for participating in this type of donor conception, as well as perceptions of disclosure issues and potential contact between donor and offspring/family. PubMed and PsycInfo databases were used in order to search for relevant empirical studies. Due to the diverse use of terminology for this type of donation  it is possible that some studies including relevant groups were missed. This overview covers only studies that specifically noted the inclusion of donors, recipients, or offspring involved in identity-release donation, but does not include studies on surrogacy, although such arrangements frequently include donor gametes. In several studies, a small subset of participants concerned identity-release donation. Such studies were included provided that they presented results from these groups separately, and were otherwise excluded e.g. ,8]. Not . Not 8)]By definition, the term donation implies altruism, and both male and female donors who agree that their identity may be released to offspring at maturity have been found to donate primarily or solely based on altruistic reasons, i.e. they want to help involuntarily childless people . HoweverThe personalities and characters of gamete donors are of interest for the recipients but also for the resulting offspring. In a Swedish national study, the Temperament and Character Inventory  was usedLittle is known about donors’ view of informing others, such as partners and biological children, about their donation. In two Swedish survey studies, each including 30 sperm donors, almost all had shared information with their partner about their intention to donate  or of beFor identity-release gamete donors, the number of children conceived with their gametes is of particular interest, since the offspring will be able to obtain the donor’s identity and may attempt to contact the donor. However, only one study was found investigating donors’ views regarding the number of children a donor may conceive . About hIn two Swedish qualitative studies, each including 30 sperm donors, most of them were positive or neutral towards contact with adult offspring from their donation ,20. ThisThe experiences, satisfaction, and consequences of being an identity-release gamete donor, i.e. with respect to the medical care and treatment, have been investigated in a few structured follow-up studies. In a Finnish follow-up study of 428 former oocyte donors, 67 of which were identity-release, almost all were satisfied with their donation . SimilarIn a qualitative study from the Netherlands, male donors expressed a need for counselling in order to discuss the emotional consequences of their donation, disclosure to their own children, family, and friends, and potential future contact with an offspring . In a SwIn general, reasons for choosing treatment with donor gametes include having a biological tie to the child, desiring to experience a pregnancy and to have a child who has a genetic link to at least one parent. The most common reasons for choosing identity-release sperm donation stated by heterosexual-couple, lesbian-couple, and single-woman parents in a US study were that this gave the child the option of getting more information about the donor, including his identity, and the option to be able to meet him . In a USIdentity-release donation gives the offspring an option to obtain identifying information about the donor. However, offspring can only make use of this option if he/she has been made aware of the donor conception, most often by his/her parents. In a Swedish study of 148 heterosexual couples with children conceived through donor insemination in the years directly after the law was introduced, only 11% had informed the child about the donor conception, 46% planned to disclose later, and one-third were unsure or planned not to disclose . Those wA UK study investigated disclosure to offspring among 31 heterosexual solo mothers and 47 heterosexual-partnered mothers with donor-conceived children aged 4–8 . About hSeveral studies have found that large groups of recipients had told other persons about their use of gamete conception ,37–39, wWhen a couple conceives with donor oocytes or sperm, this creates a family where the child has a genetic link to only one of the parents. The presence and/or absence of genetic linkage, as well as the existence of an identifiable donor, may have psychosocial consequences for the couple and the family. Two Swedish interview studies of heterosexual couples following sperm donation concerned family life. Leeb-Lundberg et al.  reportedIn the longitudinal ‘Swedish Study of Gamete Donation’, recipient couples of donor oocytes and sperm were followed 2–5 years after treatment. Heterosexual couples that had been treated with sperm donation expressed satisfaction with their relationship , and couWhile a previous study in the USA indicates that, following donor insemination, heterosexual couples, lesbian couples, and single women were positive about their decision and were quite open about the donor conception , lesbianWhen children conceived with gametes from identity-released donors grow up, parents need to deal with the question of disclosure to the child. In a study of 111 heterosexual couples following oocyte and sperm donation, one-third were not in agreement about what to disclose to their child about his/her conception, and these couples reported a lower relationship quality than couples who agreed about disclosure . HoweverIn a Swedish study including 279 heterosexual recipient couples of donor oocytes or donor sperm, about half believed that it was in the best interest of the child to be able to obtain identifying information about the donor, while the remaining were unsure, neutral, or negative . While fThere is a dearth of research including the perspectives of persons conceived with gametes from donors who originally chose to donate within an identity-release programme, and all concern persons conceived with donor sperm. Scheib and co-workers have presented several studies based on donors, recipients, and their offspring from one sperm bank that has offered identity-release donors since 1983. One interview study included 29 adolescents conceived with sperm from open-identity donors, from households led by lesbian couples, single mothers, and heterosexual couples . A majorOnly one study was found that reported on the final step of an identity-release donor programme, i.e. requests and provision of identifying donor information to adult offspring. In a follow-up study, Scheib et al.  reportedThe aim of this review was to provide an overview of the perspectives of donors, recipients, and offspring involved in identity-release donation. Identifiable donors of oocytes and sperm predominantly reported altruistic motives, in line with motives reported for anonymous and known donors ,3. StillConcerning the perspectives of offspring conceived with gametes from identity-release donors, the present review highlighted the very limited knowledge base for this specific group. Only four studies were found ,26,52,53The studies covered in the present overview were performed in Europe and the USA and included quantitative and qualitative studies with cross-sectional, retrospective, and longitudinal designs. Studies of individuals involved in gamete donation are frequently based on single clinics and suffer from relatively low response rates, which limits the generality of the findings. Research on donor-conceived offspring is hampered by specific difficulties identifying this population, as it is ethically only possible to approach individuals who are aware of their donor conception. Recruitment of participants through self-selection, e.g. membership in networks for donor conception, is feasible but introduces a selection bias. Thus, there is a lack of knowledge about the perspectives of donors, recipients, and offspring who are not interested in seeking information about genetically related persons. Also, the number of long-term follow-up studies in this field is limited, and attrition is a matter of concern, as in all longitudinal designs.Changes in legislation, DNA-based voluntary contact registers, and direct-to-consumer genetic tests constitute new challenges and may have great influence for the future for assisted reproduction with donor gametes. The possibility of identification of genetically related individuals may have an impact not only on donors, recipients, and offspring, but also on their extended families . The neeIn conclusion, donor conception creates families with varying genetic linkage between family members and where there are genetic links to individuals outside the family unit. In the case of identity-release donation, the offspring has the opportunity to obtain identifying information about his/her donor. Existing research about the perspectives of donors and recipients involved in identity-release donation indicates that both oocyte and sperm donors primarily have altruistic motivations and that recipients are increasingly open about having used donor conception. Furthermore, several studies indicate that the offspring are interested in contact with the donor, and most donors are open to such contacts. Keeping in mind the lifelong consequences of identity-release donor conception, recipient families and donors could benefit from support and counselling to increase their confidence in managing family life. In view of the present findings, as well as the rapid development and increasing use of resources to identify genetic relatives, more high-quality research is warranted on the long-term psychosocial consequences of gamete donation.


The aim of the present paper is to examine to what extent the application of surface electromyography (sEMG) in the field of exercise and, more in general, of human movement, is adopted by professionals on a regular basis. For this purpose, a brief history of the recent developments of modern sEMG techniques will be assessed and evaluated for a potential use in exercise physiology and clinical biomechanics. The idea is to understand what are the limitations that impede the translation of sEMG to applied fields such as exercise physiology. A cost/benefits evaluation will be drawn in order to understand possible causes that prevents sEMG from being routinely adopted. Among the possible causative factors, educational, economic and technical issues will be considered. Possible corrective interventions will be proposed. We will also give an overview of the parameters that can be extracted from the decomposition of the sHDEMG signals and how this can be related by professionals for assessing the health and disease of the neuromuscular system. We discuss how the decomposition of surface EMG signals might be adopted as a new non-invasive tool for assessing the status of the neuromuscular system. Recent evidences show that is possible to monitor the changes in neuromuscular function after training of longitudinally tracked populations of motoneurons, predict the maximal rate of force development by an individual via motoneuron interfacing, and identify possible causal relations between aging and the decrease in motor performance. These technologies will guide our understanding of motor control and provide a new window for the investigation of the underlying physiological processes determining force control, which is essential for the sport and exercise physiologist. We will also illustrate the challenges related to extraction of neuromuscular parameters from global EMG analysis  and when the decomposition is needed. We posit that the main limitation in the application of sEMG techniques to the applied field is associated to problems in education and teaching, and that most of the novel technologies are not open source. Traditionally, the acquisition of EMG signals is prevalent to clinical contexts—neurology, orthopedics, physiatry—and, to the best of our knowledge, it almost always involves needle/fine wire EMG. The usage of surface EMG (sEMG) for the study of motor control is primarily applied to research environments. Only few clinical laboratories adopt sEMG measures to estimate the health and potential neuromuscular changes of the nervous system. The limited usage of sEMG only to research environments is mainly dictated by the fact that the global EMG signals is associated to the activity of many motor units and the properties of the tissue between the electrodes and the muscle fibers . HoweDespite these advantages, there are major limitations for the access of sEMG analysis to exercise physiology. These limitations include the education of the exercise and sport physiologist, occupational therapists, and fitness and training experts. There is now sufficient evidence to show that it is possible to interface the output of the human spinal cord by applying high-density grids of electrodes on the surface of the muscles , 13–15. Nevertheless, as already pointed out by many authors , 16, 17 The motor unit, which comprises an alpha motoneuron and the muscle fibers innervated by its axon, represents the output final common pathway of the central nervous system. Therefore, the behavior of these individual neural cells, provides important information on the status and health of the neuromuscular system. Indeed, motoneurons convey information from afferent and efferent fibers within the sensorimotor system and generate force by sending action potentials to group of muscle fibers (the muscle units). Any potential changes in the distribution and strength of common input sent to motoneurons can likely be assessed by decoding a representative population of motoneurons, as we showed in many studies , 18–21.Our group has recently provided evidence that is possible to predict important behavioral parameters such as the maximal contractile speed of muscle , 22 and Another critical aspect that is fundamental for sport and preventions of injuries is the rate of force development of a muscle –26. WithWe investigated the role of education by looking at the first 100 bachelor and master courses, of the top 100 university (extracted via QS World Ranking and Shanghai Ranking) in the area of Human Movement, Biomechanics, Sport Science, Physiotherapy and Exercise Physiology, and we found that only a very limited number  teaches students the fundamental principles for studying the neural control of muscles at the direct motor unit level. Specifically, we aimed at finding direct evidence of theoretical or practical (lab-based) teaching of the fundamental principles of motor unit physiology and the potential methods available to the research/clinical environments. However, the full details of the course of neurophysiology for several university  was not publicly available or not found.One major limitation is the access to these technology to both research and non-research environments. There is critical need to open the access of these technologies and to instruct teachers across the disciplines of these fundamentals. Although the physiological principles and engineering developments strongly suggest that it is now the time to routinely monitor the spinal cord output by non-invasive high-density EMG recordings, we are failing to generalize and give access of these developments to the current generation of students, which would improve the applied translation in order to potentially predict and cure pathologies of the neuromuscular function. This has an impact, for example, on the student awareness level of some very simple points related to the correct collection of sEMG data. Issues such as electrodes location, innervation zone detection, skin preparation, movement artifacts and sweating are very often ignored.Before coming to the most up to date sEMG technical developments, let us consider the simplest case, were one wants to describe the timing of muscle activations during the execution of a given motor task—as walking on a flat terrain—by means of bipolar sEMG recordings. Human locomotion, in its various forms, can be used as a paradigmatic example of application of sEMG to the study of dynamic exercise. Walking involves a series of coordinated movements of the body segments, implying an interplay of muscular forces and external forces  in order to achieve locomotion of the body . The impAs already pointed out by previous papers, to facilitate the systematic interpretation of sEMG gait data, stride-to-stride variability needs to be assessed before any particular stride is considered representative of subject's performance . AveragiMoreover, it would be important to associate gait parameters to the firing synchrony of multiple motoneuron pools. For example, the neural motor commands extracted from factorization analyses applied to multi-EMG recordings  may be aIt is immediately evident from the above example that an interdisciplinary approach is needed, commonly known with the term neuromechanics . The manAs described above, it is clear that to have an overview of our body in motion we must link direct cellular behavior to function. These tasks can now be achieved by the decomposition  of HDsEMG signals. Although the acquisition and analysis is relatively automatic, there is need of careful inspection of the signals . There iAnother important main factor limiting the wide use of these technique is represented by the limited access to the software needed for separating the motor unit action potentials in the sEMG. Different research groups have proposed algorithms to decompose the sEMG interference signals, however, none of these approaches have been published open source. All of these problems impede the translation of HDEMG analysis to the applied field.The aim of this short communication also includes to provide an opinion on the costs/benefits ratio regarding the use of novel sEMG techniques. First, what is meant, or better felt, by academics with respect to benefits. The probability of a work to be published is surely one of the perceived benefits. More important than this, though, is the probability to be cited a significant number of times. This, in turn, has an impact on the probability of a successful grant application. In the case of sEMG based papers this probability is limited due to the relatively small number of researchers in the field. Besides, also in sEMG parochial environment, the most cited papers are, or at least were until recently, those more technical in nature, while basic and applied physiology papers were less cited and appeared on medium level journals. As a consequence, in this specific application, basic and applied physiology have generated limited benefits to academics, both in terms of their personal achievement and in terms of financial support. It seems that this trend is now quickly , 20, 29 It is also to be considered that professionals need to have sEMG equipment that are feasible for the field usage. To this respect, wearable devices although promising are not fully mature, particularly on a high-density EMG scale .What about benefits for companies? Selling devices to a large set of potential users is the obvious goal of a firm. In spite of this, the dissemination of information about their specific products is left mostly to standard internet channels. In our opinion, companies should increase their investments on peer to peer formation of end users provided these latter have been adequately formed by academics (see above).Companies should also think in terms of application to sport, rehabilitation, clinical evaluation in order to increase the demand from the market. This will increase their earnings, allowing at the same time a reduction of the monetary costs for the clients, irrespective from being an academic or a professional. As a matter of fact, not only the most sophisticated and reliable equipment are somehow still very expensive , but so are the consumable associated with these instruments.At the very end, it turns out that to overcome the present limitations of a large diffusion of sEMG in applied and allied sciences, a joint serious effort is needed from the many actors involved. There is not a single responsible for this situation and this, maybe, makes the problem complicated.All authors contributed in equal part to conceptualization and writing of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.