While decreased hip abductor strength, functional performance, and self-reported instability scores have all been shown in association with CAI, any sex difference in the relationship between these indicators is unclear. This study was to determine whether sex differences are present in the relationship between these indicators in individuals with CAI.t-tests and correlation analysis were conducted.Thirty-two women and twenty-nine men with unilateral CAI took part. Hip abductor strength and functional performance were respectively assessed using a hand-held dynamometer and the figure-8-hop test. All 61 participants scored the Cumberland Ankle Instability Tool (CAIT) for self-reported ankle instability. Independent sample p = 0.003) and functional performance (p = 0.001) on the affected side in females, but not in males (p = 0.361 and p = 0.192 respectively).Normalized hip abductor strength and functional performance measures for females were lower than for males. The self-reported ankle instability CAIT score, where higher values represent less instability, was significantly and positively correlated with both normalized hip abductor strength (Sex differences were observed in that there were significant relationships between normalized hip abductor strength, functional performance, and CAIT scores in female CAI participants, but not males, suggesting that CAI evaluation and rehabilitation strategies should be sex-specific.In females with CAI, hip abductor strength and functional performance showed significant relationships with self-reported instability scores.Correspondingly, in clinical practice with individuals with CAI, evaluation criteria may be formulated according to these observed sex differences.Sex differences should be factored into the evaluation and treatment of CAI individuals.Hip strength assessment should be employed with CAI individuals.Hip strengthening and functional hopping may be recommended for the rehabilitation of CAI, especially in female patients. Ankle sprain is considered to be one of the top 10 sports injuries . A well-CAI populations are defined by their lower self-reported ankle function across a variety of tasks, and they frequently display deficits in functional performance. In a previous study, the relationship between function in CAI individuals and the Foot and Ankle Ability Measure (FAAM) and the Foot and Ankle Outcome Score (FAOS) was examined, and these two functional scales were found to be significantly related to hip strength, ankle strength and balance . The CumIn addition to symptom scores, CAI individuals also have decreased functional performance. The figure-8-hop test is a functional task that requires speed, power, and agility, and it challenges the stability of the lower limb joints in individuals with CAI. The test provides high clinical utility, and is widely-used with CAI populations. In their results, Docherty et al.  found a This study aimed to explore sex differences in the relationships between hip abductor strength, functional performance, and self-reported instability scores in CAI individuals. It was hypothesized that hip abductor strength and functional performance would be positively related to self-reported instability scores, but that these relationships may differ between males and females. Given the incidence of acute ankle sprains and CAI found in females, it could also be hypothesized that stronger relationships between hip strength, functional performance, and self-report CAIT scores would be found in females compared to males. The importance of this is that if the relationship between these measures for males and females with CAI is distinctly different, evaluation criteria may need to be adjusted and targeted interventions designed that account for any sex differences.Sixty-one participants of both sexes who were aged between 18 and 45 years were recruited through advertisements. The female group consisted of 32 participants, and the male group consisted of 29 participants, both determined using a diagnosis of unilateral CAI made by following the International Ankle Consortium's criteria for CAI obtained from Gribble et al. . InclusiThis cross-sectional study was conducted without any intervention. Upon enrolling in the study, participants first completed the Cumberland Ankle Instability Tool, evaluating the stability of both ankle joints. Participants were not blinded to the purpose and details of the study, but blinded to the study hypothesis. Then, hip abductor strength and functional performance were measured and documented by an experienced physiotherapist who was blinded to the study purpose and hypothesis, and to the CAIT score of each participant. The order of testing hip abductor strength and functional performance was randomized. A statistician who was blind to the study hypothesis performed the data analysis.Participants were asked to complete the CAIT to determine the severity of their subjective symptoms associated with ankle instability. The CAIT  is a ninA MicroFET2 hand-held dynamometer  was used to measure maximal voluntary isometric contraction of the hip abductors. The device has a battery-operated load-cell system that provides a digital reading of peak force, expressed in Newtons, and was calibrated before testing. Femur length was measured by a tape from the femoral trochanter to lateral knee joint line, for normalization of isometric hip strength outcomes. Test–retest reliability for the dynamometer measure of hip abductor strength is good (Intraclass correlation coefficient = 0.76) . During One practice trial was followed by three test trials. Standardized instructions were given where participants increased contraction intensity for the first three seconds, then provided maximal effort for the fourth and fifth seconds. The maximum force measured was used as the participant’s peak force. Because participants differed in femur length and body weight, the standardized final outcome measure of hip abductor strength was calculated using the following equation: .\documenThe figure-of-8 hop test is a dynamic measure used to assess general lower body function for individuals with CAI. This test requires speed from participants, the subjects, with a faster speed meaning less time taken, and a better score. Results from this test have been positively correlated with answers to questions on self-reported feelings of ankle instability, indicating that greater feeling of instability is related to increased time taken to complete the test . Test ret-tests were used to examine between group differences. Separate Spearman’s correlations were conducted between normalized hip abductor strength and CAIT scores, and functional performance and CAIT scores, within each group. The relationship between hip abductor strength and functional performance was examined by Pearson’s product moment correlation coefficients within each group separately. Correlation coefficients of 0–0.3, 0.3–0.5, and 0.5–1.0 were considered to represent weak, moderate, or strong correlations, respectively [The Kolmogorov–Smirnov test was used to examine normality of the data distribution. Demographic characteristics of both female and male groups are presented in Table ectively . All stap > 0.05). Normalized hip abductor strength for male participants was significantly greater than that of female participants on affected sides (p < 0.05). Male participants performed significantly better than their female counterparts in the figure-of-8 hop test for the affected side (p < 0.05).The age, height, weight, and BMI of the female group were significantly lower than those of the male group Table . Female p < 0.01), indicating a moderate positive correlation (Table p < 0.01) in female participants with CAI, indicating a moderate negative correlation (Table p > 0.05).Clear differences were observed in the correlation measures between female and male CAI individuals. In females with CAI, self-reported ankle instability scores were significantly correlated with normalized hip abductor strength on the affected side .In this cohort of individuals with CAI, normalized hip abductor strength was moderately and significantly correlated with functional performance on the affected side with r values that ranged from − 0.44 to − 0.37  scores in males and females with CAI. A statistically significant correlation between hip abductor strength, functional performance, and CAIT scores was observed in female, but not in male, participants, an outcome consistent with our initial hypothesis.While baseline demographics of participants showed significant difference between the two groups, participants in this study were sampled by convenience and the results showed that the female participants were significantly younger than the male participants. Research has shown that in adults the general rule is ‘the younger the stronger’ . TherefoThe present finding may be related to sex differences in anatomical structure and postural control patterns. The quadriceps angle (Q angle) is an important indicator of biomechanical function and normal alignment of the lower leg, providing useful information regarding the functional ability of the lower extremity. The Q angle of women is approximately 5.8° larger than that of men. With greater Q-angles, women are therefore believed to be at greater risk of patellofemoral pain than men . It may Compared to males, women's functional performance was also more strongly correlated with CAIT scores. This may be related to sex differences in one-leg jump landing strategy and fear of ankle re-sprain , 26. PreThe significance of this study is that exploration of the correlation between normalized hip abductor strength, functional performance and CAIT scores in male and female patients with CAI revealed different correlations in CAI individuals of different sexes. Specifically, statistically significant correlation was found for female, but not male, normalized hip abductor strength, functional performance, and CAIT score. Thus, in future rehabilitation evaluation, corresponding evaluation criteria should be formulated according to sex differences, to aid prompt return to sport. For women, hip abduction strength assessment should be used routinely. Moreover, female CAI patients should get more attention regularly in clinical settings, especially in relation to their hip abductor strength, and targeted interventions should be implemented to solve the problem.This study has some limitations. First, the time after ankle sprain differed among participants. After a longer time, ankle injury may have a chronic psychological impact, affecting self-reported instability . The CAIOne previous study showed that normalized hip abductor strength training could effectively improve neuromuscular control, strength, and self-reported function in individuals with CAI , and a rIn females but not in males with CAI, statistically significant relationships were found between normalized hip abductor strength, functional performance and self-reported instability scores. In the future, CAI evaluation criteria should be formulated according to sex differences, and attention paid to hip strengthening and functional hopping in CAI rehabilitation with female patients.


There are paucity of studies on current fertility desire at community level.To assess current fertility desire and its associated factors among eligible couples of reproductive age group in Puducherry, India.A community-based cross-sectional study from 2016 to 2017 among 2228 currently married eligible couples assessed socio-demographic and fertility-related factors associated with fertility desire. Data were collected based on the National Family Health Survey questionnaire. Association of fertility desire was assessed by univariate and generalised linear regression analysis.Out of 1979 respondents, current fertility desire within two years was 13.7% . Mean number of children (SD) currently living and preferred was 1.77(0.851) and 2.11 (0.528) respectively. After adjusting for confounders, the significant factors positively associated with fertility desire include woman's age of 18–24 (APR = 2.91), 25–29 years (APR=2.48), 30–34 (APR=2.47), 35–39(APR=2.06), high socioeconomic status (APR=2.02), those without child (APR=52.35) and those with one child (APR=35.60).The fertility desire is comparatively lesser than other areas. Those without or with a single child and high socioeconomic status group had comparatively more fertility desire. Total Fertility Rate (TFR) has declined globally in recent years. The global TFR declined from 3.2 births per woman in the year 1990 to 2.5 births per women in the year 2019. In sub-Saharan Africa, TFR reduced from 6.3 to 4.6 during the same period Sustainable Development Goal targets 3.7 mentions that by the year 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmesMany studies on fertility desire were conducted among HIV infected eligible couples Fertility desire can be associated with number of factors related to individual, family or health care service availability characteristics. At the individual level, age, education, number of living children, number of living son or sex composition, history of abortion, age at marriage, marital life was the important associated factors This community-based cross-sectional analytical study was approved by Ethics and Scientific Committee of a tertiary care institution in Puducherry, coastal south India. Prior written permission was obtained from Deputy Director of Health Services, Government of Puducherry. Written informed consent was obtained from the study subjects.This study is a part of a project which had assessed the contraception prevalence and factors associated with unmet need for family planning among currently married women of reproductive age group in selected rural and urban area of Puducherry, India. All the eligible couples were recruited by two-stage cluster sampling method.Considering fertility desire as 63%Sampling technique was summerised in Initially, Mettupalayam PHC from urban Puducherry and Koodapakkam PHC from rural Puducherry were selected by simple random technique. Then, two areas were selected from the already selected two PHCs which included Shanmugapuram and Sonarpet areas attached to Mettupalayam PHC (Urban) and Koodapakkam and Konerikuppam areas from Koodapakkam PHC . These were selected purposively and we assume that this selection procedure will result in minimal bias because of homogeneity in socio-demographic and other characteristics in selected PHCs.Baseline data was collected for a period of one year (from 30.08.2016 to 29.08.2017) by a trained Auxiliary Nurse Midwife and supervised by investigators. Sociodemographic characteristics and household details were collected from all the currently married eligible couples using a pre-tested questionnaire. It also captured the women's personal information like include number of living children, number of living sons, age at marriage, urban or rural area, distance to health facility, family type, number of abortions etc. House to house visits were done to reach the participants. If the participants were not able to meet in first house visit, further two visits were made to reach them. Women who were not approachable even after three visits were considered as non-respondents. The questionnaire was prepared based on National Family Health Survey, India18 and revised Uday Parik scale was used to assess the socio-economic status.Fertility desire was assessed by asking the question “Would you like to have a child or would you prefer not to have any more children?” If somebody says ‘yes’ then they have asked about “How long would you like to wait from now before the birth of another child?” The responses to question are: (a) would like to have a child (b) prefer not to have a child anymore; (c) cannot get pregnant; (d) undecided or don't know. Respondents, who want another child are then asked: “How long would you like to wait from now before the birth of another child?” The answer includes (a) number of months (b)now (c) I cannot get pregnant (d) undecided. The waiting period was categorised as now, 0 to 12 months, and 13 to 24 months which was included for calculating current fertility desire. More than 24 months waiting period was an unmet need for spacing methods. Data regarding other associated factors with current fertility desire which include number of living children, number of living sons, age at marriage, urban or rural area, distance to health facility, family type, number of abortions were collected.Data were entered in Excel spreadsheet and analyzed by using STATA version 14  was used for analysis. The women with the fertility desire were expressed with proportions with 95% Confidence Intervals (CI). Univariate analysis was performed and unadjusted prevalence ratios (UPR) with 95% CI was calculated. Variables with a p-value less than 0.2 in the univariate analysis were included in the generalised linear regression analysis model to estimate the adjusted prevalence ratios (APR). A p-value of less than 0.05 was considered statistically significant.th standard.  were aged between 18–29 years and a quarter of them  were 40–49 years. Majority aged at marriage by 18 to 24 years of age  and more than half of them  had 2 children. Nearly, 80% (1576) were belonged to low socioeconomic status, and half 51.2%, 1014) were educated more than 10tandard. Current fertility desire within next two years was found among 13.7% (95% CI -12.3% – 15.3%) of the respondents . Out of After adjusting for confounders, age of 18–24 (APR= 2.91), 25–29 years (APR=2.48), 30–34 (APR=2.47), 35–39 (APR=2.06), high socioeconomic status (APR=2.02), those without child (APR=52.35) and those with one child (APR=35.60) were significantly associated with fertility desire with the p-value of less than 0.05 .This research study among currently married eligible couples found that 13.7% of them currently desired to have another child. The younger age group, without or with one child and high socioeconomic status group had more fertility desire. It was observed that majority of eligible couples are lesser than 25 years age and completed two-child norm. Most of them had their preferred number of children. The study gives information on the extent of need for fertility services required according to the felt needs of the eligible couples. The findings will be useful for concerned stakeholders to understand what proportion of eligible couples requires fertility-related services within next two years period and need for unmet need for spacing methods for those who had fertility desire after two years period. Other studies showed higher fertility desire than this study Kenya, Senegal, and Nigeria study also found that among all women in all three countries, they wanted to have child but also wants to delay a pregnancy two or more years Fertility desire also may be influenced by behavioral factors for postponement of pregnancies. If personal or family conditions remain unfavorable, desires to postpone a birth persist and may lead to long birth intervals. In contrast, short birth intervals may be seen if conditions become favorable sooner than anticipated Australian study among 18 to 30 years married females highlighted the factors which include psychosocial predictors of attitude, pressure from others, and perceived self-confidence as predictors of women's intentions to delay childbearing Exposure to awareness programs on fertility may change fertility desires and waiting time is one of the important factors influencing fertility and prevention of unwanted pregnancies The study found that sex composition of living children on fertility desire was not associated with fertility desire. A study from Malawi, Africa in contrast found that high fertility desire was associated with gender preference and sex composition of the living children We found that educated women had more fertility desires similar to Uganda's study. In contrast, other studies showed that higher education is associated with lower fertility desire Larger sample size, rural and urban area inclusion, community-based setting, and fairly representative population were strengths of the study. There are some limitations. Since our study included all the eligible couples from the selected family and cluster, design effect may play a role. Larger sample size and considering homogeneity across the clusters, we expect minimal bias related to design effect. Nonrespondents characteristics also influence the study findings. We could not collect data on social and cultural factors associated with fertility desire. A temporal relationship may be difficult to ascertain because of cross-sectional study. Larger follow up studies may further provide a change in behaviour of fertility desire among eligible couples.The fertility desire is comparatively lesser than other studies. Younger age group couples had higher desire compared to older age groups. Those without or with a single child and higher socio-economic status group had more fertility desire. Services should be given to these target groups for their felt need of fertility desire. These findings also suggest the need for strengthening reproductive health care services according to the felt need of these target groups in the population. This study recommends concerned health authority to target these women to provide fertility related services within next two years period and unmet need for spacing services for those who had fertility desire after two years period. Further follow up studies will explore the fertility desire dymamics among the women over a period of time.


Interestingly, many protist, yeast, plant and also animal species possess a sulphide-resistant alternative oxidase (AOX). In this study, we investigated whether AOX is functionally involved in the sulphide stress response of the highly invasive marine tunicate Ciona intestinalis. At the LC50, the sulphide-induced reduction of developmental success was three times stronger in AOX knock-down embryos than in control embryos. Further, AOX mRNA levels were higher under sulphide than under control conditions, and this effect increased during embryonic development. Together, we found that AOX is indeed functionally involved in the sulphide tolerance of C. intestinalis embryos, hence, very likely contributing to its invasive potential; and that the response of AOX to sulphide seems to be controlled at the transcriptional level. We suggest that AOX-possessing species play an important role in shaping marine ecological communities, and this importance may increase under ongoing global change.Ecological communities and biodiversity are shaped by both abiotic and biotic factors. This is well illustrated by extreme environments and invasive species. Besides naturally occurring sulphide-rich environments, global change can lead to an increase in hydrogen sulphide episodes that threaten many multicellular organisms. With the increase in the formation, size and abundance of oxygen minimum zones and hypoxic environments, bacterial-associated sulphide production is favoured and, as such, hydrogen-sulphide-rich environments are likely to also increase in size and abundance. Many species are challenged by the inhibiting effect of sulphide on aerobic energy production via cytochrome  Summary: A functional study on the role of the mitochondrial alternative oxidase (AOX) in an animal species indicates that AOX increases the sulphide tolerance of the marine chordate Ciona intestinalis. Ecological communities and biodiversity are shaped by two main factors, climate change and invasive species . With th2S) in the oceans. In general, high sulphide concentrations are due to geothermal and biological processes  and pH (becoming more acidic). The consequences of those changes are manifold, ranging from less oxygenated oceans to rises in sea levels, changes in ocean currents and increasing weather extremes . One addrocesses . Interesproduced , and eveproduced . This suproduced , consequ2S is the inhibition of the aerobic energy production pathway (2S inhibits cytochrome c oxidase (COX), which limits or blocks ATP production, ultimately leading to the death of the organism. However, diverse ecological communities are found around in environments with high H2S concentrations that are lethal for most species, including deep-sea hydrothermal vents, cold seeps, marine sediments, freshwater springs and caves  were collected off the coast of Brest, France, by the Centre de Ressources Biologiques Marines of the Station Biologique de Roscoff. Prior to experiments, animals were kept in an 18°C, temperature-controlled flow-through system with natural seawater at the station. A detailed visualisation and description of C. intestinalis embryonic development is provided by Adult −1 NaCl, 9 mmol l−1 KCl, 10 mmol l−1 CaCl2, 24.5 mmol l−1 MgCl2, 25.5 mmol l−1 MgSO4, 2.15 mmol l−1 NaHCO3, 10 mmol l−1 Hepes buffer, pH 8.0, 0.05 g l−1 kanamycin sulphate to prevent potential bacterial growth in embryo cultures, sterilized with a 0.22 µm filter) and 1% agarose-coated Petri dishes   stock solution (10 mmol l−1) and used specific volumes to obtain the desired final concentration. In solution, Na2S dissociates into three sulphidic species that equilibrate quickly into sulphide (S2−), sulfanide (HS−) and hydrogen sulphide (H2S). At the average physiological pH of 7.4, H2S is present at approximately 20–30% and HS− at 70–80%, while S2− is only present in negligible quantity  . In all quantity . For simC. intestinalis and the concentration that resulted in 50% embryos being dead before completing development to tailbud stage (LC50), we tested five different sulphide concentrations  on five families with technical duplicates (two Petri dishes per family) per concentration for three of the five families. After fertilization, we distributed zygotes of each family evenly across treatment dishes filled with 10 ml of ASW and directly added sulphide at concentration-specific amounts. We terminated the experiment after 18.5 h of post-fertilization development by adding paraformaldehyde (PFA) to each dish. We then analysed the successful development to tailbud stage by counting the number of embryos that did and did not fully develop to that stage using a stereo microscope and calculating the proportion of those embryos that fully developed to tailbud stage.To determine the effect of sulphide on the developmental success of C. intestinalis embryos, we conducted knock-down experiments using a morpholino (MO) anti-sense oligomer targeted to the 5'-untranslated region (UTR) of AOX transcripts to block their translation. The set-up for the MO injections is described in C. intestinalis families on three ‘MO groups’ and four of those families in a rescue group: (1) uninjected eggs (uninjected), (2) control-MO injected eggs (MOCtrl), (3) AOX-MO injected eggs (MOAOX) and (4) AOX-MO and MO-immune AOX mRNA-injected eggs (MOAOX+AOX mRNA). The rescue group addresses the specificity of AOX-MO; the MO-immune AOX mRNA consists of the AOX open reading frame  and re-cloned into the pBluescript RN3 vector . Approximately 1 h after injection and no injection for the uninjected control group, eggs were fertilized and selected for correctly developed embryos when they reached the 8-cell stage. We then distributed embryos of each MO group equally into two Petri dishes (∼50 eggs per dish) and started the experiment by adding sulphide to one of the two dishes to obtain a final concentration of 15 μmol l−1 in a final volume of 10 ml ASW  or control (no sulphide) conditions. Embryos of four families were collected at egg (control condition only), 32-cell, mid-gastrula, mid-neurula and mid-tailbud stages and immediately frozen and stored at −80°C. We extracted RNA  and removed residual genomic DNA by treatment with RNase-free DNase I  according to the manufacturer's protocol, followed by reverse transcription . Extracted RNAs were quantified spectrophotometrically . We determined transcript levels based on qPCR  with gene-specific primer sets . On each of four 96-well plates, we included sample duplicates for AOX and two housekeeping genes  and no-template controls per gene (no contaminations detected). We used the online tool Real-time PCR Miner (Cq) values and amplification efficiencies for each qPCR replicate  from the raw qPCR fluorescence data. To allow analysis of Cq values via linear models, we efficiency-standardized Cq values as ECq per gene and plate and then standardized to a common log2Cq scale across genes and plates as log2(ECq). Accordingly, all linear model contrasts represent the log2 of traditionally used Cq ratios.To test the effect of sulphide on cy=1.81, ; β-actincy=1.90, ; TCEB3 , and random terms for family, family×concentration and family×concentration×replicate (accounting for detected overdispersion). We determined the LC50 relative to the survival at sulphide absence based on the estimated model intercept=1.689±0.163 (estimate±s.e.) and regression slope=−0.132±0.009 as 15.2 μmol l−1 sulphide, which we rounded to 15 μmol l−1 for use in the AOX knock-down experiment.We analysed the dose–response data using a generalized linear mixed model with logit-link function and binomial error distribution under Laplace approximation to the likelihood as implemented in the R function glmer of the R package lme4 . The proAOX knock-down experiment data using a generalized linear mixed model with logit link function like for the dose–response data. The developmental success binaries  were modelled with fixed terms for the sulphide treatment (15 μmol l−1 or no sulphide), the MO groups and their interaction, and random terms for family, family×treatment and family×MO. We performed pairwise comparisons of predicted means for each MO group within each treatment and between treatments within each MO group using t-tests and adjusted the P-values for the false discovery rate , the five stages sampled  and their interaction, and random terms for family, family×treatment, family×stage and family×stage×treatment. We tested fixed terms using F-tests. We performed multiple comparisons of treatment contrasts within each stage similarly as reported for the AOX knock-down experiment.We analysed the qPCR data using linear mixed models. We first fitted a model to test for a constant logC. intestinalis under elevated sulphide concentrations. First, we determined the sulphide concentration at which 50% of developmental success to tailbud stage was compromised (sulphide LC50). Then, we tested whether AOX knock-down affected developmental success at those concentrations. Lastly, we gained insight into AOX mRNA responses during development in the presence and absence of LC50 sulphide concentrations.In our study, we used an MO-based knock-down approach to test whether AOX plays a role in successful embryonic development of C. intestinalis larval development success depended strongly on the sulphide concentration  to 35% (95% CI 26–45%)], for the MOCtrl-injected by 51% [from 58% (95% CI 47–69%) to 28% (95% CI 20–39%)] and for the rescue group by 52% [from 57% (95% CI 43–70%) to 27% (95% CI 17–40%)]. Importantly, however, the AOX-MO group exhibited a stronger effect of the sulphide LC50 than any of the other MO groups; the developmental success decreased by 81% [from 60% (95% CI 49–71%) to 12% (95% CI 7–18%)] , and for the rescue group, it was 3.5 (95% CI 1.7–7.6). For the AOX knock-down group, the odds to survive under control conditions were 11.6 (95% CI 5.9–23.0) times higher than to survive under sulphidic conditions. Further, to evaluate the relative effect of AOX, we contrasted the odds ratio of the AOX knock-down group with that of each of the two control MO groups. In other words, we quantified the ratio of developmental success of control embryos (uninjected and MOCtrl-injected) and AOX knock-down embryos under sulphide conditions to control conditions. We found the odds to survive under LC50 sulphide conditions were higher for control embryos than for AOX knock-down embryos. Specifically, we found the odds to survive under LC50 sulphide conditions for the uninjected control group to be three times higher (95% CI 1.7–5.3) and for the MOCtrl group 3.3 times higher (95% CI 1.8–6.2) compared with the AOX knock-down group.The developmental success under sulphide LC 7–18%)] . These s−1 sulphide treatments  allows for valid AOX transcript level contrasts between sulphide treatments. Therefore, we performed treatment contrasts, i.e. the difference in AOX mRNA levels (relative to housekeeping gene levels) between sulphide and control treatments for each developmental stage, but we did not perform treatment contrasts across development.We detected differences in the effects of developmental stage on housekeeping gene transcript levels .Because of the changing housekeeping gene mRNA levels across developmental stages, the underlying cause of this increase cannot be fully pinpointed , which lead to regular mass mortalities of fish , found a strong indication that the alternative pathway via AOX is involved in the oxidation of sulphide (A. marina can survive quite high sulphide concentrations of up to 10 mmol l−1 (Urechis unicinctus), found that AOX mRNA levels in the body wall and hindgut tissue increased with both sulphide concentration and sulphide exposure time , the freshwater mussel (Diplodon chilensis) and also in C. intestinalis adults , and the H2S-binding haemoglobins of the giant tube worm (Riftia pachyptila) and the California killifish (Fundulus parvipinnis)  . Using H l−1 H2S .AOX to sulphide exposure at different developmental stages. Unfortunately, changes of the two housekeeping gene mRNA levels across developmental stages prevented us from being able to make clearer statements on the change of AOX mRNA across developmental stages. This exemplifies the crucial need of a careful analysis of housekeeping gene responses, particularly during dynamic biological processes, such as development, to allow for more reliable conclusions on a target gene response. However, we were able to draw conclusions about the difference of AOX mRNA levels between control and sulphide conditions at each developmental stage. We found no difference in AOX mRNA levels between sulphide and control conditions at the 32-cell stage, whereas the AOX mRNA levels were increasingly higher under LC50 sulphide exposure compared with no sulphide exposure at the later stages (C. intestinalis survival under sulphide exposure, and is very likely controlled at the transcriptional level.To better understand the control of the AOX response to sulphide, we also investigated the transcriptional response of r stages . FurtherAOX gene is not required for embryonic development in normal environmental conditions. However, we demonstrated a clear link between sulphide tolerance and AOX, which appears to be regulated, at a minimum, at the level of gene transcription. On a larger scale, these results provide a valuable insight into how fluctuations in sulphide, which are expected to increase under climate change, may affect marine ecosystems. As sulphide exposure increases in frequency and severity, it becomes more and more important to understand whether and how species are affected by sulphide. Many of the AOX-hosting animal species are sessile or slow-moving marine invertebrates with free floating larval stages, making them particularly susceptible to changes in sulphide as they cannot actively avoid the stressor; however, these species comprise many successful invasive species. Our finding about the role of AOX in survival under sulphide stress in C. intestinalis embryos provides the opportunity to extrapolate to other AOX-hosting species, which we expect to have similar competitive advantages under sulphide stress. Lastly, we hypothesize that AOX is an important protein that mitigates not only sulphide but also other environmental stressors affecting aerobic energy production and under whose presence AOX-possessing species may be more competitive as a result.In summary, we showed that the


As the EU officials and their Chinese counterparts emphasised the end of 2020 as the date for a successful conclusion of the Comprehensive Agreement on Investment , the Baltic states of Estonia, Latvia, and Lithuania were sceptical. However, after discussions, with Lithuania appearing to be the most visible opponent of CAI among the Baltic nations, all three eventually upheld the proposal. Understanding that the ratification of CAI is unlikely after the mutual exchange of sanctions between the EU and PRC in March, 2021, the report nevertheless examines the roots of the Baltic position as a case study of inter-EU bargains, inspects what factors contributed to the Baltic position on the issue of CAI, presents the national pro- and counter-arguments to CAI along the domains of geo-politics, values, and economy, and brings up the dilemmas that remain unsolved. The Transatlantic link is at the cornerstone of the three Baltic states’ foreign and security policies. With the renewed possibility of the Russian threat to the sovereignty of Lithuania, Latvia, and Estonia, especially post-2014, the Baltic three are not just NATO members, but strong proponents of bilateral ties with the USA, fostering policy commitments based on personal relationships, and lobbying for the national interests in Washington. This approach is historically justified—after all, the key document stating the United States’ non-recognition policy of Soviet annexation3The Baltics constantly reaffirm the importance of the relationship with the USA and argue in favour of closer EU-US cooperation. Estonia names “reinforcing the transatlantic link both in the framework of NATO as well as in European Union–United States cooperation” an integral part of a strengthening Europe.Therefore, all three countries initially were weary of the hurriedness of the process and the lack of coordination with the USA, especially since the EU willingness to jointly negotiate its position on China could have served as a natural restart of EU-US relations under the new Biden administration.As Jake Sullivan, Joe Biden’s National Security Adviser, called for more EU-US coordination on “concerns about China’s economic practices”,As elsewhere in Europe, the debate over the Baltic national positions on CAI can be grouped into three topics: geopolitical implications, values, and economy. Since the former has already been addressed in the previous sub-chapter, the following section provides an examination of the two latter considerations.From the value perspective, the most visible argument against CAI stems from the fear of becoming effectively complicit to forced labour practices exercised by China. Under the current non-finalised edition, CAI Section IV states that “the Parties agree to promote investment policies which further the objectives of the Decent Work Agenda.. including a human-centred approach to the future of work, adequate minimum wages, social protection and safety and health at work.”The debate over the economic benefits boils down to the question: what do the Baltics have to gain from CAI given the humble track record of investment and export so far and the shrinking room for cooperation in light of US-China disputes and security concerns? The Baltic states are not avid investors in China, particularly not in the sectors the EU companies are players in  has reported on some backchannel signals from the Chinese side that, if true, are particularly alarming to the Baltic states: “I can’t prove this, but I hear that in the so-called ‘legal scrubbing’ phase of work on CAI the Chinese side is trying to re-introduce their request that member states which limit Huawei access to 5G networks should not benefit from market opening in China.”If in 2013 the EU feared that the European members of the “16 + 1” platform, including the Baltic states, could become pawns in Beijing’s play at dividing the EUUltimately, the CAI ratification is unlikely after the March 2021 exchange of sanctions, but the analysis of the Baltic perceptions and the internal and EU-wide bargaining serves as a valuable case study of EU differences in expectations and interests towards China, as well as the strong role the Transatlantic relationship plays in the Baltic China positions.


S,4S)-14-Ethyl-9-(hydroxymethyl)-4,8,13,18-tetramethyl-20-oxo-3-phorbinepropanoic acid (ETPA) as a major metabolite of the North Pacific brittle stars Ophiura sarsii. As a chlorin, ETPA efficiently produces singlet oxygen upon red-light photoactivation and exerts powerful sub-micromolar phototoxicity against a panel of cancer cell lines in vitro. In a mouse model of glioblastoma, intravenous ETPA injection combined with targeted red laser irradiation induced strong necrotic ablation of the brain tumor. Along with the straightforward ETPA purification protocol and abundance of O. sarsii, these studies pave the way for the development of ETPA as a novel natural product-based photodynamic therapeutic.Photodynamic therapy (PDT) represents a powerful avenue for anticancer treatment. PDT relies on the use of photosensitizers—compounds accumulating in the tumor and converted from benign to cytotoxic upon targeted photoactivation. We here describe (3 Photodynamic therapy (PDT) relies on the use of photosensitizers—compounds that are relatively benign until excited by light of a particular wavelength that converts them into an activated state resulting in the generation of reactive oxygen species ,2,3. PDTA number of photosensitizers have been marketed for PDT in different countries, and the search for novel compounds never ceases ,4. PhotoS,4S)-14-Ethyl-9-(hydroxymethyl)-4,8,13,18-tetramethyl-20-oxo-3-phorbinepropanoic acid (ETPA) from a North Pacific brittle star Ophiura sarsii—the first-ever porphyrin identified in Ophiuroidea (phylum Echinodermata) )O. sarsii and the ease of its purification, along with its promising applications in PDT, make it attractive to consider upscaling of production of this natural product. Its abundance in its host is multiplied by the abundance of this brittle star species, wide-spread from Northern Atlantic, over the Arctic, and all the way to Northern Pacific, inhabiting waters from shallow to deep [O. sarsii as has proven successful for other North Pacific invertebrates [The abundance of ETPA in  to deep ,36. Thestebrates . These p


Only a few studies primarily examined the associations between starchy vegetables (other than potatoes) and metabolic syndrome (MetS). We aimed to evaluate the association between starchy vegetables consumption and MetS in a population-based sample of Costa Rican adults. We hypothesized that a higher overall intake of starchy vegetables would not be associated with higher MetS prevalence. In this cross-sectional study, log-binomial regression models were used to estimate prevalence ratios (PRs) of MetS across quintiles of total, unhealthy, healthy starchy vegetables, and individual starchy vegetables , among 1881 Costa Rican adults. Least square means and 95% confidence intervals (CIs) from linear regression models were estimated for each MetS component by categories of starchy vegetable variables. Higher intakes of starchy vegetables were associated with a higher prevalence of MetS in crude models, but no significant trends were observed after adjusting for confounders. A significant inverse association was observed between total starchy and healthy starchy vegetables consumption and fasting blood glucose. In this population, starchy vegetables might be part of a healthy dietary pattern. Metabolic syndrome (MetS), defined as a group of risk factors or metabolic abnormalities including glucose intolerance, insulin resistance, central obesity, dyslipidemia, and hypertension , is assoEmerging studies investigated the associations of different dietary patterns with the prevalence of MetS, but few specifically examined the potential cardiometabolic impacts of starchy vegetables. The literature on this topic shows that not all starchy vegetables are equal with regards to health outcomes. For example, a higher intake of potatoes was shown to increase the risk of developing hypertension in both adult males and females . HoweverThe aim of this study was to evaluate the association of starchy vegetables consumption with MetS prevalence, along with each individual MetS components in a population-based sample of Costa Rican adults. Given that starchy vegetables are diverse in nutrition composition and are associated with health outcomes, and considering that starchy vegetables in Costa Rica are not always part of a Western dietary pattern, we hypothesized that a higher overall intake of starchy vegetables would not be associated with higher MetS prevalence in Costa Rican adults, while a higher intake of potatoes could still be associated with a higher MetS prevalence. All subjects of this cross-sectional analysis were population-based controls from a previously conducted case-control study of nonfatal myocardial infarction (MI) in the central valley area of Costa Rica, between 1994 and 2004 . The detThe data collection methods were described in detail in previously published articles ,12. In sA semi-quantitative Food Frequency Questionnaire (FFQ) explicitly developed and validated for the Costa Rican population  was usedMetS was defined by the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) as the subject meeting three or more of the following criteria—abdominal obesity (waist circumference n = 29), (2) subjects who had missing data on major potential confounders , (3) subjects who had caloric intakes greater than 5000 kcals or less than 500 kcals (n = 19), and (4) subjects who had a history of diabetes . After the exclusion, 1881 subjects remained in the analytic sample for this report. Eligible participants from the Costa Rica MI case-control study  consisteFood intake frequencies reported on the FFQ were first recoded into semi-continuous variables representing the nine possible responses of standard servings per day showing on the FFQ . Then, they were multiplied by the standard portion sizes to generate continuous weighted dietary variables (in grams). The weighted dietary variables were further adjusted for total energy intake by using the residual method, and were used in the statistical models .t-tests were used for normally distributed variables, whereas Wilcoxon tests were used for the non-normally distributed variables. Starchy vegetables were further categorized into three main exposure variables: (1) unhealthy starchy vegetables—potatoes including French fries, baked/boiled/mashed potatoes and potato chips; (2) healthy starchy vegetables—plantain, purple sweet potatoes, corn and cassava; and (3) total starchy vegetables—the sum of unhealthy and healthy starchy vegetables. Prevalence ratios (PRs) and 95% confidence intervals (CIs) for MetS associated with the three main exposure variables and each individual starchy vegetable , were estimated by multivariable log-binomial regression models. Confounders were selected based on prior knowledge and the association of the confounder with the dietary exposures were evaluated among people free of MetS. The first model was adjusted for age (continuous), sex, income (continuous), current smoking status , and urban residence . The final model was additionally adjusted for history of hypertension (yes or no), alcohol , and total energy expenditure (continuous). In all models, the indicator method was used to address the missing income data. Other potential confounders such as history of high cholesterol (yes or no) and total fat intake (continuous) were examined as covariates but these were not retained in the final model as they did not distinctly impact the effect estimates. In order to deal with model convergence issue, a modified Poisson regression with robust variance estimation was used [Baseline sociodemographic characteristic, dietary variables, and each MetS components were investigated by the MetS status. To test the differences, chi-square tests for binary variables were used and two-sample was used . We usedTheoretical substitutions were assessed with substitution models. The potential association of substituting 50 g of non-starchy vegetables for 50 g of starchy vegetables with MetS, were investigated by using servings (standardized to 50 g) as continuous variables in the same final fully adjusted models . The potIn order to examine the robustness of the results, sensitivity analyses were performed. First, waist circumference was adjusted for age and BMI, by using the residual method. Second, the analysis was repeated after excluding subjects with history of hypertension. Third, least square means for systolic blood pressure, diastolic blood pressure, and fasting blood glucose were calculated after excluding subjects who reported taking hypertension medication  or diabetes medication . Fourth, the analysis was repeated on the main exposure variables after excluding people who reported that they had changed their long-term intake of fruits and vegetables in the last 10 years, previous to the data collection. Finally, the substitution analysis was repeated in the same fully adjusted model after excluding subjects with history of hypertension or history of hypercholesterolemia. All data analyses were performed by using the SAS software, version 9.4 .n = 1123) and subjects with MetS (n = 758), except for urban residence, income, total fat as a percentage of total energy, and protein as a percentage of total energy . For total starchy vegetables and healthy starchy vegetables, a higher consumption was associated with lower fasting blood glucose in the fully adjusted models . The difference in glucose concentrations between the lowest and highest quintile was 5.1 mg/dL for the total starchy vegetables and 3.5 mg/dL for the healthy starchy vegetables . Similarly, substituting healthy starchy vegetables for unhealthy starchy vegetables was not associated with a significantly different prevalence of MetS .Substituting non-starchy vegetables for the three types of starchy vegetables were not found to be associated with a significantly different prevalence of MetS  , as wellConsumption of potatoes, in particular, might not be contributing to the same metabolic responses and health effects in the Costa Rican sample, given the different varieties and cooking methods ,25,26. Pp = 0.93) or MetS (p = 0.76) [Starchy root vegetables have a higher GI compared to non-starchy vegetables, and a higher GI can induce insulin resistance . However = 0.76) . The GI  = 0.76) . Additio = 0.76) . Several = 0.76) . TherefoRegardless of the high carbohydrate content, starchy vegetables are still rich sources of micronutrients and other healthy biological compounds . These nPrior studies showed that reducing the consumption of starchy vegetables might result in improved insulin sensitivity . In the To the best of our knowledge, this is the first study investigating the association between starchy vegetables intake and MetS in a Hispanic/Latino population. The strength of this study includes a population-based design in which the subjects were randomly selected from the target source population, who were representative within the matching strata of the original case-control study . The results were also more likely to be generalizable to the entire Costa Rican population, given their lifestyle and socioeconomic characteristics. However, the study had few limitations. First, due to the observational study design, we cannot rule out residual confounds despite controlling for many potential confounders. Second, we cannot rule out reverse causation due to the cross-sectional nature of the study. Third, there is a potential for differential exposure misclassification, since a retrospective FFQ was used to determine the exposure starchy vegetable intake level. However, we believe that the risk of recall bias is minimal, because at the moment of the study, people in Costa Rica were not very aware of the associations between diet and MetS. Fourth, dietary assessment via an FFQ show more measurement errors than multiple 24-h foods recalls or diet records . NeverthIn summary, our study showed that a higher intake of starchy vegetables is not associated with the prevalence of MetS and that starchy vegetables could be part of a healthy dietary pattern. Future studies are necessary to further investigate the potential cardiometabolic impacts of different types of starchy vegetables in other populations.


In recent years, local governments in Japan have established a public financial support system for fertility preservation in pediatric, adolescent, and young adult cancer patients. Fertility preservation has become popular for patients with cancers included in the gonadal toxicity risk classification of the 2017 edition of the Guideline for Fertility Preservation in Children, Adolescents and Young Adult Cancer Patients from the Japan Society of Clinical Oncology. However, patients with cancer and non-cancer diseases that are not included in the Guideline’s gonadal toxicity risk classification also often receive treatment that may affect fertility, but they are often denied the opportunity of fertility preservation because no public financial support is available for diseases not listed in the Guideline. The national research project proposes including these diseases in the indications and treatment for fertility preservation. Therefore, we cooperated with the Japan Society for Fertility Preservation and the Ministry of Health, Labour and Welfare research group to solicit opinions from experts in each therapeutic area and reviewed the literature and overseas guidelines. This paper summarizes the findings of the project. We believe that it will be an important source of information for clinicians treating patients who need fertility preservation but note that the appropriateness of fertility preservation for the disorders listed in this report needs to be continuously reviewed as medical care advances. The world's first baby resulting from in vitro fertilization, Louise Brown, was born in Britain in 1978, and in vitro fertilization/embryo transfer technology subsequently started to be used globally as an innovative treatment for infertility. Thereafter, additional technological advancements occurred in the form of embryo freezing and ovarian tissue freezing, and in 2004 Donnez et al. in Belgium reported a spontaneous pregnancy and delivery after ovarian tissue freezing and transplantation in a young patient with stage IV Hodgkin lymphoma . In addiHowever, recommendations for fertility preservation have yet been established for cancers and treatment modalities not listed in the Guideline or for non-cancer disorders and their treatments. Consequently, in such cases healthcare providers in clinical practice  and patients often have to search for information on fertility preservation. On this background and because of the advancements in fertility preservation technology, fertility preservation must be considered for non-cancer disorders and for pediatric, adolescent, and young adult patients with cancer. Moreover, clinicians and patients have an increasing need for information on this topic . FinallyThe national research project in Japan (19EA1015) was initiated in April 2019 and aimed to give all patients the opportunity of fertility preservation. It proposes including additional types of cancer and non-cancer diseases in the indications and treatment for fertility preservation. To determine these indications and treatments, participants in the project cooperated with the JSFP and the Ministry of Health, Labour and Welfare research group to solicit opinions from experts in each therapeutic area and reviewed the literature and overseas guidelines.The types of disorder and treatments identified in this study as missing from the Guideline are listed Table , and infTwo types of breast cancer treatment that are not included in the Guideline are relevant for fertility preservation: hormone therapy, namely tamoxifen (standard duration of therapy: 5–10 years), and anti-HER2 antibodies, e.g., with pertuzumab, trastuzumab and trastuzumab emtansine (standard duration of therapy: 1 year) . TamoxifBladder cancer treatment can damage the gonads, particularly treatment for juvenile bladder cancer. If patients require chemotherapy, testicular sperm extraction is recommended prior to treatment. Total cystectomy can also affect fertility by causing ejaculation failure, so after treatment, patients will also require testicular sperm extraction for reproduction .The following diseases may affect the hematopoietic system in young adults: myelodysplastic syndrome, myeloproliferative neoplasm, chronic lymphocytic leukemia, Waldenstrom macroglobulinemia, plasma cell neoplasms , hemophagocytic syndrome, chronic active Epstein–Barr virus infection, histiocytic and dendritic cell tumors, idiopathic thrombocytopenic purpura, and immunodeficiency-related lymphoproliferative tumors . In JapaThe diseases in this list may be treated by chemotherapy and hematopoietic stem cell transplantation. Chemotherapy is the first-line treatment, but hematopoietic stem cell transplantation is used in patients with intractable disease. Although many chemotherapy treatments for these diseases are considered to have low risk for gonadal toxicity, regimens containing alkylating agents may affect fertility, in which case fertility preservation should be considered.The following pediatric non-cancer disorders may be treated by hematopoietic stem cell transplantation if initial treatments are unsuccessful; therefore, patients may require fertility preservation because conditioning regimen for stem cell transplantation has a significant impact on fertility  : aplastiThe effects on fertility vary depending on the conditioning regimen. For example, busulfan and total body irradiation significantly affect fertility . In receSome pediatric non-cancer disorders are treated with alkylating agents, which can also affect fertility. Such disorders include the following: systemic lupus erythematosus, lupus nephritis, juvenile idiopathic arthritis, dermatomyositis, Sjogren's syndrome, systemic scleroderma, rheumatoid arthritis, multiple sclerosis, Crohn's disease, nephrotic syndrome, vasculitis syndrome, pure red cell aplasia, autoimmune hemolytic anemia, thrombotic thrombocytopenic purpura, and acquired hemophilia. However, in recent years, some of these diseases have been increasingly treated with biologics and less often with alkylating agents. Nevertheless, some patients are still treated with the alkylating agent cyclophosphamide, which affects fertility. US and European guidelines recommend sperm cryopreservation in postpubertal men and fertility preservation with gonadotropin-releasing hormone agonists in postpubertal women . In addiThe bone and soft tissue tumors in which fertility preservation may be relevant include giant cell tumor of bone (GCTB) and desmoid .In recent years, the effectiveness of denosumab therapy has been established for GCTB. Denosumab therapy may be continuously given to pediatric, adolescent, and young adult patients with non-resectable GCTB and may affect fertility –23.In desmoid (desmoid fibromatosis), in which symptoms such as tumor growth and pain can appear and require treatment, antitumor drugs such as methotrexate plus vinblastine combination chemotherapy and the multitarget tyrosine kinase inhibitor pazopanib are increasingly being used in clinical practice and can affect fertility –27.A malignant lymphoma of the central nervous system is a typical brain tumor with a relatively young age of onset . AlthougTreatment for inflammatory bowel disease may affect fertility and require fertility preservation , 30.Treatment for various types of connective tissue disorders may affect fertility in young adults, including cyclophosphamide for systematic lupus erythematosus and cyclophosphamide and other alkylating agents for a variety of other disorders . These tCyclophosphamide has been used for many years to treat major organ damage associated with systemic lupus erythematosus . AlthougFor interstitial pneumonia associated with polymyositis and dermatomyositis, immunosuppressants  are used in combination with steroids . InterstIn addition to skin sclerosis, scleroderma may involve other organ disorders, such as interstitial pneumonia, pulmonary hypertension, and gastrointestinal lesions. If interstitial pneumonia is progressive or predicted to progress, patients are treated with cyclophosphamide  or mycophenolate mofetil. In some cases, treatment may be combined with steroids at a moderate or lower dose , 39.Depending on the type and severity of vasculitis, steroids, immunosuppressants , or biologics  may be used in combination , 41. TypPulmonary arterial hypertension associated with systemic lupus erythematosus, mixed connective tissue disease, and primary Sjogren's syndrome is treated with moderate or higher doses of steroids and intermittent high-dose cyclophosphamide  DependinThe following drugs are used, depending on the type and severity of the lesion: steroids , colchicine, immunosuppressants , biologics (mainly tumor necrosis factor inhibitors).Glucocorticoids are the main treatment for connective tissue diseases and related disorders, and cyclophosphamide has ample evidence as a concomitant drug, especially in patients with severe life-threatening or organ-threatening diseases. In recent years, immunosuppressants, biologics, and Janus kinase inhibitors have been increasingly used to treat these disorders, and use of alkylating agents (cyclophosphamide) has decreased. However, cyclophosphamide is still used because it is the treatment with most evidence for certain conditions involving damage to important organs. Cyclophosphamide can affect fertility, so cryopreservation of sperm is recommended for men of reproductive age. In women of reproductive age, fertility preservation with gonadotropin-releasing hormone agonists is recommended , 20. FerThis article summarizes diseases and treatments suitable for fertility preservation that are not listed in the gonadal risk classification of the Guideline. Identifying these diseases and treatments is important to ensure that affected patients have access to fertility preservation measures.In 2016, Shiga Prefecture launched the first public subsidy program in Japan for fertility preservation for pediatric, adolescent, and young adult cancer patients. In addition, after publication of the Guideline by the Japan Society of Clinical Oncology in 2017, Kyoto Prefecture started the "Kyoto Prefecture Cancer Patient Fertility Preservation Subsidiary System," which requires close cooperation between oncologists and reproductive medicine doctors in accordance with the Guideline, and established a system to prevent patients not being able to receive fertility preservation for financial reasons. Since then, this project has expanded to local governments across the country. In recent years, a regional network of fertility preservation cooperation has been built nationwide that provides relevant information to patients and supports them in decision-making. Nevertheless, the high cost of fertility preservation by assisted reproductive technology that is not covered by health insurance, together with the cost of cancer treatment, can result in some patients not preserving their reproductive functions. Thus, this issue must be urgently addressed.The relationship between fertility preservation and cancer outcomes must be verified from the perspective of cancer and reproductive medicine, and long-term, close follow-up should be provided by oncologists and reproductive medicine doctors. Therefore, in November 2018, the JSFP established the Japan Oncofertility Registry (JOFR), a registration project that collects data from cancer patients who received fertility preservation counseling or treatment. At present, registration with JOFR is mandatory if patients want to receive subsidies for fertility preservation from the public subsidy system. The purpose of JOFR is to continuously collect useful information on cancer patients with fertility problems with the aim to help better understand the current status of cancer and reproductive medicine (fertility preservation counseling and fertility preservation) in Japan and treatment outcomes .Patients requiring fertility preservation who were included in the ongoing survey by the JOFR do not have only malignant diseases, such as cancer, but also blood disorders requiring hematopoietic stem cell transplantation and autoimmune diseases not listed in the Guideline. International fertility preservation guidelines are also not limited to cancer but classify gonadal toxicity by treatment method , 47. Cla


Background: Given the concurrence of medical residency and fellowship training with typical childbearing years, trainees often must make difficult decisions regarding family planning, requiring the support of their residency and fellowship program directors (PDs) to guide them.Objective: Our hypothesis was that PDs have knowledge gaps and varying levels of support in terms of their trainees' fertility, and the goal of our study was to assess the knowledge and support of residency and fellowship PDs in the United States toward trainees' reproductive needs.Methods: Cross-sectional survey distributed to all residency and fellowship PDs providing contact information through the Accreditation Council for Graduate Medical Education website in August 2019.Results: Of 299 respondents, the most common lengths of leave reported were 6–8 weeks of maternity leave and under 2 weeks of paternity leave. A total of 57.2% did not know their program's insurance for infertility treatment, and 68.6% did not know fertility preservation coverage. A total of 52.2% of PDs were unaware of if their trainees faced infertility. PDs supported residents' needs through moral support (68.2%) and time off for appointments (65.2%). Similarly, most PDs (66.2%) never had a trainee express interest in fertility preservation to them but offered moral support (59.2%) and time off (48.5%). Respondents felt it was important to increase resources for trainees by increasing their awareness of needs (47.5%) and establishing reproduction-related policies (34.1%).Conclusion: The study found variations regarding PDs' knowledge and support levels for trainees' fertility needs. Most were unaware of their trainees' fertility needs, and many PDs felt it would be important to improve resources by increasing personal awareness and creating policies for support to promote reproductive health equity for trainees. Oocyte cryopreservation has become widely utilized since 2013, when the American Society of Reproductive Medicine removed the technique's designation as “experimental.”21–24Because medical training typically occurs during prime reproductive years, physicians-in-training are often faced with difficult family planning decisions. In fact, a study of female physicians in the United States found that nearly one-quarter reported being diagnosed with infertility, a higher prevalence than in the general population.25 Examining PDs' attitudes toward infertility treatment and fertility preservation is important to increase the understanding and support for trainees. Literature is limited in this area, and a lack of awareness may contribute to reproductive inequities. Opinions of PDs may be critical to improving support for residents to access fertility treatment. Our study is the first to our knowledge to examine residency and fellowship PDs in the United States across specialties to assess their knowledge and support regarding infertility treatment and fertility cryopreservation for their trainees.Postgraduate medical education can delay childbearing by years. While trainees have demonstrated interest in fertility preservation, lack of support from residency and fellowship program directors (PDs) discourages them from pursuing treatment.This study was a cross-sectional survey conducted through Qualtrics, an online survey software. The survey was distributed to all residency and fellowship PDs providing contact information through the Accreditation Council for Graduate Medical Education (ACGME) website from May and June 2019. The study received Institutional Review Board approval from Stanford University.The survey was sent out to e-mail addresses of programs on the ACGME website, which were manually extracted from the site. Primarily, the e-mail address listed was for the PDs themselves, but if the program coordinators' contact was listed, they were asked to forward the survey to the PD. Programs were sent one reminder to increase response rates. While the survey was sent to 4366 programs, it is uncertain how many PDs actually received the e-mail, as some e-mails bounced, and it was not possible to determine if program coordinators forwarded the e-mail to PDs. Therefore, the final response rate cannot be determined due to indirect distribution and no confirmation on the number of people receiving the survey.26 The survey consisted of 40 questions in 5 subsections: Demographics, Residency Policies, Infertility Support, Fertility Preservation Support, and Fertility and Residency. Each question was multiple choice with some “Select all that apply” questions, and respondents could opt out of answering any question. Participants were informed their responses were anonymous. The total number of responses was 299. The complete survey is available in The questions asked in this survey were based on a previously conducted pilot survey assessing the fertility and reproductive needs of residents and fellows across the United States.Percentages of each response out of the total respondents to the entire survey were calculated, as well as the total number of respondents to a particular question. Because of the sensitive nature of the topics covered in the survey, all of the questions were optional, which resulted in many responses missing at least an answer. We did not ultimately exclude any of the survey responses because we wanted to present all responses completely but have included how many responses we received for each question, as well as the number of responses for each question that were declined to answer. All percentages presented in the article were calculated from the total number of respondents to the entire survey.a priori. Multivariable logistic regression was then used to determine factors associated with support or nonsupport of infertility or fertility preservation using Stata version 5.1. The covariates included specialty, region, age, gender, marital status, parental status, and whether the person had a child during training.Bivariate analysis using logistic regression was performed to test the relationship between predictor and outcome variables. Predictor variables were classified into categorical variables and chosen The outcomes examined were perceived program and personal level of support for trainees dealing with infertility or undergoing fertility preservation—responses of “very” or “somewhat supportive” were grouped as supportive, while responses of “minimally” and “not supportive” were labeled unsupportive.Association was also calculated between support level, respondent demographics—age, gender, marital status, whether they had children, and whether they had children during training—and program demographics, including surgical versus nonsurgical specialty, program region, and whether the program was in a state mandating fertility insurance coverage. To create binaries, age was categorized into older than and younger than 50 years, and marital status was separated into partnered (responses of married and partnered) and unpartnered .Out of 299 respondents, the most represented specialties were emergency medicine (11.0%) and obstetrics and gynecology (9.7%). A total of 49.5% of respondents were female and were most commonly aged 40–49 (39.1%). A total of 70.4% of respondents were Caucasian. Most PDs were married (80.3%) and had children (80.6%). Of the respondents who reported having children, 51.0% had their children in training.The majority of programs overseen by respondents had 20 or fewer trainees (52.5%), and most programs lasted three (40.8%) years. The residency programs were distributed across the United States, and 28.8% of the programs were located in states mandating fertility coverage  and under 2 weeks of paternity leave (33.1%), with the possibility of extending time allowed in 62.5% of programs. During parental leave, the majority of missed work is covered by other residents (81.9%), as well as nonresidents, such as attendings and nurse practitioners (27.4%).Most respondents lacked information on their program's insurance policies regarding infertility treatment and fertility preservation, with 57.2% not knowing coverage of infertility treatment and 68.6% not knowing policies for fertility preservation. Of those surveyed who did know their program's coverage, only 7.7% of programs provided full coverage for infertility treatment, and 1.7% fully covered fertility cryopreservation.Over half (52.2%) of PDs stated that none of their residents had ever disclosed facing infertility or RPL, although 55.2% estimated at least 5% of their residents were facing infertility or RPL. For residents with infertility, the most common resources offered were moral support from PDs (68.2%), time off for appointments (65.2%), and insurance coverage (36.1%).Programs allowing their residents to take time off for treatment typically gave at least 2 days off each year (63.9%), which was primarily given on a case-by-case basis (75.6%). Overall, most PDs felt their personal level of support for residents facing infertility aligned with their program's level of support (56.2%). Those who felt the support levels were unaligned typically felt their program was less supportive (22.7%), as illustrated in A total of 66.2% reported that none of their residents had ever expressed interest in fertility preservation to them. A total of 71.2% stated that, to their knowledge, none had undergone cryopreservation. For residents who did express interest, PDs stated that common resources included moral support from PDs (59.2%) and time off for appointments (48.5%). Residents were mostly granted time off on a case-by-case basis (72.2%), and 61.2% of programs gave residents at least 2 days off each year. A total of 55.9% of PDs believed their personal level of support for residents interested in fertility preservation was aligned with their program, and of respondents who felt support levels were unaligned, 19.1% felt their program was less supportive .A total of 55.9% of residency PDs indicated that it was very or somewhat important to increase resources for residents undergoing fertility treatment, similar to 53.2% who felt the same for residents undergoing fertility preservation. Regarding residents' pregnancies, 25.4% of PDs strongly or somewhat encouraged it, and 43.1% stated they neither encouraged nor discouraged it; 74.6% said this stance did not differ between male and female trainees. A total of 55.9% of PDs agreed that a discount would alleviate the costs of infertility treatment, and 56.5% felt the same regarding cryopreservation.Time (32.1%) and costs (24.8%) were seen as the two biggest hindrances to residents pursuing fertility treatments. PDs were also asked what should be changed to better support residents' reproductive needs, and the responses were as follows: “increasing awareness of individual needs” (47.5%), “official policies on fertility treatment” (34.1%), “financial support” (33.4%), “time off for treatment” (31.1%), “counseling” (24.4%), “reach out to department leadership, GME, or dean's office” (18.4%), and “nothing” (7.7%).Bivariate analysis of each covariate was performed, and the predictor variables were not found to be statistically significantly correlated with support or nonsupport of infertility or fertility preservation services. Complete data tables from the multivariate analysis can be found in After stratifying responses by PDs in surgical and nonsurgical specialties, the demographics of the two groups were similar. However, they reported differing maternity leave policies, with 67.0% of surgical specialties granting 4–8 weeks, while 62.1% of nonsurgical specialties granted 6–12 weeks. Nonsurgical PDs were more likely to state they were “very supportive” of their residents facing infertility, 82.2% compared with 74.7% of surgical PDs, and more surgery PDs did not give residents time off for infertility treatment (23.2% compared with 16.9%).When surveyed about fertility preservation support, more surgery PDs (24.7%) reported that residents had expressed interest to them in fertility preservation than nonsurgery PDs (17.1%). Nonsurgical PDs (76.7%) stated that they felt they were “very supportive” of residents interested in fertility preservation, similar to surgical PDs (69.1%). Similar rates of surgery (22.7%) and nonsurgery programs (20.0%) did not allow residents to take time off for fertility preservation.More surgery PDs felt it was “very important” to increase resources for residents undergoing infertility treatment and fertility preservation compared with nonsurgery PDs; however, more nonsurgical PDs “strongly supported” their residents getting pregnant. In addition, more surgery residency PDs “strongly agreed” that trainee discounts would help with the costs of treatment and cryopreservation. Both groups most commonly agreed that time and finances were the biggest barriers to residents pursuing fertility treatments and that the best ways to improve support were to increase their personal awareness of individual needs and to have official fertility treatment policies.Stratifying data by male and female respondents showed roughly equal representation (148 women and 145 men). Of the respondents with children, 50.8% of men and 46% of women had children during their residency. While distributions of maternity leave lengths were similar, more male PDs reported giving <2 weeks of paternity leave, compared with female PDs (41.5% vs. 32.8%). In addition, male PDs were more likely to state that they did not know about residency insurance coverage of infertility treatment and fertility preservation.Over two-thirds (67.7%) of male PDs reported that none of their residents had told them about facing infertility or RPL, compared with half (51.9%) of female PDs, and were more likely to estimate that none of their residents had infertility. While the majority of both groups stated that they felt that their personal level of support for trainees facing infertility was aligned with their program's support, 31.5% of female PDs felt their program was less supportive than they were, compared with 21.1% of males.The majority of both male (83.1%) and female (77.6%) PDs stated that none of their trainees had expressed interest to them in fertility preservation, but most commonly offered time off and moral support for their residents. Most male respondents (57.4%) stated that their program was “very supportive” of residents interested in fertility preservation, while most female respondents (48.4%) reported their program was “somewhat supportive.”More female PDs (32.5%) believed it was “very important” to increase resources for residents undergoing infertility treatment, compared with 16.2% of male PDs. Similarly, 30.3% of female PDs felt it was “very important” to increase resources for residents undergoing fertility preservation, whereas 16.4% of male PDs agreed. In addition, 38.8% of female respondents “strongly encouraged” pregnancy, but only 24.3% of male respondents did so. Most respondents from both groups stated their opinion did not differ between their male and female trainees, but female PDs (5.8%) were more likely to discourage their female residents from getting pregnant. More female PDs strongly agreed a trainee discount would help with the costs of assisted reproductive technologies.Both groups agreed time and finances were the biggest barriers to trainees pursuing fertility treatments but differed in what they felt should be improved. Male respondents most commonly felt that increasing personal awareness regarding individual needs (59.1%) and financial support (37.3%) should be improved, while female respondents most commonly stated that personal awareness (62.8%) and time off for appointments (55.4%) needed improvement. A total of 13.6% of male PDs believed nothing currently needed improvement, compared with 6.6% of female PDs.14Due to the time-consuming nature of residency, age-related fertility decline is highly relevant for trainees who may then seek infertility treatment or fertility cryopreservation. Particularly because infertility has been previously determined to be prevalent at a higher rate in female physician than in the general population, this issue must be addressed during the postgraduate training period.While previous studies have examined this issue from the trainees' perspectives, confirming their interest in such treatments, this study is the first to determine PD opinions. Because PDs have influence over residents' access to these services, such as through determining financial support and establishing leave policies, it is important to examine their opinions to get a fuller perspective on how to improve the current situation.27 In addition, our study found that only 55.9% of PDs felt it was important to increase resources for residents undergoing infertility treatment, and 53.2% said the same for residents undergoing fertility preservation. This inconsistent support may add stress onto an already rigorous training schedule, discouraging parenthood in fear of hindering one's career.29Our study found variation in parental and medical leave policies for fertility treatments, highlighting the need for standardized practices. These differences could contribute to inequities in training, due to sex or specialty.30Only 35.1% of PDs correctly identified age 35 as when female fertility decreases, and only 21.7% knew male fertility decreased around age 45, highlighting misinformation regarding reproduction, potentially impacting decision making on program policies. Most PDs also did not know their program's insurance coverage of fertility treatments. Trainees often turn to their PDs for guidance on policies, and lack of knowledge decreases the likelihood that trainees will consider those options for their reproductive needs.25 However, given that infertility prevalence in the United States is 15.5% and previous studies stated at least 7%–8% infertility rate in residents,31 PDs may be underestimating the number of residents with infertility.Most respondents stated none of their residents expressed interest in infertility treatment and estimated that the percentage of their residents facing infertility was around 5%–10%, consistent with a previous study's findings of a perceived lack of program support for residents with fertility concerns.32 Trainees with infertility are burdened with medical school debt, low salary, and an intense schedule, further discouraging them from pursuing treatment.33In addition, time off and moral support were the most common resources for residents undergoing infertility treatment, but few programs provided financial support, even though high costs are a major barrier for trainees.Similarly, the majority of respondents stated that none of their residents had expressed interest to them regarding fertility preservation and did not know any resident who had undergone the procedure. Most PDs were unaware of their program's insurance policy on fertility preservation but said that time off and moral support were the main resources for residents interested in cryopreservation. This lack of resources and knowledge regarding fertility cryopreservation may result in less dialogue between residents and PDs, discouraging them from pursuing treatment.25In a survey of OB/GYN residents, 29% of respondents considered fertility preservation, but only 2% sought consultation, revealing that residents actively choose not to try the procedure. Sixty-three percent of survey respondents had attributed their decision against fertility preservation to a lack of support, through scheduling and finances, from their program.34Although only 1% of PDs discouraged residents from being pregnant, perceived lack of support can intimidate residents from approaching PDs with reproduction-related issues. Previous studies have suggested that PDs view pregnancies as detrimental to their programs: Sandler et al. found that general surgery PDs felt having children negatively impacted residents' work.35 However, PD support has been improving, according to a survey of residents across specialties from 2008 to 2015,36 as well as our data.A similar survey of surgery residents found that most residents did not feel supported by their programs during pregnancy, with 39% of respondents considering leaving the program and 30% advising future residents to not specialize in surgery if considering parenthood during training.31When asked about increasing resources for infertility treatment and fertility preservation, only a slight majority of residency PDs ranked the issue as important and agreed that a trainee discount would help with costs, compared with almost half of respondents who felt that increased support was not important. Time and finances were viewed by PDs as the primary barriers to pursuing treatments, the same reasons reported by trainees in prior surveys.37 These positions are consistent with areas that PDs view as shortcomings in their support for trainees' reproductive needs, highlighting an opportunity for policy implementation and action.The American Medical Women's Association Infertility Task Force has similarly called for reforms to address these hurdles to reproductive equity, advocating for more awareness of trainees' fertility issues, increased insurance coverage of reproductive treatments, and support for residents undergoing any fertility treatment.38 In addition, more surgery PDs felt it was necessary to improve resources to meet their residents' needs, such as through cost assistance.Stratifying results by specialty revealed that nonsurgical PDs provided more time off for maternity leave and fertility treatments. Surgical PDs more commonly stated their residents expressed interest in fertility preservation to them, reflecting findings concluding that physicians are increasingly interested in oocyte cryopreservation due to their demanding careers.20 our findings also showed that female PDs emphasized the importance of increasing support for infertility treatment and fertility preservation more than males.Stratifying data by gender found that female PDs were more knowledgeable on their program's fertility insurance policies, as well as their residents' fertility issues, and were more likely to feel their program was not as supportive as they personally were with residents facing infertility. In addition to previous findings that female physicians retrospectively would have opted for more fertility support during their training,Strengths of the study include the in-depth survey questions, allowing for data on a broad range of subjects regarding fertility and residency. No other study has surveyed residency and fellowship PDs on their opinions regarding the fertility needs of their residents, and this study gave a new perspective on this issue from those who have the ability to affect change for residents. In addition, the survey reached a diverse variety of PDs, allowing us to stratify responses by gender and specialty.As discussed in the 39–41Participation in the survey was optional, which may contribute to selection bias in respondents. This bias is potentially evident in the fact that more than half of respondents were female, a much larger percentage than the proportion of existing female PDs, which could have potentially skewed the results more favorably because these PDs were likely more supportive.Selection bias based on specialty also could have impacted the results. Of the programs we contacted, 5.0% were from emergency medicine specialties, and 6.0% were PDs in obstetrics and gynecology. Given that emergency medicine and obstetrics and gynecology comprised 11.0% and 9.7% of respondents, respectively, their relatively disproportionate representation within the survey's respondents could also have impacted the results.Similarly, the specialties with the largest number of programs that we contacted, family medicine and internal medicine, were also not proportionately represented within the survey's respondents. In addition, the survey did not assess the length that a respondent had been a PD, and their responses to the survey questions could be affected by the amount of experience they have had in their position.There are potentially institutional variations between programs, based on GME office or state law, which were not accounted for in this study. Despite these limitations, we believe this study highlights important and novel findings about PDs' perspectives and potential influence on medical trainees' fertility.Wide gaps of knowledge and awareness exist among postgraduate medical PDs on the impact of age on fertility and mechanisms of support for trainees accessing infertility treatment and fertility preservation. Coupled with previous research, the findings of this study highlight the increasing need for improved PD awareness of fertility-related issues, program insurance coverage of infertility treatment and fertility preservation services, and improvement in pregnancy and parental policy.These changes would help meet medical trainees' reproductive needs and create a more equitable workplace for aspiring parents. We believe future research and education should focus on increasing dialogue between PDs and residents regarding fertility, improving family planning resources from PDs and their programs, and increasing resident awareness of these resources.


Studies have reported autonomic impairment in patients with idiopathic REM sleep behaviour disorder (iRBD), which is considered a prodromal stage of alpha-synucleinopathies. It is still debated whether central or peripheral pathologies are first manifestations of alpha-synucleinopathies. This study aimed to characterize autonomic and somatosensory function in iRBD patients.This cross-sectional prospective case–control study included 17 iRBD patients (mean age 66.3 ± 9.2 years) and 16 healthy controls . Quantitative sensory testing, neurological and neuropsychological assessments, norepinephrine blood plasma levels, tilt table examination with orthostatic blood pressure, and heart rate variability were carried out. Longitudinal data of 10 iRBD patients, including neurological, neuropsychological, and tilt table examination, were assessed.p < 0.0001). Supine norepinephrine plasma levels were normal, but lower in iRBD . Quantitative sensory testing revealed impaired cold (CDT) and vibration detection thresholds (VDT) on the foot in iRBD . Cold detection thresholds differed between the foot and hand among iRBD patients . Longitudinal data revealed an increase in maximum systolic and diastolic orthostatic blood pressure changes and a decrease in the Valsalva ratio in the follow-up group (p < 0.05).iRBD patients more frequently presented with orthostatic dysfunction than HCs (70.6% vs. 6.3%, This study revealed autonomic dysfunction with somatosensory impairment, and decreased norepinephrine levels in iRBD, which may serve as a possible prodromal marker for developing alpha-synucleinopathy.The online version contains supplementary material available at 10.1007/s00415-021-10675-7. Idiopathic REM sleep behaviour disorder (iRBD) is characterized by pathological dream-enacting behaviour during REM sleep and is considered a premotor stage of alpha-synucleinopathies (α-SYN), such as Parkinson’s disease (PD) or multiple system atrophy (MSA) , 2. It iclinical motor signs, as assessed through detailed neurological examination and the Unified Parkinson’s Disease Rating Scale (UPRDS-III)  (cut offsleep apnoea syndrome (higher than grade two);severe heart failure;long-standing diabetes mellitus with HbA1c > 7% as well as deficits of vitamin B12 or folic acid; in HC subjects, signs suggestive for peripheral neuropathy including abnormalities in nerve conduction studies and reduced clinical vibration detection.Seventeen male iRBD patients from the prospective natural history cohort study of the German RBD Study Group were examined at the Department of Neurology, RWTH Aachen University, between February 2016 and May 2018 and were compared to 16 healthy controls (HCs) matched for sex and age. iRBD was screened using the RBD Screening Questionnaire and was polysomnographically confirmed by diagnostic criteria established by the American Academy of Sleep Medicine, including abnormal behaviour during REM sleep, electromyographic activity, and dream enactment, as described previously in Schrempf et al. . The stuIn addition to carrying out a cross-sectional, case–control design, we also analyzed longitudinal data in a subgroup of ten iRBD patients with follow-up assessments following their inclusion in the natural history study between 2010 and 2016.The autonomic testing battery included sympathoneural function  and cardiovagal function . Tests were always performed in a fasted, standardized manner in the morning without morning medication, smoking or caffeine intake for at least 12 h. BP, breathing rate, and heart rate were recorded continuously using a Finometer Midi  and Fan 4.1.0 . BP measurement was consistently assessed in a standardized manner, using calibration between the brachial arterial pressure and the finger artery pressure, correcting for height, and continuous recording at the cardiac level. During two minutes of deep breathing, defined as six inspirations per minute, respiratory sinus arrythmia (RSA) was quantified as the median difference between the maximal and minimal interbeat (R–R) intervals per respiratory cycle (diffR-Rmax-R-Rmin). Parameters of heart rate variability , were calculated and rated pathologically, as previously described . The tilAccording to the protocol of the German Research Network on Neuropathic Pain (DFNS), QST was consistently performed in the same procedure on the left hand dorsum and left foot dorsum, as described previously . StandarNeuropsychological and neurological assessments were performed, as described previously : the MonFor this autonomic subproject, we added QST and NE levels in 2016 to our natural history study (started on 09/2010). A subgroup of patients participated in follow-up assessments, allowing for longitudinal analysis of tilt table examination and neuropsychological and neurological assessments.t test and Mann–Whitney U test, as appropriate. Fisher’s exact test was used to analyse NMS Quest frequency distributions and heart rate variability parameters. Smelling and heart rate variability parameters were compared between groups using ANCOVA with age as the covariate. Paired supine and upright systolic and diastolic BP, heart rate, NE plasma levels, and QST data were analysed using ANOVA with repeated measures. Cohen’s f was used as the effect size, defined as f = 0.10 mild, f = 0.25 moderate and f = 0.40 for severe effects. For QST data, ANOVA was followed by Fisher’s LSD post hoc tests. Most QST values were normally distributed in log-space and transformed logarithmically before calculating z-scores in relation to log-data of HC subjects. For correlation analyses, we used Spearman’s coefficient. To compare follow-up and baseline assessments in the subgroup of iRBD, the paired sample t tests and Wilcoxon signed-rank tests were used. A p value of ≤ 0.05 was considered significant. Statistical analysis was performed with IBM SPSS Statistics Version 25  and Statistica software for Windows 7.1 .We compared the differences between groups (iRBD vs. HCs) using the two-sample F = 23.17 p < 0.0001; left: 9 (interquartile range 6–10) in iRBD vs. 14 (interquartile range 11.5–15) in HCs, F = 12.26 p = 0.004), and iRBD patients displayed more depressive symptoms . The incidence of motor and non-motor symptoms was also significantly higher in iRBD patients than in HCs, as expected  were compared with 16 male HCs (mean age 66.5 ± 11.3 years). See Table t =  − 3.03 p = 0.005, max. change − 10.92 ± 8.76 mmHg diastolic, t =  − 2.86 p = 0.008). ANOVA with repeated measures confirmed a significant difference in NE levels in iRBD vs. HCs  and in the supine vs. upright position, as expected . With regard to individual values, NE supine was lower in iRBD , whereas the NE ratio (NE supine vs. upright) did not differ significantly between iRBD patients and HCs  than in HCs . In addition, the cold detection threshold on the left foot was significantly increased in comparison to the cold detection threshold on the left hand within iRBD patients . The vibration detection threshold was significantly increased in iRBD patients on the foot compared to that in HCs . In iRBD patients with electrophysiological signs of sensorimotor polyneuropathy, the vibration detection threshold did not significantly differ from those with normal electrophysiological test results. None of the other QST parameters differed significantly between iRBD and HCs .In QST, the cold detection threshold on the left foot dorsum in iRBD patients was significantly higher than that in HCs  and maximum diastolic BP change  were significantly higher at follow-up than at baseline. The heart rate in the upright position was significantly lower at follow-up (70.61 ± 11.71) than at baseline , and the Valsalva ratio was significantly reduced at the follow-up than at baseline . None of the remaining parameters changed significantly ; the possible confounders in NE metabolism ; and the possible intra- and inter-individual variability of plasma NE levels.As there are recent theories on different subtypes in PD , iRBD isOverall, this study confirms early peripheral autonomic dysfunction in the form of somatosensory impairment and decreased NE plasma levels, which is in line with the peripheral-to-central α-SYN spreading hypothesis. The findings support the concept of a peripheral origin and suggest autonomic testing as a feasible method to find predictive markers of conversion to α-SYN and future-directed potential protective therapies. This is important in light of a severe phenotype and poor prognosis. Further longitudinal investigations of QST, autonomic assessment, and NE levels may clarify the progression and severity of autonomic dysfunction in iRBD.Supplementary file1 (DOCX 23 KB)Below is the link to the electronic supplementary material.