Uterine fibroids (UFs) are the most important benign neoplastic threat to women’s health worldwide, with a prevalence of up to 80% in premenopausal women, and can cause heavy menstrual bleeding, pain, and infertility. Progesterone signaling plays a crucial role in the development and growth of UFs. Progesterone promotes the proliferation of UF cells by activating several signaling pathways genetically and epigenetically. In this review article, we reviewed the literature covering progesterone signaling in UF pathogenesis and further discussed the therapeutic potential of compounds that modulate progesterone signaling against UFs, including selective progesterone receptor modulator (SPRM) drugs and natural compounds. Further studies are needed to confirm the safety of SPRMs as well as their exact molecular mechanisms. The consumption of natural compounds as a potential anti-UFs treatment seems promising, since these compounds can be used on a long-term basis—especially for women pursuing concurrent pregnancy, unlike SPRMs. However, further clinical trials are needed to confirm their effectiveness. Uterine fibroids (UFs) are the most common benign tumor of the female genital tract that develops in the muscular wall of the uterus. Recent findings show that stem cells, growth factors, genetic and epigenetic factors, ovarian steroid hormones, cytokines and chemokines, and extracellular matrix (ECM) components are the critical factors involved in the development and growth of UFs ,5,6,7,8.Although the leading causes of fibroids are unknown, accumulating epidemiological, clinical, and experimental evidence supports the pivotal role of ovarian steroid hormones in the growth and pathogenesis of UFs . As a stGenerally, progesterone modulates physiological processes through two actions, which are classical and nonclassical. Classical actions are mediated by nuclear progesterone receptors (nPRs). These nPRs have two well-described isoforms such as PR-A and PR-B, which were shown to have higher expression in UFs tissue compared with adjacent myometrium . Non-claDisrupted progesterone signaling is causally linked to many reproductive diseases that result in subfertility or infertility, including UF . ProgestAXIN2, leads to the proliferation of fibroid side population (SP) cells [Studies demonstrated that progesterone signaling promotes the growth and proliferation of fibroid cells through increasing proliferating cell nuclear antigen (PCNA) expression, which increases both the number of fibroid cells and the size of fibroid tumors . This isP) cells . The sidP) cells . The SP P) cells ,42,43,44P) cells . MoreoveP) cells ,47. ProgApoptosis, or programmed cell death, is a mechanism by which abnormal or damaged cells are eliminated from the body. Progesterone has been shown to suppress apoptosis in fibroid cells, which may contribute more to the growth of UFs via B-cell lymphoma- (Bcl-) 2 protein expression induction  than myoRANKL) was recently identified as a novel progesterone/PR responsive gene that plays a vital role in promoting the growth of UFs by activating cyclin D1 [in vivo, which may provide a potential alternative therapeutic strategy [Cytokines are signaling molecules that play a significant role in the regulation of fibroid growth. Progesterone has been shown to modulate the production of cytokines such as TNF-α and IL-6 . In addiyclin D1 . Furtherstrategy .RANKL gene expression, with an essential role in activating stem cell proliferation and fibroid tumor development [Hoxa10 gene in uterine tissue in early life and increased the E2/P4 ratio serum level in middle age. This indicates estrogen dominance and is considered to be a risk factor for hormonal carcinogenesis [The findings of Liu et al. suggested that DNA methylation and MED12 mutation together constitute a complex regulatory network that affects progesterone/PR-mediated elopment . Neonataogenesis . By dissogenesis .Since the formation of new blood vessels is vital for the delivery of nutrients and oxygen to the growing tumors , progestECM is an intricate network composed of an array of multidomain macromolecules organized in a cell/tissue-specific manner that provide structural support to cells . In fibrAll these molecular mechanisms of action demonstrate the complex and multi-faceted role of progesterone in the regulation of UFs . FurtherA Cochrane review was conducted in 2017 using data from 11 randomized controlled trials, and included 1215 study participants. It consisted of five studies about mifepristone, four about ulipristal acetate (UPA), and two about asoprisnil . FibroidIn a study by Murphy et al., mifepristone was found to be effective in treating symptomatic fibroids in 10 patients, with a significant decrease in lesion dimensions (49.0 ± 9.2%) observed after 3 months of therapy with 50 and 25 mg daily . A recenAnother meta-analysis also showed that mifepristone was able to lower uterine and fibroid volume considerably and decrease related symptoms, including heavy menstrual bleeding, dysmenorrhea, pelvic pain, and anemia. The optimal dose of between 2.5 and 5 mg/day of mifepristone for a period of 3–6 months was established. Notably, the authors pointed out that special attention should be paid to the long-term observation of endometrial hyperplasia .In phase III of a placebo-controlled study (NCT00133705), 5 mg/day of mifepristone influenced menstrual bleeding, quality of life, pain, and uterine size in 42 women with symptomatic UFs . After 2Ulipristal acetate (UPA) is the most known and tested SPRM . The effIn the PEARL II trial (NCT00740831), administration of 5 and 10 mg of UPA was compared to 3.75 mg of leuprolide acetate in 3 months of observation . No diffThe PREMYA trial (NCT01635452) in Germany, France, UK, Romania, Portugal, Sweden, Poland, Hungary, Slovenia, and Austria assessed the safety, efficacy, and QoL after UPA administration in 15 months of observation. Around 40% of the included participants required surgery. Even after the end of treatment, pain and quality of life were better . In the Chronic use of these agents may be associated with abnormal liver enzymes and, rarely, hepatic failure; however, the underlying mechanism for such induced liver toxicity is still not fully understood . Some yeAnother SPRM is asoprisnil, which is currently assessed in two placebo-controlled Phase III randomized trials (NCT00152269 and NCT00160381) . Upon coTelapristone acetate was assessed as 12.5, 25, or 50 mg/day dose ,90. In 3Vilaprisan is the most recently developed SPRM, and was tested in regimens of 0.5 mg/day, 1 mg/day, 2 mg/day, and 4 mg/day as compared to placebo in a placebo-controlled phase II trial called ASTEROID 1 (NCT02131662) . AmenorrPhytoprogestins, plant-derived compounds, are progesterone antagonists and are often used to combat gynecological diseases that can be stimulated by steroid hormones, among which apigenin, kaempferol, luteolin, and naringenin are particularly common . SeveralBerberine, a natural alkaloid isolated from Berberis species, has a variety of biological activities , includiIsoliquiritigenin, one of the bioactive components of licorice, has the potential to be used as an anti-cancer agent. As a phytoestrogen, isoliquiritigenin is thought to interact with estrogen receptors and affect the ability of antral follicles to synthesize estradiol. Furthermore, isoliquiritigenin at 100 μM also reduced progesterone levels in ovarian antral follicles . Lin et Adlay (Coxi lacryma-jobi L. var. ma-yuen Stapf.) has been used in in vitro experiments to evaluate the viability of UFs cells, and the results showed that adlay sub-fractions were able to inhibit the proliferation of ELT3 and primary UF cells . Based o2D3’s proliferation inhibition ability may be related to the PR modulation effect [Vitamin D, a fat-soluble vitamin series, modulates several actions in the human body through its steroid compound properties . The main effect . Besidesn effect , showingn effect ,117, butTraditional herbal medicine has been widely used in UFs treatments  to decreGreen tea is shown to have a beneficial effect on health. Without the fermentation step, in order to keep the polyphenols component preserved, its active ingredient, EGCG, maintains its anti-proliferation and anti-metastasis effects . EGCG shCurcumin is an active component found in Curcuma longa, and is used as a food additive, cosmetic ingredient, and supplement due to its multiple health benefits, including anti-tumor, anti-inflammatory, and anti-fibrosis effects ,133,134.Progesterone signaling plays a crucial role in the development and growth of UFs. Progesterone promotes the proliferation of UF cells by activating several signaling pathways genetically and epigenetically, including the Akt/MEK/ERK pathway. The expression of progesterone receptors is significantly higher in UFs tissues compared to normal myometrium. Therefore, targeting the progesterone signaling pathway may be a potential therapeutic strategy for treating UFs. Various drugs that inhibit progesterone signaling, such as SPRMs, have been developed and are currently being evaluated in clinical trials. However, further studies are needed to fully understand the mechanism of progesterone signaling in UFs and to develop more effective treatment options. In addition, there is a need for a better understanding of the interplay between various signaling pathways and their role in the development and growth of UFs. For instance, recent studies have shown that there is a crosstalk between the progesterone and estrogen signaling pathways, suggesting that both hormones may contribute to the development of UFs. Therefore, a more comprehensive approach that targets multiple signaling pathways may be required for the effective treatment of UFs. Consumption of natural compounds as potential anti-UFs treatments is promising, since these compounds can be used on a long-term basis. This is especially beneficial for women pursuing pregnancy while undertaking treatment, since other pharmacological treatments such as SPRMs are not fertility friendly. However, further research is needed in this regard.


As cancer therapies continue to improve, the survival rates of adolescent and young adult patients have increased. Consequently, considering patient quality of life after cancer, including family building, has become an essential aspect of establishing a treatment plan. However, the gonadotoxic nature of many chemotherapeutic agents limits the option of using one’s own gamete for family building. In recent years, significant advancements have been made in oncofertility, particularly vitrification of oocytes. Unfortunately, as with many areas of medicine, health disparities limit those that can access and utilize fertility preservation prior to cancer treatment. This review aims to shed light on existing disparities in oncofertility for female patients, to offer recommendations to enhance education, access, and advocacy, as well as identify potential areas for future research. With remarkable advances in anti-cancer therapies, adolescent and young adult patients with cancer are surviving into adulthood at increasing rates. As a result, issues related to survivorship, such as family building after completing treatment, are becoming more important. The field of oncofertility has made significant progress in ensuring a reproductive future for these patients, and now it is the standard of care to offer fertility preservation counseling prior to gonadotoxic therapy in patients of reproductive age. Fertility preservation procedures most commonly include sperm, oocyte, and embryo cryopreservation . AdditioSeveral professional societies including the American Society for Clinical Oncology (ASCO), American Society for Reproductive Medicine (ASRM), and American College of Obstetricians and Gynecologists (ACOG), recommend that healthcare providers discuss the possibility of infertility related to cancer therapies and fertility preservation options with patients. Referral to a reproductive specialist should occur as soon as possible before cancer treatment is initiated ,4,5. UnfIt is well-established that, outside of an oncofertility context, racial disparities exist in access to and utilization of fertility services. Compared to white women, African American and Hispanic women attempt to conceive for a longer period before seeing a reproductive specialist and face greater difficulty in obtaining an appointment, taking time off from work, and paying for treatment . Black wDisparities have been documented at all stages of the fertility preservation continuum of care, from referral and counseling to treatment. The odds of fertility preservation referral are approximately two times higher for white women . Even inA survey of women under the age of 40 with a new diagnosis of breast cancer found that non-white race was significantly associated with increased concern about fertility, suggesting that these disparities are not due to lack of interest . InteresSocioeconomic disparities within reproductive care are vast, given the substantial financial burden of fertility treatments, which is exacerbated in the context of a new oncologic diagnosis. One large survey study at an academic medical center found that women with an annual income of <USD 30,000 were less likely to report receiving fertility preservation counseling; however, income was not associated with who ultimately underwent fertility preservation procedures . HoweverPatients from low socioeconomic groups may be uninsured or have public insurance, which limits their access to care in general and certainly to fertility preservation. In a large study of nearly 3000 adolescents and young adults with a cancer diagnosis at an academic medical center, those with public insurance or uninsured were significantly less likely to be referred for fertility preservation counseling by 7.1% and 4% points, respectively, when compared with patients with private insurance. However, insurance status is not necessarily predictive of who ultimately underwent a fertility preservation procedure . HoweverA patient’s age may also impact their likelihood of being referred for or undergoing fertility preservation. One survey study found a trend towards patients older than 35 years old being less likely to pursue fertility preservation . A retroThe decreased fertility preservation utilization for older patients is likely multifactorial. Referring providers might assume that older women are less inclined to pursue fertility preservation due to their age. Alternatively, providers may avoid raising false hope, considering the well-known challenges associated with achieving positive outcomes with fertility preservation in older age groups. A retrospective review of 137 women who utilized autologous vitrified oocytes, cryopreserved for elective or non-oncologic medical indications, revealed that age played a significant role in fertility preservation success. Women aged 36 years or older exhibited lower clinical birth rates upon returning to use their vitrified oocytes than younger women . This deA patient’s family size at time of cancer diagnosis may influence their likelihood of being referred for fertility preservation counseling. It may not be surprising to find that women without children are more likely to undergo fertility preservation consultation . HoweverIn discussions about access to fertility care, insurance mandates are often mentioned as a way to increase affordability and utilization of fertility treatment. While insurance mandates increase access to fertility treatment overall, they do not necessarily ameliorate racial disparities in treatment . Given tThe literature identifies several factors that impede decision making about fertility preservation, including inadequate provision of fertility information, fear related to perceived risks of pursuing fertility preservation, non-referral, competing priorities, personal situation , and financial factors . HoweverIt may be a viable option to address gaps in counseling by improving patient access to fertility preservation information. While information regarding fertility preservation is often available on the Internet, not all patients have Internet access, and much of the available information is written above the recommended reading level of the American Medical Association and the National Institutes of Health (6th–7th grade) ,41,42. FRacial disparities in clinical settings are influenced by implicit bias that exists among healthcare professionals. This bias leads to inequities in healthcare and must be acknowledged ,45. One One potential area of intervention to improve fertility preservation access is to improve healthcare provider education on available options, as the field is rapidly evolving. However, even with knowledge of the options, healthcare providers may still face discomfort in discussing fertility preservation with their patients, leading to further barriers to care. This discomfort may stem from uncertainty about available options, leading to a reluctance to refer to fertility specialists. Additionally, the treating oncologist may be guarded in their prognosis for patient survivorship and less likely to refer in these situations to avoid giving false hope. These barriers in provider education are echoed in the literature; a study analyzing qualitative data from interviews of adult and pediatric oncologists found that providers reported a lack of knowledge of fertility preservation due to having received no formal training in the subject. They also noted that discussions about fertility preservation added an extra layer of stress to an already burdensome situation for the patient . One croProvider education is a significant gap in fertility preservation care and is not necessarily a topic that is formally covered in oncology fellowship . TherefoAnother factor contributing to the limited oncologist education may be the lack of easily accessible IVF centers in their vicinity. According to the 2020 ART Fertility Clinic and National Summary Report, 499 clinics reported outcomes to the CDC . While sPatients with a new cancer diagnosis are overwhelmed with information, and programs with opt-out or included consultations with fertility specialists can help give patients the information they need in order to make an informed decision regarding whether or not to proceed with consultation. However, as mentioned previously, although increasing referrals for fertility preservation for all reproductive-aged cancer patients may help alleviate disparities, it is important to consider the potential impact on the capacity of fertility specialists programs. Additionally, not all patients referred will be able to afford the fees associated with the consultation, let alone the treatment. One possible solution is for fertility specialists to utilize trainees and mid-level providers and offer free or discounted consultationss to provide initial patient education. We found that offering a no-charge telephone consultation conducted by a reproductive endocrinology fellow or nurse practitioner prior to a formal in-person consultation led to an increase in completed consultations for fertility preservation . This alOnce a patient elects to proceed with fertility preservation, the associated costs can be a substantial burden, often not covered by insurance, and can preclude a patient from proceeding. A 2010 study assessed the average cost of fertility preservation at 154 reproductive clinic locations from consultation to procedure, finding that the average cost for egg or embryo cryopreservation is USD 8655. While cancer patients typically qualify for supportive programs or grants, such as Livestrong or Heartbeat, the resulting subsidized cost is still significant, especially considering the other financial and social stressors of a new oncologic diagnosis. To increase access to fertility preservation, increased support in assisting patients to apply for financial assistance programs and creative solutions to decrease costs should be considered. The circumstances that impact the decision of minority patient groups to pursue treatment represent the next frontier in fertility preservation research. As our exploration of the literature here has demonstrated, there are extensive gaps in our understanding of underrepresented minorities’ utilization of fertility preservation and why patients of a certain race, socioeconomic group, age, or family size are less often referred for care. In addition to the questions raised in this review, there is a relative paucity of data in the literature as it pertains to similar disparities in sperm-producing individuals. Given the missing pieces in our understanding, it is essential to directly engage with these groups to address disparities and promote equity. We need to ensure that those who have been historically excluded from the table are invited and encouraged to participate. It is time to ask ourselves if the table can be set in a way that is inclusive and welcoming for all.Moving forward, it is clear that more research is needed to identify the factors that impact the decision-making process of underrepresented groups when considering fertility preservation. This research should focus on understanding the unique needs and experiences of these communities, and on developing interventions to address disparities in access to care. This will likely require a comprehensive approach that includes education and outreach, research, and policy changes . By work


Human T-lymphotropic virus-1 (HTLV-I) is an enveloped, single-stranded RNA virus of the Retroviridae family. The virus causes two well-recognized disease associations: adult T-cell leukemia/lymphoma (ATL) and HTLV-I-associated myelopathy (HAM), also known as tropical spastic paraparesis (TSP). We report a case of HTLV-1-induced adult T-cell lymphoma/leukemia in a 45-year-old female who presented with complaints of swelling on the right side of her neck and rash on her upper and lower extremities and abdomen. The patient also had a history of strongyloidiasis infection and Crohn's disease. She was found to have hypercalcemia and multiple lytic lesions of the bone found on the imaging. She also tested positive for HTLV-1 and T cell-positive for cluster of differentiation (CD) 2, CD3, partial CD5, and minimal CD56, later confirmed by the bone marrow (BM) and skin punch biopsies. ATL is characterized by the clonal proliferation of CD4+ T cells containing randomly integrated HTLV-I provirus, often associated with T-cell receptor gene rearrangements. ATL, in its aggressive forms, has one of the poorest prognoses of non-Hodgkin lymphoma. It is essential to raise awareness of ATL, although further research and trials are needed to solidify the treatment options to prevent mortality. Adult T-cell lymphoma (ATL) has four types depending on the presentation: acute, lymphomatous, chronic, and smoldering . Acute'sHelicobacter pylori infection, and asymptomatic thymic enlargement presented with a papular, painful, and pruritic rash for one month. The rash started on the back of her hands and extended to the feet, extensor surfaces, abdomen, and buttocks. The patient visited her primary care physician two weeks ago, and oral allergy medications plus topical medications were prescribed along with the discontinuation of gabapentin, but that did not help the rash. The patient endorsed nausea and vomiting for the past week, weight loss of an unknown amount, and right-sided neck swelling with tenderness for six months. She denied smoking, drinking, or illicit drug use. The patient was febrile and hemodynamically stable, and the laboratory results of the initial presentation are mentioned in Table A 45-year-old female from Ghana (recently visited in 2021 and immigrated in 2017) with a past medical history of hypertension, prediabetes, lumbar spine radiculopathy with disc herniation, Crohn's disease, tension headaches, strongyloidiasis, On physical examination, the neck was noted to have tenderness and mobile anterior cervical right-sided lymph nodes. The rash was raised with hyperpigmentation and scaling. A computed tomography (CT) of the abdomen and pelvis revealed bilateral iliac and groin lymphadenopathy and widespread lytic bone lesions, suggesting widespread bony metastatic disease, as shown in Figure  The flow cytometry shows atypical T-cell populations expressing CD2, CD3, partial CD5, and minimal CD56. Lymph node biopsy revealed the complete effacement of nodal architecture with a diffuse polymorphous infiltrate, atypical lymphoid cells with irregular nuclei, Hodgkin and Reed-Sternberg cell-like morphology, and increased mitotic activity, as shown in Figure The patient underwent a right-sided supraclavicular lymph node excision biopsy and a punch biopsy of the skin on the abdominal wall. The patient was started on intravenous (IV) crystalloid fluids for hypercalcemia, and calcium started to trend down, as shown in Figure . Approximately 95% of individuals who contract the virus remain lifelong asymptomatic carriers [Human T-lymphotropic virus-1 (HTLV-1) is a CD4+T retrovirus. It was first discovered by the Gallo in 1979 -7. Whilecarriers ,9.The major routes of viral transmission include vertical transmission, sexual transmission, and transmission via blood transfusion . While sStrongyloides' infective course is either asymptomatic or mild in the healthy population [Strongyloides infection among HTLV-1-infected individuals [Strongyloidiasis infection is strongly associated in those with symptomatic associations with the HTLV-1 virus. pulation . The danpulation . The HTLividuals .Adult T-cell lymphoma caused by HTLV-1 and its subtypes are rare neoplasms with CD4+ CD25+ T-cell markers . This lyATL diagnosis is based on clinical features, characteristics, and morphologic and immunophenotypic changes of malignant cells . IdeallyIn the case of the patient presented, she offered several pathological correlates, including dermatologic manifestations, hypercalcemia, and previous strongyloidiasis infection. ATL, in its aggressive forms, carries one of the poorest prognoses in non-Hodgkin lymphoma. This case report illustrates the diverse complexity of patients with ATL. It is one of the few cancers that are caused by a virus. The findings are only sometimes typical. Recent advances in oncology and hematology have shown promising results for mogamulizumab and lenalidomide. As physicians, we should keep a low threshold for these diagnoses. It is essential to raise awareness of ATL, although further research and trials are needed to solidify the treatment options to prevent mortality.


FGF9) is crucial for the growth and development of hair follicles (HFs); however, its role in sheep wool growth is unknown. Here, we clarified the role of FGF9 in HF growth in the small-tailed Han sheep by quantifying FGF9 expression in skin tissue sections collected at different periods. Moreover, we evaluated the effects of FGF9 protein supplementation on hair shaft growth in vitro and FGF9 knockdown on cultured dermal papilla cells (DPCs). The relationship between FGF9 and the Wnt/β-catenin signaling pathway was examined, and the underlying mechanisms of FGF9-mediated DPC proliferation were investigated. The results show that FGF9 expression varies throughout the HF cycle and participates in wool growth. The proliferation rate and cell cycle of FGF9-treated DPCs substantially increase compared to that of the control group, and the mRNA and protein expression of CTNNB1, a Wnt/β-catenin signaling pathway marker gene, is considerably lower than that in the control group. The opposite occurs in FGF9-knockdown DPCs. Moreover, other signaling pathways are enriched in the FGF9-treated group. In conclusion, FGF9 accelerates the proliferation and cell cycle of DPCs and may regulate HF growth and development through the Wnt/β-catenin signaling pathway.Fibroblast growth factor 9 ( Small-tailed Han sheep have bright coloured hair with a fine and soft texture, making it a good raw material for leather. However, compared with that of Merinos, its wool production performance needs to be improved . Wool isDP, which are found at the base of the HF, serve as regulatory centres and are essential for the formation, development, and regulation of HFs and their cycles ,5. They FGF1, FGF2, FGF5, FGF7, FGF10, FGF13, FGF18, and FGF22 were expressed at different stages of the HF proliferation cycle and that their expression peaks varied. The mRNA expression of FGF18 and FGF13 peaked during the telogen phase, that of FGF7 and FGF10 peaked during anagen phase V, and that of FGF5 and FGF22 peaked during anagen phase VI. Housley et al. demonstrate that FGF5 inhibits hair growth by promoting the transition from the anagen to the catagen phase in HFs ). Gene expression in each sample was analysed using the HTSeq software (version 0.5.4) in combination with a union model. The fragments per kilobase of exon model per million mapped reads (FPKM) value was used as a measurement of the gene expression level. A ∣log2 (fold change)∣ > 1 and p < 0.05 were used as the criteria to identify differentially expressed genes (DEGs).Raw sequencing data were filtered using Trimmomatic software (version 0.33). Cleaned data were mapped onto the reference genome of FGF9 in skin tissues containing HFs in the anagen, catagen, and telogen phases were also tested using qPCR. ACTB was used as the internal control. After the exogenous addition of FGF9 protein and inhibition of FGF9 gene expression in DPCs, several key genes of the Wnt/β-catenin signalling pathway, including CTNNB1, GSK3β, LEF1, DVL2, LRP5, and LRP6, were selected for qPCR quantification. The first strand cDNAs were created after the total RNA was extracted. Using the Primer Premier (version 5.0) program, primers were created following the assembly sequences of the investigated genes in GenBank  , a lysis buffer. Protein concentrations were measured using an Enhanced BCA Protein Assay Kit (Beyotime) according to the manufacturer’s instructions. Proteins were separated through sodium dodecyl sulphate–polyacrylamide gel electrophoresis (SDS-PAGE), transferred to PVDF membranes, and treated with 1:1000 rabbit anti-β catenin , and 1:2000 rabbit anti-glyceraldehyde 3-phosphate dehydrogenase (GAPDH)  antibodies, followed by 1:3000 goat anti-rabbit immunoglobulin G (IgG) horse radish peroxidase (HRP)-labelled antibody . The signals were detected using an ECL Western Blot Kit  according to the manufacturer’s instructions. Protein testing and analysis were performed using a ChemiScope 6000 Touch Imaging System .FGF9 protein-supplemented and control groups, we set the significance threshold (p < 0.05) and used cluster analysis software to perform GO  and KEGG  pathway enrichment analyses on the DEGs. GO was divided into three categories: molecular function, biological processes, and cellular composition.To gain insight into the biological relationship between the DEGs of DPCs in the −∆∆CT method. Statistical analyses were performed using SPSS 22.0 software. The independent sample T-test and one-way analysis of variance (ANOVA), as well as LSD, Tukey’s-b, and Waller–Duncan tests, were used for variance analysis and significance tests. Data analysis was performed using GraphPad Prism 7.0 software. All experimental data are expressed as the mean ± standard error of the mean (SEM), and statistical significance was set at p < 0.05.The results of the real-time PCR analysis were processed using the 2The HF samples extracted in July 2022 were in the anagen phase, in which the DP consisted of fibroblasts embedded in the mesenchyme of connective tissues by the epithelial cells of the bulb. In January 2022, the HFs were in the catagen phase, in which the DPs were located at the proximal ends of the HFs and the DPCs were arranged closely together with minimal ECM. In April 2022, the HFs were in the telogen phase, in which the DP had reduced mesenchyme, the epithelial cells of the bulb shrank, and the DP was released a. These FGF9 gene is expressed in the skin tissues, HFs, and DPCs of small-tailed Han sheep . The CCK-8 assay results show that cell proliferation is reduced after the inhibition of FGF9 expression compared with that in the control group  signaling pathways in diabetic complications, and ECM receptor interactions. The top 20 most significant KEGG pathways were selected in the order of their p-values and plotted  in DPCs supplemented with FGF9 protein compared to the control group, while it shows an upregulation trend in DPCs with FGF9 downregulation. Therefore, FGF9 may regulate the growth and development of HFs through the Wnt/β-catenin signaling pathway. Similarly, Enshell-Seijffers et al. [FGF9 on the proliferation of DPCs may be synergistic through multiple signaling pathways. The signaling cascade in which FGF9 acts in DPCs may act antagonistically with Wnt/β-catenin, and competitive inhibition leads to a decrease in CTNNB1 expression.Some previous studies partially explained the association between FGF family members and mechanisms related to the Wnt/β-catenin signaling pathway. Notably, FGFs and the Wnt signaling pathway interact within the DP to regulate the expression of various molecules, including Wnt agonists (R-spondins) and antagonists (DKK2 and Notum) . β-catens et al.  show thaLEF1, DVL2, LRP5, and LRP6, we speculated that FGF9 might regulate DPC proliferation through other signaling pathways. Therefore, we performed transcriptomic analysis of DPCs in the FGF9 protein-treated and control groups. Through GO and KEGG pathway enrichment analyses of the DEGs, we identified the genes most associated with FGF9 expression that regulate the biological processes and cellular composition during DPC proliferation. In the cellular composition category, most single genes are enriched in the ECM, which is consistent with the fact that FGF9 exerts its biological functions primarily through a paracrine mechanism of action [FGF9 may play a role in promoting cell cycle transition and regulating cell metabolism. By analysing the sequencing results, we speculate that FGF9 synergistically regulates DPC proliferation through multiple signaling pathways. However, the mechanisms of interaction between FGF9 and various signaling pathways still need to be further explored.The synergistic involvement of multiple signaling pathways in DPC proliferation has been established, and studies show that FGF signaling crosses and acts in concert with the NOTCH, WNT, and TGF-β signaling pathways to control cell maturation ,13. Owinf action . In the FGF9 is expressed in varying extents in small-tailed Han sheep and that the addition of exogenous FGF9 protein can encourage DPC proliferation and cell cycle progression. Furthermore, FGF9 may regulate HF growth and development through the Wnt/β-catenin signaling pathway. Lastly, the positive effects of FGF9 on DPC proliferation and the cell cycle may be the result of the synergistic effects of multiple signaling pathways. These findings provide the basis for further production of genetically modified sheep that produce more and better wool. Future research will focus on the molecular mechanism through which FGF9 promotes DPC proliferation to elucidate how FGF9 induces hair follicle growth and development through multiple signaling pathways.In conclusion, our study shows that


Uterine adenomyosis (UA) has a significant negative impact on the individual’s quality of life due to pain, abnormal uterine bleeding, and subfertility. The impact on women’s health and sexuality has never been underestimated by physicians, but treatment modalities have been shown to be problematic. Therapies for UA have several insufficiencies to be dealt with. Medical treatment seems successful, but only to a certain degree, and for the duration it is used. Furthermore, it is often counterproductive when used during assisted reproductive therapy . Even noAs always in medicine, when the existing treatment pathways do not reach curative goals or ensure a high efficacy probability, other options should be evaluated. High-intensity ultrasound (HiFu) ablation, guided by diagnostic ultrasonography, all in the hands of the treating gynaecologist, seems to be a promising tool in UA . IntraopAvoiding technically complex major surgery or eventually compromising medical therapy, this alternative treatment modality appears a promising option for diffuse UA . FollowiDue to the high importance of the UA, a new Working Group of the European Society for Gynaecological Endoscopy (ESGE)- European Society of Human Reproduction and Embryology (ESHRE) – World Endometriosis Society (WES) has been inaugurated, to give expert recommendations on diagnostics and therapies for UA based on available evidence and experience, described in separate parts. This working group of experts will diligently scrutinise the available evidence before summarising their recommendations. Imaging by MRI and possibilities of transvaginal and transabdominal ultrasound and medical therapies will be evaluated. There will be a special scope on open and laparoscopic surgery, as only a few expert centres are performing adenomyosis surgery on a regular scale. Distinction will be made between solitary or localised disease, and the diffuse form. The non-surgical ablative therapies such as HiFu and uterine artery embolization will also be analysed, highlighting the upcoming importance. It is anticipated that the resulting documents will be published concomitantly both in this journal, FVVO and Human Reproduction Open during the year 2023.


Hyperuricemia is influenced by diet and can cause gout. Whether it is a potential risk factor for cardiovascular disease (CVD) remains controversial, and the mechanism is unclear. Similar to CVDs, gout attacks occur more frequently in the morning and at night. A possible reason for this is the diurnal variation in uric acid (UA), However, scientific data regarding this variation in patients with CVD are not available. Thus, we aimed to investigate diurnal variations in serum levels of UA and plasma levels of xanthine, hypoxanthine, and xanthine oxidoreductase (XOR) activity, which were measured at 18:00, 6:00, and 12:00 in male patients with coronary artery disease. Thirty eligible patients participated in the study. UA and xanthine levels significantly increased from 18:00 to 6:00 but significantly decreased from 6:00 to 12:00. By contrast, XOR activity significantly increased both from 18:00 to 6:00 and 6:00 to 12:00. Furthermore, the rates of increase in UA and xanthine levels from night to morning were significantly and positively correlated. In conclusion, UA and xanthine showed similar diurnal variations, whereas XOR activity showed different diurnal variations. The morning UA surge could be due to UA production. The mechanism involved XOR activity, but other factors were also considered. Diet and sleep play important roles in the development of cardiovascular disease (CVD) ,2. DisorThis is a prospective observational study enrolling male patients with CAD. They were admitted for elective percutaneous coronary intervention at Juntendo University Hospital between June 2016 and November 2017. In this study, we established inclusion criteria that restricted participation to male patients, as UA levels vary significantly between males and females and UA levels also exhibit sex-specific differences as a CAD risk marker . We excl2  hypoxanthine and  xanthine as internal standards. The mixtures were centrifuged at 3000× g for 15 min at 4 °C. Subsequently, 30 μL of the supernatant was transferred to new tubes, diluted with 120 μL of distilled water, and analyzed using liquid chromatography–triple quadrupole mass spectrometry (LC/TQMS). The concentrations of hypoxanthine and xanthine in the plasma were quantified from calibration curves obtained using calibration standards xanthine and LC/TQMS as previously described [2 > 0.995), with a lower limit of quantitation of 4 nmol/L. This lower limit corresponds to an XOR activity of 6.67 pmol/h/mL of plasma.The XOR activity assay was conducted using a stable isotope-labeled substrate and LC/TQMS  . In detaescribed . This ast-test was used to compare the UA, xanthine, hypoxanthine, and XOR activities at 18:00, 6:00, and 12:00. The Bonferroni correction was used after the paired t-test. Repeated-measures analysis of variance (ANOVA) was used to assess diurnal variation at three time points . The percentage changes in UA, xanthine, and hypoxanthine from 18:00 to 6:00 and 6:00 to 12:00 are expressed as ΔUA (18:00–6:00), ΔUA (6:00–12:00), Δxanthine (18:00–6:00), Δxanthine (6:00–12:00), Δhypoxanthine (18:00–6:00), and Δhypoxanthine (6:00–12:00), respectively. Pearson correlation analysis was used to compare ΔUA, Δxanthine, and Δhypoxanthine values. Analyses were performed using JMP .In this study, for continuous variables, values are presented as mean ± standard deviation or median (interquartile range), and for nominal variables, they are expressed as numbers (%). Due to the skewed nature of XOR activity, all statistical analyses employed the natural log-transformed XOR activity (log XOR). The sample size calculation relied on data from the initial five subjects, as no prior relevant studies were available. These data revealed mean values and standard deviations of changes in UA levels as 0.1 mg/dL and 0.19, respectively. With a significance level of 0.05 and 80% power, the calculated sample size was 30. A paired 2. The prevalence rates of hypertension, dyslipidemia, diabetes mellitus, and current smoking were 73%, 90%, 53%, and 27%, respectively. A total of 53% were taking angiotensin-converting enzyme inhibitor/angiotensin Ⅱ receptor blocker, 70% were taking β blockers, and 93% were taking statins.Overall, 30 patients were enrolled in this study. p = 0.012) but significantly decreased from 6:00 to 12:00  (p for ANOVA = 0.010). Similarly, plasma xanthine levels significantly increased from 18:00 to 6:00  but significantly decreased from 6:00 to 12:00  (p for ANOVA < 0.001). Plasma hypoxanthine levels did not significantly change between 18:00 and 12:00 or between 12:00 and 6:00  , and no diurnal variation was observed (p = 0.009) and 6:00 to 12:00  (p for ANOVA < 0.001).Serum UA levels significantly increased from 18:00 to 6:00  . UA show< 0.001) . Plasma observed . On the < 0.001) . XOR actp = 0.020) and Δhypoxanthine  (p < 0.001) and 6:00 to 12:00 .As the diurnal variations in UA and xanthine were similar, we evaluated the association between ΔUA and Δxanthine and Δhypoxanthine at the respective time points (18:00–6:00 and 6:00–12:00). From 18:00 to 6:00, a significant positive association was found between ΔUA and Δxanthine  . From 6:= 0.040) . The assThe present study demonstrates that serum UA, plasma xanthine, and XOR activity showed diurnal variation in male patients with CAD. Our previous study showed that UA levels significantly increased from night to morning in male patients with CAD. In addition, we demonstrate that UA levels significantly decreased from 6:00 to 12:00 in this study. Previous studies have reported that UA levels show similar diurnal variations in healthy subjects, patients with diabetes, and patients with multiple sclerosis. In healthy individuals, UA oscillates with gradually increasing concentrations throughout the night, peaking in the morning . In anotFurthermore, xanthine showed a diurnal variation similar to UA. By contrast, hypoxanthine showed no diurnal variation. To the best of our knowledge, this study is the first to demonstrate diurnal variations in xanthine. UA is the end product of purine metabolism in humans. Purine metabolism is a complicated mechanism consisting of the de novo pathway, salvage pathway, and degradation . In the In summary, the UA and xanthine levels were significantly elevated from night to morning, and the rate of increase was positively correlated. These results suggest that the increase in serum UA levels from night to morning may be due to increased UA production. Although both decreased from morning to noon, no correlation was found with the rate of decrease. In healthy men, peak urinary UA excretion has been reported to occur between 08:00 and 10:00 and between 22:00 and 24:00 . TherefoBased on the results for serum UA and plasma xanthine levels and the mechanism of purine metabolism, we expected XOR activity to show similar diurnal variations. However, the XOR activity was significantly elevated from night to morning and was also significantly elevated from morning to noon. XOR is a rate-limiting enzyme in purine metabolism, which mainly catalyzes the conversion of hypoxanthine to xanthine and UA with the concomitant generation of superoxide. XOR activity is increased by hypoxia and various cytokines, such as pro-inflammatory cytokines and tumor necrosis factor ,38. In oFurthermore, XOR activity increased from morning to noon in the present study. Sun et al. and Kanemitsu et al. reported that XOR activity increases from late light to early dark in rats and in the livers of mice ,42. HoweThis finding suggests that UA production is involved in the increase in UA levels from night to morning. Although XOR activity is speculated to be involved as one of the mechanisms, other triggering factors besides XOR activity may be present. The decrease in UA and xanthine from morning to noon, despite an increase in XOR, suggests that the morning-to-noon variation reflects both production and excretion. Gout attacks occur more frequently during the night and early morning. Based on the results of this study, one possible reason for this may be increased UA production during the night and early morning. Therefore, for clinical application, it is expected that gout attacks can be suppressed by inhibiting XOR activity from night to morning, i.e., by oral administration of XOR inhibitors before sleep. This finding warrants further clinical research.The present study has several limitations. First, it was a single-arm observational study. This study was conducted only on patients with CAD, and it is necessary to study healthy subjects as a control group. Second, this study was conducted at a single center, and the study population was relatively small in size. However, it is noteworthy that we took measures to determine the appropriate sample size through power analysis, utilizing data from our pilot study involving the initial five subjects. We believe that our findings are reasonable based on previous studies. Third, the inclusion criteria for this study were restricted to male patients only. This decision was influenced by the significant difference in the prevalence of CAD between males and females. Furthermore, female patients with CAD are often older, and a large number of cases is needed to account for age-related bias. Therefore, this study was limited to males. Future studies including females are needed, as the results of this study cannot be applied to females. Fourth, we did not assess UA excretion. Approximately two-thirds of UA is excreted by the kidneys, with the remaining one-third eliminated through the gastrointestinal tract. Future research endeavors should focus on investigating both the production and excretion pathways, utilizing blood, urine, and stool samples. This comprehensive approach will help to further elucidate the mechanisms of diurnal variation in UA, xanthine, and XOR activity. Fifth, we collected samples at only three time points: 18:00, 6:00, and 12:00. These were not equally spaced, and time effects can occur; however, previous reports of diurnal variation in UA have shown a peak at 6:00 and a minimum at 18:00. In addition, to reduce the influence of meals as much as possible, we collected samples at three time points in all patients, at 18:00, 6:00, and 12:00, prior to each meal. Finally, the UA intake was not measured. All patients consumed hospital food; therefore, we considered nutrients and calories within the margin of error. Since individual differences exist in food intake, these differences should be discussed in the results and how they can be interpreted from the perspective of previous studies and of the working hypotheses. The findings and their implications should be discussed in the broadest context possible. Future research directions may also be highlighted.Serum UA and plasma xanthine levels showed diurnal variations in patients with CAD. Although XOR activity showed diurnal variation, it was different from that of UA and xanthine. The increase in UA from night to morning was speculated to be due to UA production, whereas the decrease in UA from morning to noon was speculated to be due to both production and excretion.Furthermore, increased XOR activity from night to morning has been reported to be related to clock genes in addition to hypoxia, which contributes to increased UA production. Gout attacks, which occur more frequently at night and at dawn, may be prevented by suppressing XOR activity before it increases.


The BMP (Bone morphogenetic protein) signaling pathway plays a central role in metazoan biology, intricately shaping embryonic development, maintaining tissue homeostasis, and influencing disease progression. In the context of cancer, BMP signaling exhibits context-dependent dynamics, spanning from tumor suppression to promotion. Cancer stem cells (CSCs), a modest subset of neoplastic cells with stem-like attributes, exert substantial influence by steering tumor growth, orchestrating therapy resistance, and contributing to relapse. A comprehensive grasp of the intricate interplay between CSCs and their microenvironment is pivotal for effective therapeutic strategies. Among the web of signaling pathways orchestrating cellular dynamics within CSCs, BMP signaling emerges as a vital conductor, overseeing CSC self-renewal, differentiation dynamics, and the intricate symphony within the tumor microenvironment. Moreover, BMP signaling’s influence in cancer extends beyond CSCs, intricately regulating cellular migration, invasion, and metastasis. This multifaceted role underscores the imperative of comprehending BMP signaling’s contributions to cancer, serving as the foundation for crafting precise therapies to navigate multifaceted challenges posed not only by CSCs but also by various dimensions of cancer progression. This article succinctly encapsulates the diverse roles of the BMP signaling pathway across different cancers, spanning glioblastoma multiforme (GBM), diffuse intrinsic pontine glioma (DIPG), colorectal cancer, acute myeloid leukemia (AML), lung cancer, prostate cancer, and osteosarcoma. It underscores the necessity of unraveling underlying mechanisms and molecular interactions. By delving into the intricate tapestry of BMP signaling’s engagement in cancers, researchers pave the way for meticulously tailored therapies, adroitly leveraging its dualistic aspects—whether as a suppressor or promoter—to effectively counter the relentless march of tumor progression. The BMP (Bone morphogenetic protein) signaling pathway plays a crucial role in various aspects of metazoan biology. From embryonic development to tissue homeostasis and disease progression, the BMP signaling exerts a profound influence on cellular processes and organismal physiology Massagué . The outCancer stem cells (CSCs), also known as tumor-initiating cells, are a small subpopulation of quiescent, pluripotent, self-renewing neoplastic cells that were first identified in hematologic tumors and later in solid malignancies   is a malignant brain tumor in adults, is challenging to treat due to its diverse cellular populations with varying transcriptional profiles, morphology, invasive potential, tumorigenicity, and drug sensitivity  and DLX2  survive longer than patients with low expression of DLX2  is a devastating brainstem tumor located in the pons, accounting for 10–15% of all pediatric brain tumors, with a median survival of only 9–12 months  alone are not sufficient to induce DIPGs  targeting CHRDL1, an antagonist of the BMP pathway, could be achieved by inhibiting its activity, potentially utilizing a neutralizing antibody against CHRDL1; (2) inhibiting FPKBP12, a negative regulator of BMP receptors, through degradation or blocking strategies such as PRO-TAC technology or FK50663, could activate BMP signaling and impede tumor growth; (3) augmenting CXXC5 activity, a positive regulator of BMP signaling, could be pursued to suppress tumor growth; (4) HDACis drugs, which have exhibited anti-tumor efficacy in DIPG and can positively regulate BMP signaling, holds promise for improved therapeutic outcomes. These approaches provide encouraging avenues for the development of novel therapies targeting this aggressive cancer.In sum, given the contrasting roles of BMP signaling in the two subtypes of DIPG, it is essential to explore distinct therapeutic strategies tailored to each subtype.The intestinal mucosa harbors self-renewing stem cells in the crypt base and differentiated cells in the villus, which are tightly regulated by gradients of BMP and WNT signaling pathways . BMP signaling promotes intestinal differentiation while inhibiting stem cell activation. However, germline mutations in BMPR1A and SMAD4 are responsible for familial juvenile polyposis syndrome, which carries a high lifetime risk of CRC  to form a complex with β-catenin. This complex negatively regulates WNT signaling by inhibiting the transcriptional activity of β-catenin/TCF4 on promoters of WNT target genes like the oncogene The potential of BMP signaling in the treatment of CRC has been explored, and it has been found that BMP signaling enhances the cytotoxic effects of chemotherapy, suggesting that combining BMP4 administration with current standard chemotherapy could provide clinical benefits for CRC patients  is a highly aggressive hematological malignancy that is characterized by the uncontrolled proliferation of hematopoietic stem/progenitor cell (HSPCs) and blockage of myeloid differentiation  inhibits BMP signaling to promote self-renewal in AML cells, which acts as a BMP signaling antagonist  proximal promoter and then suppress the BMP3B expression, which is regarded as a tumor growth inhibitor and a gene silenced in lung cancers , orchestrating transitions from a stemness state to a differentiation state. Simultaneously, BMP signaling can paradoxically stimulate osteosarcoma cell migration and invasion, particularly when certain osteosarcoma cells develop resistance to BMP-induced osteogenic differentiation. This intricate interplay is facilitated through crosstalk with fibronectin-integrin-β1 signaling pathways.These discoveries provide a foundational framework for evaluating the clinical relevance of BMP signaling in predicting the outcomes of osteosarcoma and chondrosarcoma. Furthermore, they underscore the potential of modulating BMP signaling as a therapeutic avenue for curbing osteosarcomagenesis, inhibiting growth, and thwarting invasive tendencies in these malignancies.Tumor metastasis stands as the primary culprit behind cancer-related fatalities. Grasping the intricate molecular mechanisms that underlie this menacing process holds the key to reigning in this formidable ailment. Within the metastatic cascade, numerous signaling pathways choreograph the intricate cellular ballet, encompassing stalwarts such as TGFβ Massagué , BMP Re, PDGF N, and theIn the realm of cancer, the TGFβ pathway’s duality has been long acknowledged. Its role wavers between anti-tumor sentinel and pro-metastasis instigator, its inclination hinging upon cellular phenotype, genetic aberrations, and an array of allied factors Massagué . SimilarBMP signaling frequently intersects with other signaling pathways, sometimes acting as a facilitator of tumor metastasis. Recent investigations have unveiled intriguing insights. Notably, in the context of highly invasive breast cancers, TGFβ signaling has been found to counteract BMP-induced SMAD1/5/8 activation. This interplay leads to a substantial reduction in tumor self-seeding, as well as diminished liver and bone metastasis  and SMAD6, using small molecule inhibitors could effectively promote BMP signaling activity and potentially inhibit tumor growth.Conversely, in situations where BMP signaling act as tumor promoters, interventions at different levels could be considered. Direct delivery of inhibitors, such as antisense oligonucleotides, specifically targeting BMP ligand production within the tumor, could potentially offer a means to prolong patient survival. Furthermore, inhibiting ligand-receptor interactions using antibodies against BMP ligands or BMP receptors, as well as employing small molecule inhibitors that target BMP receptor kinases, like LDN-193,189, could provide alternative and potentially more effective therapeutic approaches for blocking BMP signaling in tumors.Lastly, since BMP ligands and antagonists are secreted proteins, the measurement of their concentrations in a patient’s blood or specific tissues may have diagnostic value and could aid in assessing the level of tumorigenesis. Monitoring the levels of these signaling molecules may offer valuable insights into disease progression and guide treatment decisions.In conclusion, the comprehensive understanding of BMP signaling in cancer is a complex and evolving field. The intricate interplay between BMP, TGFβ and other signaling pathways, the balance of BMP ligands and antagonists in the tumor microenvironment, and the potential for targeted therapeutic interventions make this an area of great interest for future research and the development of personalized cancer therapies.


Assisted reproduction technology (ART) has made considerable progress in recent years; in particular with regard to cryopreservation, long-term storage, successful thawing, and embryo transfer of cryopreserved embryos. Regarding gestational surrogacy, progress has been made in the areas of awareness, social acceptance, regulation, legislation, availability, streamlining, and optimization of cross-border care. The above is being highlighted in the current presentation of a particularly challenging and novel case. A 43-year-old woman visited our clinic in Greece, seeking international gestational surrogacy due to recurrent breast cancer which rendered her medically unfit for pregnancy. Ten years before her initial visit to our clinic the patient had undergone fertility preservation due to breast cancer, her oocytes had been fertilized with her husband’s sperm, and the embryos were cryopreserved and stored in a fertility clinic based in the United Kingdom. The stored embryos were transported to Greece, thawed, and successfully implanted to the selected gestational surrogate. Following an uneventful pregnancy, the surrogate delivered a healthy girl. This successful outcome exemplified innovation, motivation, and hope and may represent a paradigm of team scientific excellence associated with positive patient outcomes. Furthermore, this case constitutes the successful culmination of major advances made in various different sectors of cross-border reproductive care; laboratory, clinical, legal, ethical, and logistical.  Infertility is becoming an increasingly prevalent condition in the modern world, with increasingly more couples and single individuals seeking assisted reproduction technology (ART) services . Given tThis process entails the extraction, cryopreservation, and storage of genetic material or embryos and its use at a later time when it is medically safe and indicated or based on the couple’s family planning. In view of the above, long-term cryo-storage of embryos has been a fairly common occurrence.However, in certain challenging cases, even if fertility preservation has been successfully performed, pregnancy and delivery may not be medically indicated or feasible, due to a plethora of different reasons. Such reasons may include anatomical conditions , medical reasons , iatrogenic  and many more. For such cases, another ART technique, gestational surrogacy (GS) may be indicated, as an advanced, final-line fertility treatment option. Entailing the implantation and gestation of an embryo created from the genetic material of the intended parents to the uterus of a surrogate mother, GS is a challenging, but immensely rewarding and effective program and, sometimes, the only option available to certain individuals to become parents.The aforementioned ART techniques may be further complicated in cases of cross-border patients and when genetic material is required to be transported between different fertility clinics based in foreign countries. Under these circumstances, legal and logistical considerations further exacerbate the already difficult journey of the patients . DespiteThe aim of this report is to highlight this remarkable progress through the presentation of a case of successful delivery of a healthy child through cross-border GS with the use of cryopreserved embryos stored for over a decade abroad, following fertility preservation for breast cancer.The current report presents the case of a 43-year-old woman and her 48-year-old husband who became parents via an international gestational surrogacy programme. The couple first visited our clinic in March 2019. The woman had been diagnosed with breast cancer in 2010, which was initially treated surgically and subsequently with adjuvant chemotherapy, hormonal therapy, and radiotherapy. Prior to her breast cancer treatment, the patient had undergone fertility preservation in the UK at the age of 34 years.Fertility preservation and cancer treatmentFollowing controlled hormonal ovarian stimulation, oocyte retrieval, in vitro fertilization (IVF), and intra-cytoplasmic sperm injection (ICSI) with the husband’s sperm, five embryos were created. The embryos were cultured using the SAGE® sequential medium, until they reached the blastocyst stage on the fifth day of embryo culture, with one embryo reaching the blastocyst stage on the sixth day of culture. Subsequently, the embryos were cryopreserved via the slow-freeze method, using the Quinn’s Advantage® blastocyst freeze kit (Ref. No: ART-8015). The embryos were stored in PETG® 91mm embryo straws (Ref. No: 006433) and remained in storage at the UK-based fertility clinic.The patient continued breast cancer treatment with tamoxifen for five years post-operatively and adhered to a frequent follow-up protocol. Two years following the discontinuation of her hormonal treatment, the patient initiated fertility investigations in the UK with a view to proceed with IVF treatment by means of frozen/thawed embryo transfer. However, three years after the discontinuation of her hormonal treatment , the patient suffered from breast cancer recurrence and she underwent bilateral mastectomy and bilateral axillary lymphadenectomy. Histopathological analysis revealed a G2 invasive ductal adenocarcinoma in the left breast, 17mm in diameter, without lymph-node metastases, positive for estrogen receptors (ER-positive) and negative for human epidermal growth factor receptor 2 (HER2-negative). Postoperatively, the patient was treated with letrozole and goserelin.Gestational surrogacy decision and preparationGiven the patient’s medical history, IVF and pregnancy were contraindicated and gestational surrogacy was offered to the couple as a fertility option. Due to availability issues in the UK, the couple opted for international gestational surrogacy care in our clinic in Greece. The cryopreserved embryos were subsequently transported to our clinic, with the use of a specialized biological courier service, certified for cross-border transport of human genetic material. Following the appropriate medical screening of the gestational surrogate, in addition to several other logistic and legal preparations, including the issuance of a parental court order, she was ready to proceed with the embryo transfer.Embryo transfers and pregnancy outcomesThe gestational surrogate underwent an embryo transfer on 20/10/2020. One embryo was thawed, using the FertiPro® Warming Kit (Lot No: FP20FVW10) and cultured for four hours in a continuous single culture, supplemented with human serum albumin; however, the embryo did not progress satisfactorily and was hence discarded. Two embryos were thence thawed, with the use of the same protocol and, following laser-assisted hatching (LAH), progressed normally and were subsequently transferred to the gestational surrogate. The embryo transfer was performed with the use of a Wallace Classic® embryo transfer catheter . Under transabdominal ultrasonographic guidance, the catheter was gently passed through the cervix and into the endometrial cavity until the catheter’s tip reached approximately the second third of the endometrium, just above the level of the isthmus. Subsequently, the embryos were gently injected into the endometrium, and their position was verified via ultrasound.The transferred blastocysts were of 3BB and 3AB quality according to the Gardner score scale [This second embryo transfer was successful, resulting in a healthy singleton and uneventful pregnancy, which resulted in a spontaneous vaginal delivery of a healthy girl at 36 weeks and three days gestation. The neonate weighed 2620 g, had normal appearance, pulse, grimace, activity, and respiration (APGAR) scores, and required no specialized interventions and intensive care. At present, at 20 months old, the child has demonstrated normal physical and cognitive development, with no abnormalities whatsoever.The present case report highlights the significant, rapid advances of ART services in recent years, in both laboratory, clinical, and logistical terms. Firstly, the successful, long-term cryopreservation of genetic material collected prior to cancer treatment and its successful use a decade later. Secondly, the development, expansion, and availability of gestational surrogacy as an option for women to whom pregnancy is contraindicated. Thirdly, the international aspect of fertility care, with legislation and services that facilitate direct communication and coordination between clinics in different countries, forgoing lengthy and complicated bureaucratic procedures for cross-border transfer of genetic material and the increased popularity of “fertility cross border care”.The evolution of fertility preservation options has considerably affected the landscape of reproductive medicine. In this case, the patient underwent fertility preservation prior to her treatment for breast cancer. Given the fact that breast cancer is the most frequent malignancy in females, with over 2.2 million new cases recorded worldwide in 2020 alone , many woApart from the improvements made in the laboratory aspect of ART, several advances have been made in the clinical and legal aspects as well. Gestational surrogacy (GS) entails the gestation by a surrogate carrier, usually a young, healthy, and motivated woman. GS is typically reserved as an advanced option for select cases with specific indications, such as in this case, and has become popular recently. Data from the USA indicate that GS was representing 1% of all ART procedures in 1999 and 2.5% in 2013 ,11, withDespite the recent rise of GS in popularity, there are some ethical considerations that are still raised . One of Despite the rising popularity of GS and all the above considerations, legislation is not yet in place in every country to regulate its use in clinical practice; with added legal issues regarding child custody being also a consideration in many contexts . Greek lThe existence of such legislation regarding GS, in particular with regard to the legal safety of the intended parents and gestational surrogate alike, is indicative of the astonishing progress made in reproductive medicine in recent years and is a significant contributor to the increase in cross border fertility care observed in Greece and other countries where similar legislation applies . This isThis report presented the case of the delivery of a healthy child via GS from cryopreserved embryos, which were created a decade ago in the context of fertility preservation due to breast cancer diagnosis and treatment. This case highlights a culmination of many notable advances in the field of ART throughout the years, such as the safety and success of long-term embryo cryo-preservation, the expansion of altruistic GS programs, and the cross-border interconnection of fertility clinics worldwide. As ART technology and scientific protocols continue to evolve, more similar successful cases are likely to emerge and eventually become the norm. In addition to technological evolution and scientific advancement, the continued collaboration between medical practitioners, lawmakers, and ethicists is vital in order to ensure similar improvement in the ethical and legal aspects of ART services. It is to those ends that research, development, legislation, and discussion in the field of ART should strive towards, constantly optimizing the medical aspect while ensuring that the ethical and legal aspects are aligned with the evolving medical landscape; with the ultimate objective of assisting individuals in their journey to parenthood.


Understanding of human T-lymphotropic virus (HTLV) remains largely based on epidemiologic and clinical data from endemic areas. Globalization has resulted in migration of persons living with HTLV (PLHTLV) from endemic to non-endemic areas, and a rise of HTLV infection in the United States. Yet, due to the historical rarity of this disease, affected patients are often under- and mis-diagnosed. Thus, we sought to characterize the epidemiology, clinical features, comorbidities, and survival of HTLV-1- or HTLV-2-positive individuals identified in a non-endemic area.Our study was a single institution, retrospective case–control analysis of HTLV-1 or HTLV-2 patients between 1998 and 2020. We utilized two HTLV-negative controls, matched for age, sex, and ethnicity, for each HTLV-positive case. We evaluated associations between HTLV infection and several hematologic, neurologic, infectious, and rheumatologic covariates. Finally, clinical factors predictive of overall survival (OS) were assessed.p < 0.001). Hepatitis C and HTLV co-infection resulted in decreased OS, compared to no infection, hepatitis C infection alone, or HTLV infection alone. Patients with any cancer diagnosis and HTLV infection had worse OS compared to patients with cancer or HTLV alone. HTLV-1 positive patients had lower median OS compared to HTLV-2 patients (47.7 months vs. 77.4 months). In univariate analysis, the hazard for 1-year all-cause mortality was increased among patients with HTLV-seropositivity, adult T-cell leukemia, acute myelogenous leukemia, and hepatitis C infection. When corrected, multivariate analysis showed that HTLV seropositivity was no longer associated with 1 year all-cause mortality; however association with AML and hepatitis C infection remained significant.We identified 38 cases of HTLV infection, of whom 23 were HTLV-1 and 15 were HTLV-2 positive. The majority (~54%) of patients in our control group received HTLV testing for transplant evaluation, compared to ~24% of HTLV-seropositive patients. Co-morbidities associated with HTLV, hepatitis C seropositivity were higher in HTLV-seropositive patients compared to controls (OR 10.7, 95% CI = 3.2–59.0, HTLV-seropositivity was not associated with increased 1 year mortality in multivariate analysis. However, our study is limited by our small patient sample size, as well as the biased patient control population due to selection factors for HTLV testing. The first human oncogenic retrovirus discovered, human T-lymphotropic virus type 1 (HTLV-1) affects around 10 to 20 million individuals worldwide . HTLV-1 Despite sharing considerable structural homology and transmission routes with HTLV-1, human T-lymphotropic virus type 2 (HTLV-2) has a distinct geographic spread, with endemic regions in indigenous populations in the Americas and cohorts of intravenous drug users in the United States and Europe . HTLV-2 Much of our current knowledge of HTLV is based on research in endemic areas. A prospective cohort study in Nagasaki identified 1997 HTLV-1+ patients and found that carrier status was associated with increased risk of all-cause mortality and development of non-neoplastic diseases and heart disease . AnotherIn recent years there has been an increased incidence of HTLV in the United States. However, affected patients are often under- and mis-diagnosed due to low testing rates and poor understanding of the disease in non-endemic regions. In addition, HTLV-1 disease associations, including polymyositis, uveitis, thyroiditis, and bronchiectasis, are rarely considered unless patients have already been diagnosed with HTLV. This makes understanding HTLV and its relationships to other disease processes a significant challenge outside of regions of traditionally defined endemicity. Thus, we sought to better characterize the clinical features, comorbidities, and survival of HTLV-1- or HTLV-2-positive individuals identified in a non-endemic area, using patient information from our academic institution.We conducted a retrospective, case–control study of patients with HTLV-1 or HTLV-2 newly diagnosed between January 1, 1998 and December 31, 2020 at a single institution. To obtain our patient group, we extracted data for patients with positive HTLV testing in our electronic health record and collected relevant patient level clinical information through direct chart abstraction. The diagnostic criteria for HTLV seropositivity in this study was defined by positive screening enzyme-linked immunoassay (EIA) or particle agglutination (PA) assays, with subsequent confirmation western blot or polymerase chain reaction (PCR) assays to discriminate between HTLV-1 and HTLV-2 seropositivity . Using nThe sample size was calculated based on the prevalence of symptoms of HAM estimated at 3.7% of HTLV-1 positive individuals, with variance of 5%, based on a prior longitudinal study of HTLV-1/2-seropositive blood donors . In our Clostridium difficile infections.We collected relevant information on demographic, laboratory, and clinical variables from the electronic medical record database. Route of infection information including history of sexually transmitted infections, intravenous drug use, breast feeding in setting of known maternal infection, blood transfusions, and transplantation (including both solid organ and hematologic) were obtained. Reasons for HTLV testing were grouped into eight mutually exclusive categories: neurologic deficits, hematologic disorders, transplant evaluation, dermatological, gastrointestinal, lymphadenopathy, infection, and other/unknown. Co-infections with HIV, hepatitis B, or hepatitis C were evaluated from serological tests. HBV infection was defined by hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs), and total hepatitis B core antibody  serologies. Opportunistic infections were defined by positive testing for CMV, EBV, Cryptococcus, Toxoplasmosis, bacterial blood stream, or We reviewed data on potential clinical manifestations of HTLV infection. Neurologic symptoms were defined by symptoms of lower extremity weakness and/or spastic paraparesis. Dermatologic symptoms were defined by eczematous, papular, or erythrodermic rash and/or confirmatory biopsy results. Ocular disturbances/uveitis included sudden onset of floaters, visual blurring, or discomfort. Pulmonary symptoms of pneumonitis were defined by computed tomography (CT) findings of parenchymal abnormalities, including centrilobular nodules, ground-glass opacities, and bronchiectasis . Comorbit-test for numerical values. Univariate odds ratios (ORs) with 95% confidence intervals (CIs) were calculated with small sample adjustment using “epitools” in Rstudio. Overall survival (OS) was defined as elapsed time from diagnosis until death from any cause. Event-free patients were censored at date of last clinical follow-up. Survival estimates were calculated by Kaplan–Meier method and compared using the log-rank test. Both univariate and multivariate Cox regression models were fitted to assess clinical variables and OS. A two-sided p value <0.05 was considered statistically significant.Standard descriptive statistics were used to describe the baseline characteristics of the population. Statistical comparisons between groups were performed with a chi-square test for categorical values and a We identified 160 patients with positive HTLV screening tests. Of these positive screening tests, 16 patients had no follow-up confirmatory western blot, 89 patients had negative western blots, and 16 patients had indeterminant western blots. There were 39 HTLV-seropositive patients confirmed with positive western blot, of whom 24 were HTLV-1 positive and 15 were HTLV-2 positive. One HTLV-1 positive patient was excluded who did not have any other clinical data available other than their HTLV status. The baseline patient characteristics are summarized in The distribution of matching factors—age, sex, and ethnicity—was similar between HTLV seropositive patients and seronegative controls. Compared to control population, the HTLV seropositive population had higher rates of intravenous drug use (IVDU) , which iThe reasons for HTLV testing are identified in HTLV-seropositive patients predominantly underwent HTLV testing because of neurologic deficits (31.5%)—including spastic paraparesis, weakness, and gait disturbances. The second most common reason for HTLV testing was for transplant screening tests. HTLV screening was included in the routine serologic panel obtained prior to transplant and often was diagnosed incidentally in asymptomatic patients. Notably, the majority (53.9%) of patients in our control group received HTLV testing for transplant evaluation testing, compared to 23.7% of HTLV-seropositive patients.Due to the increased representation of transplant evaluation patients in the control group, we sought to further evaluate the prevalence of malignancies, solid/hematologic transplants, and potential biases in survival in our study population.p = 0.0021). In particular, around half of the hematologic malignancies in the control population  were multiple myeloma.We found that there was no difference in the frequency of solid or hematologic malignancies between HTLV seropositive patients and the control population . Eight pMoreover, our study control population had increased rates of autologous stem cell transplant (auto-SCT) compared to our HTLV patient population, likely reflecting the increased representation of multiple myeloma patients. There was an insignificant difference in allogeneic stem cell transplants  and solid organ transplants. In our HTLV-seropositive patient population, there was one patient who underwent both auto- and allo-SCT for relapsed and refractory DLBCL. In our control population, one patient underwent both solid organ deceased donor kidney transplant and auto-SCT for multiple myeloma.p = 0.66), 3 years (p = 0.66), or 5 years (p = 0.09) in patients who had history of allo-SCT, auto-SCT, both allo-SCT and auto-SCT, or no transplants , 3 years (p = 0.87), or 5 years (p = 0.53) after HTLV diagnosis , with only three cases directly attributed to HTLV-1 associated myelopathy (HAM) (n = 1) or HTLV-2 spastic myelopathy (n = 2) (n = 6), ocular disturbances/uveitis in 3% (n = 1), and pneumonitis in 13% (n = 5) of patients. Comorbidities evaluated included rheumatoid arthritis , hypothyroidism , ITP , malignancies , and mood disorders . Odds ratios for these clinical manifestations and comorbidities were not statistically significant for HTLV-seropositivity when compared to controls (p = 0.027) and weakness with HTLV-2 infection   . Other ccontrols . Further= 0.020) .Notably, there were no cases of co-infection with HIV in our patient population.n = 2) had prior HBV infection, 74% (n = 28) were negative, and 21% (n = 8) had not undergone complete hepatitis B serologic testing. HCV antibodies were observed in 29% (n = 11) of the patient population. Hepatitis C seropositivity was strongly associated with HTLV-seropositivity   (n = 7), blood stream infections (n = 9), Clostridioides difficile (C. diff) (n = 1), and strongyloidiasis (n = 1), but these were not associated with higher risk with HTLV-seropositivity, HTLV-1 infection, or HTLV-2 infection.When evaluating for hepatitis B virus infection, we found that in our patient population, 5% (< 0.001)  and HTLV = 0.71) . Other cMedian follow-up was 39.7 months and median OS was 67.2 months for HTLV-seropositive patients, compared to 49.6 months and 131.2 months, respectively, for HTLV-seronegative patients. HTLV-1 positive patients had lower median OS compared to HTLV-2 patients (47.7 months vs. 77.4 months). During follow-up, 21 of 38 (55.3%) HTLV-seropositive patients died, while 33 of 76 (43.4%) HTLV-seronegative patients died.p = 0.006), HTLV-1 infection , ATL , AML , and HCV infection  (p = 0.0003) and HCV infection  remained significant.In univariate analysis, the hazard for 1 year all-cause mortality was increased among patients with HTLV-seropositivity  . When coIn Kaplan Meier analysis, HCV and HTLV co-infection resulted in decreased 1 year and 3 year OS, compared to no infection, HCV infection alone, or HTLV infection alone –C. This Similarly, patients with any cancer diagnosis and HTLV infection had worse 1 year, 3 year, and 5 year OS compared to patients with cancer or HTLV alone –C. This Since the discovery of HTLV-1 as the first oncogenic virus in 1980, our understanding of HTLV infection remains largely based on limited epidemiologic and clinical data from known endemic areas. With globalization, more and more PLHTLV have migrated from endemic to non-endemic areas, and recent studies have shown a rise of HTLV infection in the United States. As the majority of infected individuals remain asymptomatic, diagnosing and managing an infrequently encountered disease remains a significant challenge for many physicians in non-endemic areas. We sought to better characterize HTLV from data from our institution and identified 38 cases of HTLV-seropositive patients.Our study supports previous findings of increased prevalence of intravenous drug use and hepatitis C virus (HCV) co-infection in the HTLV seropositive population . EpidemiNotably, in our evaluation of clinical covariates, we found that HTLV seropositivity was associated with increased all-cause mortality in univariate analysis, but when corrected, this was no longer true. Rather, all-cause mortality appears to have been driven by other diseases, including HCV infection and AML. A seminal meta-analysis by Schierhout et al. examining epidemiologic associations between HTLV and adverse health outcomes reported that HTLV-1 infection was associated with increased risk of premature death, independent of ATL or HAM . The authors theorize that given the dearth of evidence for fatal comorbidities with HTLV-1 that would contribute to this increased mortality, HTLV-1 infection may cause systemic effects that have not yet been sufficiently studied or understood .Interestingly, our study found that HTLV/HCV co-infection resulted in decreased OS compared to HCV or HTLV infection alone. Several studies from Japan found similar results and showed worsening HCV viremia, more rapid progression of liver disease to cirrhosis and hepatocellular carcinoma, and decreased response to treatment in patients with HTLV/HCV co-infection . AnotherIn vivo laboratory studies of HTLV-1 have shown that even asymptomatic PLHTLV have higher serum levels of inflammatory cytokines  compared to healthy controls  which have been described in prior larger studies. This may largely be attributed to the fact that our study was underpowered. For example, to detect HTLV-associated myelopathy (HAM), our power calculation indicated that we would need to identify 230 HTLV-1 patients, however, our study was only able to obtain records from 24 HTLV-1 patients, three of whom had a formal diagnosis of HAM. Interestingly, nine of 39 HTLV-seropositive patients had neurological symptoms of lower extremity weakness and/or spastic paraparesis—it is possible that many of these cases may have been misdiagnosed due to the rarity of HAM and its clinical overlap with other neurological conditions, including multiple sclerosis, nutritional deficiencies, primary lateral sclerosis, and other inflammatory disorders .Future studies with a larger patient cohort are critical to further evaluate co-morbidities and associated disease characteristics of HTLV-1 and HTLV-2 seropositive patients.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Washington University Institutional Review Board. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.MG, TT, and LR conceived and designed the study, and wrote the manuscript. SP, TT, and LR designed the protocol and submitted the IRB. MG collected, analyzed, and assembled the data. FG verified the analytical methods. All authors contributed to the article and approved the submitted version.This project was supported by the Washington University Institute of Clinical and Translational Sciences which is, in part, supported by the NIH/National Center for Advancing Translational Sciences (NCATS), CTSA grant #UL1 TR002345. Funding was also provided through the Washington University Clinical- Scientist Training and Research (C-STAR)/Mentors in Medicine (MiM) Program. This project was also funded in part by the Alvin J. Siteman Cancer Center and Barnes-Jewish Hospital. The Siteman Cancer Center is supported in part by an NCI Cancer Center Support Grant #P30 CA091842. Additional support was provided by the Barnard Cancer Institute.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.The reviewer JCR declared a past collaboration with the author LR to the handling editor.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This study intended to compare the difference between the anterior talofibular ligament (ATFL) and posterior talofibular ligament (PTFL) angle with chronic ankle instability (CAI) patients and healthy volunteers, and to confirm whether using the ATFL–PTFL angle could be a reliable assessment method for CAI, so as to improve the accuracy and specificity of clinical diagnosis.This retrospective study included 240 participants: 120 CAI patients and 120 healthy volunteers between 2015 and 2021. The ATFL–PTFL angle of the ankle region was gaged in the cross-sectional supine position on MRI between two groups. After participants undergoing a comprehensive MRI scanning, ATFL–PTFL angles were regarded as the main indicator of patients with the injured ATFLs and healthy volunteers to compare, and were measured by an experienced musculoskeletal radiologist. Moreover, other qualitative and quantitative indicators referring to anatomical and morphological characteristics of the AFTL were included in this study with MRI, such as the length, width, thickness, shape, continuity, and signal intensity of the ATFL, which can be used as secondary indicators.p < 0.001). As for the ATFL-MRI characteristics, the length (p = 0.003), width (p < 0.001), and thickness (p < 0.001) in the CAI group were also significantly different from the non-CAI group. Over 90% of the cases, patients of the CAI group had injured ATFL with an irregular shape, non-continuous, and high or mixed signal intensity.In the CAI group, the ATFL–PTFL angle was 90.8° ± 5.7°, which was significantly different from the non-CAI group where the ATFL–PTFL angle for 80.0° ± 3.7° (Compared with healthy people, the ATFL–PTFL angle of most CAI patients is larger, which can be used as a secondary index to diagnose CAI. However, the MRI characteristic changes of ATFL may not relate to the increased ATFL–PTFL angle. Ankle joint lateral collateral ligament (LCL) complex, including the ATFL, the PTFL, and the calcaneo-fibular ligament (CFL), has an extremely high incidence of injuries in daily living and sports activities, which accounts for 80–90% of ankle sprain , 5, 7, 8Magnetic resonance imaging (MRI) can be used in the diagnosis and prognostic assessment of LCL complex injury , 10, 17,Inspired by Li et al. , we carrAll study procedures were approved by the Ethical Committee of The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University (NO.KY2022041). CAI includes functional ankle instability, mechanical ankle instability, and recurrent ankle instability. Here patients with mechanical ankle laxity were included. One hundred and twenty CAI patients admitted to The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University from January 2015 to September 2021 would be included as the experimental group. An experienced orthopedist conducted history screening for ankle sprains, physical examination, varus pressure test, or front drawer test in the experimental group, and all the results suggested that the patients had suffered from CAI based on clinical symptoms, stress X-rays and MRI. The inclusion criteria were as follows: (1) Over the past year, there have been more than one and non-simultaneous cases of unilateral ankle sprains, most recently four weeks ago. (2) Patients with subjective sensation of ankle instability, persistent fatigue, pain during exercise, loss of function, or relaxation of ankle joint during assisted examination or MRI signs of ligament damage. The imaging data of the subjects were analyzed by two other doctors.The control group consisted of 120 participants who had undergone MRI for reasons unrelated to CAI had been included and excluded by the same orthopedist. And the exclusion criteria were as follows: (1) previous ankle sprains; (2) a history of ankle surgery or a history of ipsilateral lower limb surgery; (3) malformation related to the ankle joint, for example, high arch, flat foot, inverting tibial plateau or varus heel; (4) previous history of ankle fracture; (5) PTFL tearing patients; (6) ATFL tearing patients and the ligament absorbed absolutely; (7) age more than 80 years or less than 18 years.The demographic data of the participators are presented in Table All MRI examinations were performed using a three-dimensional MRI superconducting scanner  with special coil adopted in a standardized fashion. In our radiology department, the standard protocol for ankle MRI is in a neutral position without any fixation applied in the supine position. Scanning sequence and parameters: axial T2WTSE sequence , coronal PD FSE TS sequence .Previous researches indicated that the optimal position for MRI scanning is the supine position because of a long examination. In addition, the ATFL–PTFL angle of the ankle region can be displayed more clearly in the transverse axial plane , 16. In In the control group, the length of the ATFL was also gaged in the transverse section, and the ATFL’s width was gaged at the midpoint of the total ligament length Fig.  a, b. WhAngle measurements, anatomical assessments, and morphological evaluations would put to use a picture archiving and PACS communication system. All measurements were accurate to one or two decimal places after the decimal point . One independent observer was blinded to grouping, and gaged all the values of the MRI scan. Each survey was repeated at least three times to calculate the mean and the intra-observer analysis. In order to eliminate subjective consistency of data due to recall, the measurement interval was at least two weeks.All statistical analyses were performed using SPSS 26.0 . All measurements were expressed as the mean and the standard deviation. Intra-observer measurement reliabilities were analyzed with the intra-class correlation coefficient (ICC). Receiver operating characteristic curves (ROC) were used to analyze the ATFL–PTFL angle of CAI patients and control group. And the sensitivity and specificity for evaluating were calculated. Since the data of the ATFL–PTFL angles were normally distributed, at the same time there was homogeneity of variance, the ATFL–PTFL angles between CAI patients and non-CAI individuals were compared by the independent t-test. In CAI patients, the relationship between the ATFL–PTFL angle and other MRI data was analyzed by Person correlation coefficient. P < 0.05 was deemed statistically significant. Post hoc analysis was used to evaluate the statistical power. The sample size was 120, the α level is 0.05, and the evaluation power is 1.0.p < 0.01), and the mean angle of the group CAI was significantly greater than that of the group non-CAI. In the group CAI, as for the ATFL-MRI characteristics, the length, the width, and the thickness were also significantly different from the group non-CAI. They were longer, narrower, and thinner in the group CAI. Over 90% of the patients, patients of group CAI had injured ATFL with irregular shape, non-continuous, and high or mixed signal intensity , width , thickness , and the ATFL–PTFL angle. The intra-observer and inter-observer reliabilities for all measurements were good (p < 0.001) (Table p < 0.001). The best ROC curve truncation point for ATFL injury diagnosis is ATFL–PTFL angle 85.05°, sensitivity is 0.858, and specificity is 0.942 . The study conducted by Kim et al. . focusesFor orthopedic medicine world, in terms of imaging examination, we recommend using the ATFL–PTFL angle as the primary indicator for the initial diagnosis of CAI. When the diagnosis is unknown or a large rate of angular change is observed in individual patients, the ATFL-MRI characteristics can be taken as a secondary index, which partly improves the sensitivity and specificity of confirmed CAI. It is a rapid and accurate diagnosis for orthopedic surgeons and a non-invasive examination for patients. In addition, orthopedic surgeons can choose the treatment plan through the size of the ATFL–PTFL angle, perform conservative treatment or surgical treatment, but this cut-off value needs further research.There are some limitations to this study. MRI scans were obtained in a supine position, a non-weight-bearing position. Since the ATFL–PTFL angle may vary in the weight-bearing and non-loading position, the ATFL–PTFL angle can be changed. Nevertheless, all patients in this study underwent scanning in the same posture. Accordingly, the measurement results between the two groups were considered comparable. Further study in weight-bearing positions of ankles will be required in future. Furthermore, the CAI is defined far beyond ligament laxity, though pathologic laxity of the ankle was the initial cause of the functional instability of the foot , 22. AftATFL–PTFL angle provides a novel and indirect MRI signature for CAI diagnosis. Compared with healthy individuals, most CAI patients have a larger ATFL–PTFL angle, which can assist in the diagnosis of CAI. But the MRI characteristic changes of ATFL may not relate to the increased ATFL–PTFL angle.