HIV/HTLV coinfection was more frequent in women (69.0%); the median age of coinfected individuals was 47.2 years [interquartile range (IQR): 41.6–55.4 years]. In the 14/417 (3.4%) municipalities where at least one case of HIV/HTLV coinfection was detected, the overall HTLV coinfection rate in HIV-positive samples was 0.25 (range: 0.17–13.84) per 100,000 inhabitants. Most cases of HIV/HTLV-1 coinfection  were concentrated in the municipality of Salvador. Isolated instances (one or two cases) of HIV/HTLV-1 coinfection were distributed across municipalities known to be endemic for HTLV infection.Human Immunodeficiency Virus (HIV) and Human T-Leukemia Virus (HTLV) are retroviruses that share similar routes of transmission. In Brazil, the prevalence of HIV and HTLV varies according to geographic region. The state of Bahia, located in the Northeast region, is considered endemic for both retroviruses. The present study aimed to characterize the frequency of HIV/HTLV coinfection and evaluate the geographic distribution of coinfection throughout the state. This cross-sectional study was conducted at the state's Central Laboratory of Public Health (LACEN-BA) and included all samples from 2004 to 2013 submitted to serological testing for anti-HIV and anti-HTLV-1/2, screened by chemiluminescence/ELISA and confirmed by Western blot. Infection rates are expressed as the number of infected individuals per 100,000 inhabitants from each municipality. A total of 129,158 samples originating from 358/417 (85.8%) municipalities in Bahia were evaluated. HTLV was detected in 2.4% of the HIV-positive samples ( Human Immunodeficiency Virus (HIV) and Human T-Leukemia Virus (HTLV) are retroviruses that share similar routes of horizontal transmission, including unprotected sex, the sharing of needles, syringes, or other drug injection devices, as well as vertically from mother to child . HIV is In Brazil, the prevalence of HIV and HTLV vary according to geographic region, with higher rates of HIV found in the Southeast and South regions, while HTLV is more frequently detected in the North and Northeast regions , 9. Stud+ T-lymphocytes, which may provoke dysfunction in this cellular subset, possibly favoring the appearance of opportunistic diseases, the progression to AIDS and increased mortality in co-infected patients  for Human Research at the Goncalo Moniz Institute, Oswaldo Cruz Foundation (IGM-FIOCRUZ), Salvador, Bahia-Brazil (CAAE number 22478813.7.0000.0040). All identifiable patient information was anonymized to maintain confidentiality, thereby avoiding the need for individual verbal or written consent.2  (http://www.ibge.gov.br). The state is comprised of 417 municipalities, which have been grouped into 32 microregions and seven mesoregions by the Brazilian National Institute of Geography and Statistics (IBGE) in accordance with the economic and social similarities , with an overall density of 27 inhabitants per kmlarities .A cross-sectional study was conducted using data obtained from the Central Laboratory of Public Health of Bahia (LACEN-BA), responsible for infectious disease surveillance via laboratory analysis throughout the state. This laboratory's target population is mainly comprised of blood donors, pregnant women and individuals exhibiting symptoms of infectious disease, whose blood samples are referred by blood banks, prenatal physicians or clinicians working in the public health system. All individuals who were tested for both HIV and HTLV and had one or more serological samples submitted for analysis at LACEN-BA between 2004 and 2013, were investigated. Samples were classified as HTLV-1, HTLV-2 or co-infection with HTLV-1/2—the latter indicating that WB testing bands were positive for both HTLV-1 and HTLV-2 infection accordingly to the manufacturer's instructions. To avoid multiplicity, each individual's most recent HIV and HTLV serological results were considered. Only individuals with HIV and HTLV positivity confirmed by Western blot were included.HIV serology was performed from 2004 to 2008 using an Elecsys HIV combi PT kit , which offers 100% sensitivity and 99.88% specificity; in 2009, the Architect HIV Ag/Ab Combo , with 100% sensitivity and 99.5% specificity, was adopted. After detection of HIV seropositivity, confirmatory Western blot  was performed for all samples. Serological testing for HTLV was performed by ELISA from 2004 to 2008 using the Murex HTLV-1/2 kit  with a sensitivity of 100% and a specificity of 99.94%, whereas from 2009 to 2010 the anti-HTLV-1/2 kit Sym Solution  was used . In 2011, a microparticle CLIA chemiluminescence assay  was used, offering a sensitivity of 100% and a specificity of 99.5%. If HTLV seropositivity was detected, all samples were submitted to confirmatory Western blotting .http://qgis.osgeo.org) to determine the geographical distribution of HIV and/or HTLV in the state of Bahia. Three-year moving averages were calculated between 2004 and 2013 to construct spatial distribution maps and to minimize the effects of random fluctuations. Infection rates are expressed as the number of infected individuals per 100,000 inhabitant.Data were extracted from clinical records at LACEN using the SMART LAB laboratory manager, then transformed using Talend Open Studio Data Integrator software to integrate serologic and confirmatory test results on an annual basis. The analyzed database was formatted using high volume extract, transformation and load throughput (ETL). Subsequently, a CVS table  was generated for validation using the R package and extant analysis by the STATA v13.0 software. Absolute and relative frequencies were calculated for the following categorical variables: age group , sex and serological test result. All extracted data were grouped according to municipality and/or microregion for improved accuracy with regard to differences among regions. Digital maps obtained from the IBGE cartographic database in shapefile format (.shp) were subsequently reformatted and analyzed using QGIS software version 3.10  in the samples analyzed, while the global prevalence of HTLV was 0.56% (n = 719). HTLV was detected in 2.4% of the HIV-positive individuals (n = 42) compared to 0.5% of samples with negative HIV serology (n = 677)   .n = 42) was more frequently found in women (69.0%) compared to men (31.0%) (p < 0.0001) (HIV/HTLV coinfection ( 0.0001) . The med 0.0001) .n = 677), 617 of these samples were positive for HTLV-1 (91.1%), 24 for HTLV-2 (3.6%) and 36 (5.3%) were positive for both HTLV-1 and HTLV-2.In the 42 cases of coinfection, WB identified 37 (75.5%) samples as positive for HTLV-1 , 3 (6.1%) for HTLV-2  and 2 (4.1%) were positive for both HTLV-1 and HTLV-2  . ConsideOut of 417 municipalities in the state of Bahia, 358 (85.8%) sent samples to LACEN at some time during the study period. At least one case of HIV was reported in 155 (37.2%) municipalities, while HTLV-1, HTLV-2 and HTLV-1/2 coinfection were detected in 121 (29.0%), 13 (3.1%) and one (0.2%) of the municipalities, respectively .n = 21), Porto Seguro (n = 5), and Feira de Santana (n = 2) microregions.In all, 14 (3.4%) municipalities presented at least one case of HIV/HTLV-1 coinfection, with an overall rate estimated at 0.25 per 100,000 inhabitants  . The higThe global rate of HIV/HTLV-2 coinfection was estimated at 0.02 per 100,000 inhabitants  and identified in two municipalities: one case in Paramirim (4.80 cases per 100.000 inhabitants) and two cases in Salvador (0.07 case per 100.000 inhabitants) .The two cases of triple infection were found in the Salvador microregion  . The oveOur work represents the first large-scale study to evaluate HIV/HTLV coinfection in the state of Bahia (Brazil), an area considered endemic for both infections , 23. WhiIn the present study, 2.4% of HIV-infected individuals were found to be coinfected with HTLV, in contrast to just 0.5% among those not infected with HIV. This translates to an almost five times greater risk of HTLV infection in individuals infected with HIV. Several studies have demonstrated that individuals infected by HIV have an increased risk for HTLV infection than the general population. In Brazil, the reported prevalence of HTLV infection in HIV-infected individuals ranges between 1.6% and 10.9% –16; loweStudies have associated HIV/HTLV coinfection with risk factors that include previous blood transfusion, intravenous drug use and sexual contact with multiple partners , 33, 34.The main limitation of the present study was the use of non-random sampling, which resulted in a predominance of females. In the state of Bahia, serological HTLV screening for pregnant women was become compulsory in 2011, which surely contributed to a higher proportion of women in the samples analyzed. Therefore, gender imbalance may have impacted the higher frequency of HIV/HTLV coinfection in women observed herein. Another limitation was the absence of information collected on risk factors for HIV/HTLV coinfection. However, with respect to the representativeness of the municipalities, ~86% of the state municipalities were evaluated throughout the study.In conclusion, HIV/HTLV coinfection in Bahia, an area endemic for both viruses, can be considered a rare event, detected in just 2.4% of all HIV-infected individuals evaluated and in 3.4% of the municipalities throughout the state. The areas with higher numbers of coinfection cases were those considered hotpots for HTLV and HIV, representing important economic or tourist centers in the state. The identification of relevant risk factors associated with HTLV/HIV coinfection can lead to efficacious actions in a variety of epidemiological contexts specific to each affected region. It is our hope that these findings will provide support for the implementation of preventive measures to contain the spread of these viruses, especially in areas where higher rates of HTLV/HIV coinfection were described.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Institutional Review Board (IRB) for Human Research at the Goncalo Moniz Institute, Oswaldo Cruz Foundation (IGM-FIOCRUZ). Written informed consent from the participants' legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.FP, FS, BG-C, and MR: conceptualization. FP, FS, ÂS, NN, MA, RC, and MR: data curation. FP, FS, MA, RC, and MR: formal analysis and methodology. All authors involved in investigation, writing—original draft, review and editing, contributed to the article, and approved the submitted version.This work was supported by the Coordination of Superior Level Staff Improvement Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) finance code 001, National Council for Scientific and Technological Development , National Foundation for the Development of Higher Education , and Foundation for Research Support of the State of Bahia (Fundação de Amparo à Pesquisa do Estado da Bahia-FAPESB). Maria Fernanda Rios Grassi, Bernardo Galvão-Castro, and Fred Luciano Neves Santos are research fellows of CNPq .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.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.


Coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), is associated with a high mortality rate. The majority of deaths in this disease are caused by ARDS (acute respiratory distress syndrome) followed by cytokine storm and coagulation complications. Although alterations in the level of the number of coagulation factors have been detected in samples from COVID-19 patients, the direct molecular mechanism which has been involved in this pathologic process has not been explored yet. The PI3K/AKT signaling pathway is an intracellular pathway which plays a central role in cell survival. Also, in recent years the association between this pathway and coagulopathies has been well clarified. Therefore, based on the evidence on over-activity of the PI3K/AKT signaling pathway in SARS-CoV-2 infection, in the current review, the probable role of this cellular pathway as a therapeutic target for the prevention of coagulation complications in patients with COVID-19 is discussed. Coronavirus disease 2019 (COVID-19) is characterized by acute respiratory distress syndrome due to hyperactivity of the immune system , 4. RegaThe phosphatidyl-inositol-3-kinase (PI3K)/AKT signaling pathway is a major regulator of cell biology. It regulates different aspects of cell survival such as protein synthesis, apoptosis inhibition, and cell proliferation , 10. The. Although alterations in the activity of the PI3K/AKT signaling pathway in biopsies from COVID-19 patients have not been studied so far, studies on the effect of the virus on this pathway have been performed. For instance, it has been reported that the PI3K/AKT signaling pathway could be phosphorylated by the N protein of SARS-CoV, causing the establishment of persistent SARS-CoV infection in Vero E6 cells [It has been shown that the PI3K/AKT/mTOR pathway plays a crucial role in the pathogenesis of MERS-CoV, and inhibition of this pathway prevents MERS-CoV proliferation in vitro . AlthougE6 cells , 16. FurE6 cells . Also, iE6 cells . In thisE6 cells , 21. IntE6 cells . This stE6 cells . In addiE6 cells . On the E6 cells , 26. AddE6 cells . Based oAmong the downstream targets of the PI3K/AKT signaling pathway, mTOR and nuclear factor kappa B (NF-κB) are mostly linked to the pathogenicity of SARS-CoV-2. For instance, hyper-activity of NF-κB has been shown in SARS-CoV-2 infected cells . Also, iAnyway, in addition to probable direct activation of the PI3K/AKT pathway by SARS-CoV-2, there are several other routes that should be examined. Previously, we hypothesized the potential role of Ang II in PI3K/AKT signaling activation after SARS-CoV-2 induced infection . In addiCollectively, these data suggest that the PI3K/AKT signaling pathway can be over-activated in COVID-19 patients via direct or indirect mechanisms. The expression of mentioned factors’ receptors on different cells involved in coagulopathies will be discussed in the next sections.Dracaena), has been shown to suppress platelet activation through PI3K/AKT signaling pathway inhibition [Different PI3K isoforms, including all class I isoforms and PI3KC2a and PI3KC2b of class II isoform, are expressed in platelets, indicating the major role of this factor in platelet activity regulation . In thishibition .AKT is the major downstream effector of PI3K in platelets. The PIP3-binding domain of AKT recruits it to the platelet plasma membrane, where it is activated by mammalian target of rapamycin (mTOR) and pyruvate dehydrogenase kinase 1 (PDK1) , 41. AKTAs described above, alterations in levels of several coagulation factors have been detected in samples from COVID-19 patients. Here we examine the role of PI3K/AKT signaling pathways in regulation of these factors’ expression and activity.TF, a member of the cytokine receptor superfamily, is considered as an initiator of coagulation in different conditions such as blood vessel damage . After mThe other main coagulation factor is fibrinogen, which is cleaved by thrombin to generate fibrin clots . It has Regarding thrombin, there are no data indicating the regulation of its expression by the PI3K/AKT signaling pathway. Nevertheless, numerous studies show that thrombin induces PI3K/AKT signaling activation, leading to activation of platelets and increased coagulation factor expression . For insAng II is a vasoconstrictor factor which plays a crucial role in vascular disease. In addition to its physiologic activity, Ang II is known for its pro-inflammatory and pro-coagulatory properties. Elevated levels of Ang II have been detected in patients with COVID-19 , 57. ThiIn addition to the role of Ang II in platelet activation, its role in TF expression has been examined in different studies. In this case, AT1R blockers have been shown to reduce TF expression in hypertensive patients . Also, aAs described, the PI3K/AKT signaling pathway is one of the main downstream effectors of AT1R, and the Ang II-AT1R axis contributes to activation of this pathway . To provCollectively, these data suggest that elevated levels of Ang II in COVID-19 patients may contribute to the PI3K/AKT signaling over-activation, leading to induction of platelet activation and coagulation factor expression.The other PI3K/AKT signaling pathway stimuli which have been increased in COVID-19 patients are inflammatory cytokines, including IL-6, IL-1, TGF-β, and TNF-α. These factors are closely associated with blood coagulation by different mechanisms. IL-6 and IL-1β have been shown to increase hypercoagulability of whole blood by a direct effect on platelets . Also, iOverall, these data suggest the role of elevated inflammatory cytokines in COVID-19 patients in blood coagulation which may be mediated by the PI3K/AKT signaling pathway. Figure Based on the existence evidence, it can first be noted that the PI3K/AKT signaling pathway may be over-activated during SARS-CoV-2 infection by two mechanisms: (1) direct activation through its receptors, furin and CD147, on different cells such as platelets and (2) indirect activation via elevated levels of Ang II, inflammatory cytokines, and thrombin. On the other hand, due to the central role of the PI3K/AKT pathway in platelet activation and expression of coagulation factors, it can be said that this pathway may be a therapeutic target to reduce coagulation complications in COVID-19 patients.


Individuals with chronic ankle instability (CAI) exhibit many biomechanical changes to lower limbs during walking. However, only a few studies have investigated the differences in lower limb biomechanics of individuals with CAI compared to healthy controls using a comprehensive approach including kinematic, kinetic and electromyography (EMG) measures. Consequently, the theoretical framework explaining the biomechanical adaptations in individuals with CAI is mostly based on the results of studies including heterogenous methods and participants’ specificities . More studies using a comprehensive approach are needed to better understand the biomechanical adaptations associated with CAI. The objective of this case-control study was to identify the kinematic, kinetic and EMG differences between individuals with CAI and healthy controls during walking.Twenty-eight individuals with CAI and 26 healthy controls were recruited to walk at a self-selected speed during which lower limb kinematics, kinetics and EMG were analysed. Ankle and knee angles and moments as well as gluteus medius, vastus lateralis, gastrocnemius lateralis, peroneus longus and tibialis anterior muscles activity were compared between the CAI and control groups using one-dimensional statistical parametric mapping.p = 0.008), ankle eversion moments from 40 to 78%SP (p < 0.001), knee abduction moments from 3 to 6%SP and peroneus longus muscle activity from 0 to 15%SP (p = 0.003) and 60 to 76%SP (p = 0.003) compared to the control group. No significant between-group differences in ankle sagittal and transverse angles and moments, knee angles, knee sagittal and transverse moments as well as gluteus medius, vastus lateralis, gastrocnemius lateralis and tibialis anterior muscles activity were found.The CAI group exhibited greater ankle inversion angles from 14 to 48% of the stance phase (%SP) (During the first half of the stance phase, individuals with CAI could be at more risk of sustaining recurrent LAS mostly due to greater ankle inversion angles. However, the greater ankle eversion moments and peroneus longus muscle activity during the second half of the stance phase were an efficient mechanism to correct this maladaptive gait pattern and allowed to attenuate the faulty ankle movements during the pre-swing phase.The online version contains supplementary material available at 10.1186/s13047-021-00476-6. Lateral ankle sprains (LAS) are very common in the active population  with neaSince several decades, clinical gait analysis provides objective useful information about the mechanical and neuromuscular deficits in individuals with CAI . During Previous studies reported inconsistent knee biomechanics deficits in individuals with CAI , 19, 20.The objective of this case-control study was to identify the kinematic, kinetic and EMG differences between individuals with CAI and controls during overground walking. It was hypothesised that individuals with CAI will exhibit greater ankle inversion angles and peroneus longus muscle activity as well as smaller ankle inversion moments compared to controls.Fifty-four participants  were recruited among the staff and students of the Université du Québec à Trois-Rivières (UQTR), Canada, by means of referral from the UQTR outpatient podiatry clinic and via social media advertisements. Sample size was determined, using the preliminary results of this study, with G-Power software . It was determined that, for ankle frontal angles and moments, at least 50 participants were necessary to obtain a Cohen’s d effect size > 0.50 using alpha< 0.05 and beta> 0.80. To ensure adequate power owing technical difficulties during data acquisition or analyses, 54 participants were included in this study. The used inclusion criteria for the CAI group were based on the recommendations of the International Ankle Consortium  except fBefore undertaking the clinical gait analysis, participants had to fill the validated French version of the FAAM-ADL, FAAM-S  and InteA wireless surface electromyography (EMG) system  was used to record the activity of gluteus medius, vastus lateralis, gastrocnemius lateralis, fibularis longus and tibialis anterior muscles according to the SENIAM recommendations . The fouDuring the clinical gait analysis, all participants had to walk at a self-selected speed on a 7.5-m walkway with the force plate located in the centre. First, participants completed five familiarisation trials to calculate their mean walking speed. Then, five walking trials were recorded. The trials during which walking speed exceeded ±5% of the previously determined mean speed or the foot did not entirely strike the force plate were rejected and retaken. During all trials, participants were asked to look straight ahead and not to aim to strike the force plate.Kinematic, kinetic and EMG data were analysed using Visual 3D software . Ankle and knee joint angles and moments were calculated using a X (extension/flexion), Y (adduction/abduction) and Z  Cardan sequence. Dual-pass, fourth-order Butterworth low-pass filters with cut-off frequencies of 6 Hz and 50 Hz were used to smooth the marker trajectories and force plate data, respectively. Joint moments were normalised to body mass. EMG data were filtered with a zero lag, bidirectional, 20–450 Hz band-pass fourth-order Butterworth filter. Root Mean Square (RMS) of the raw data were calculated with a 25-ms moving window. To ensure the external validity or our results, EMG data were normalised with the mean quiet stance RMS amplitude for each muscle during the calibration trial. This method was commonly used in previous studies assessing the EMG of the lower limbs during gait in individuals with CAI , 29, 30.www.spm1d.org) in MATLAB R2020b .Shapiro-Wilk’s tests were used to evaluate the distribution of the descriptive data . Mann-Whitney U tests were used to compare age, FAAM-ADL, FAAM-S and IPAQ scores between the CAI and control groups as these data were not normally distributed. Independent t tests were used to compare weight, height, FPI scores and mean walking speed between groups. The distribution of EMG, kinematic and kinetic data was evaluated using D’Agostino-Pearson tests. As the data were normally distributed, one-dimensional statistical parametric mapping (independent SPM(t)) was used to compare each individual point of the curves between the CAI and the control groups , 32. Maxp = 0.139), weight (p = 0.234), height (p = 0.704), FPI (p = 0.131), IPAQ scores (p = 0.209) and walking speed (p = 0.328). FAAM-ADL (p < 0.001) and FAAM-S (p < 0.001) scores were lower for the CAI compared to the control group  compared to the control group   and greater knee abduction moments from 3 to 6%SP  compared to the control group  and 60 to 76%SP  compared to the control group (see Fig. The CAI group exhibited greater peroneus longus muscle activity from 0 to 15%SP (o at 20%SP (see Additional file This case-control study aimed to identify lower limb kinematic, kinetic and EMG differences between individuals with CAI and healthy controls during walking. This study was deemed important as only a few studies compared the biomechanics of the lower limbs of individuals with and without CAI using a comprehensive approach including kinematic, kinetic and EMG measures , 20, 30.Consistent with Monaghan et al.  results,In agreement with previous findings from our research group, participants with CAI exhibited greater knee abduction moments during the early stance . This reOur study allows validation and precision of previous results regarding the biomechanics of the lower limb of individuals with CAI during walking, namely the increased ankle inversion angles and moments as well as peroneus longus muscle activity. In clinical contexts, both the cause and consequence of CAI should be addressed. Sensorimotor deficits in motor-neuron pool excitability, reflex reactions, muscular strength and proprioception  could beOur results should be interpreted in light of a few limitations. First, forefoot and midfoot segments kinematics were not analysed. Individuals with CAI present kinematic changes for these segments compared to controls during walking , 45. ThuDuring the first half of the stance phase of gait, individuals with CAI could be more at risk of sustaining recurrent LAS mostly due to greater ankle inversion angles. However, the greater ankle eversion moments and peroneus longus muscle activity during the second half of the stance phase could be an efficient mechanism to correct this maladaptive gait pattern and allow attenuation of the faulty ankle movements during the pre-swing phase. Rehabilitation protocol should focus on the faulty ankle movements during the initial stance.Additional file 1. Mean differences between the CAI and control groups for all biomechanical variables during the stance phase of gait. Mean differences between the CAI and control groups for all biomechanical variables during the stance phase of gait.Additional file 2. Cohen’s d effect sizes for all biomechanical variables during the stance phase of gait. Cohen’s d effect sizes for all biomechanical variables during the stance phase of gait.


Research on endocannabinoid signaling has greatly advanced our understanding of how the excitability of neural circuits is controlled in health and disease. In general, endocannabinoid signaling at excitatory synapses suppresses excitability by inhibiting glutamate release, while that at inhibitory synapses promotes excitability by inhibiting GABA release, although there are some exceptions in genetically epileptic animal models. In the epileptic brain, the physiological distributions of endocannabinoid signaling molecules are disrupted during epileptogenesis, contributing to the occurrence of spontaneous seizures. However, it is still unknown how endocannabinoid signaling changes during seizures and how the redistribution of endocannabinoid signaling molecules proceeds during epileptogenesis. Recent development of cannabinoid sensors has enabled us to investigate endocannabinoid signaling in much greater spatial and temporal details than before. Application of cannabinoid sensors to epilepsy research has elucidated activity-dependent changes in endocannabinoid signaling during seizures. Furthermore, recent endocannabinoid research has paved the way for the clinical use of cannabidiol for the treatment of refractory epilepsy, such as Dravet syndrome, Lennox-Gastaut syndrome and tuberous sclerosis complex. Cannabidiol significantly reduces seizures and is considered to have comparable tolerability to conventional antiepileptic drugs. In this article, we introduce recent advances in research on the roles of endocannabinoid signaling in epileptic seizures and discuss future directions. Epilepsy is one of the most common neurological disorders, with an incidence of 50.4 per 100,000 people per year . Althoug9-THC), the main psychoactive component, in 1964  and type 2 (CB2), were cloned in 1990  , which has become a subject of intense interest in recent years, was first successfully extracted in 1940 , and Δ-9 in 1964 . The Gi/ in 1990  and 1993 in 1990 , respect in 1990  and 1995 in 1990 , respect (GPR55)  and tran (GPR55) .1 receptors, leading to a transient suppression of synaptic transmission  or inhibition (DSI), respectively. DSE/DSI was found to be totally abolished in mice deficient in diacylglycerol lipase α (DGLα), the major 2-AG producing enzyme from diacylglycerol     . Anotherse (RER) . Importa(Ca-RER) . In post(Ca-RER)  and by a(Ca-RER) . Due to 1 receptors at the presynaptic terminal as a full agonist  signaling, which eventually results in a persistent reduction in the efficacy of neurotransmitter release  with hippocampal sclerosis show reduced levels of DGLα mRNA compared to specimens from the non-epileptic control subjects . In cont1 and CB2 receptors have also been investigated. The mRNA level of the CB1 receptor in the hippocampus was significantly decreased in patients with mTLE when compared to that in control subjects  and showed that CB1 receptors mediated the higher Gi/o protein activation induced by WIN 55212-2 in the hippocampus of mTLE patients  several years before the onset of recurrent spontaneous seizures. The period between the initial insult and the onset of spontaneous seizures is called the latent period. The discovery of kindling , i.e., rA receptor antagonists such as pentylenetetrazole (PTZ) or picrotoxin. All kindling protocols fulfill the famous notion of “seizures beget seizures,” which means that seizures promote epileptogenesis.To investigate epileptogenesis, severe initial insults, such as prolonged generalized tonic-clonic seizures that is termed status epilepticus (SE), febrile seizures in newborns, and TBI are delivered to animals. These severe insults trigger epileptogenesis in neural circuits and result in spontaneous seizures several days to weeks after the insults . PilocarWhen the concentration of 2-AG was measured in rat hippocampi 15 min after the initiation of pilocarpine-induced SE, an approximately 1.5-fold increase in 2-AG levels compared to vehicle-treated controls was observed . SimilarHowever, in sharp contrast to the above results, The reason for these discrepant results of 2-AG and AEA levels could be the difference in the timing of sampling of brain tissues after SE or kindling epileptogenesis. As observed in the endocannabinoid imaging using GRABeCB2.0, the endocannabinoid level changes rapidly depending on neural activity, which is ascribed to rapid degradation of endocannabinoids . In addiin vitro ] induced the downregulation of CB1 receptor signaling in non-epileptic wild-type mice -positive interneurons and those of pyramidal neurons  into rat pups 1 h before the start of febrile seizures blocked the seizure-induced enhancement of DSI and increase of CB1 receptors in adults  ligand 2 (CCL2), CCL3, and CCL4  rats   rats . InteresACI rats , suggestrol rats . In a moanalysis . In contmaximum) . Taken tAs described above, ictogenesis is the process of transition from the non-ictal (non-seizure) to ictal (seizure) state. This process is usually investigated in epileptic animals showing spontaneous seizures or in non-epileptic animals subjected to chemical convulsants or electrical stimulation .The role of 2-AG signaling in ictogenesis has been investigated using DGLα knockout mice . After kA contrasting result was reported in the excitatory neurons of the dentate hilus, CA1, and CA3 of MGL-overexpressing mice . In pyra1 receptor initially, but later was predominantly mediated through mechanisms independent of CB1 receptor signaling -induced seizure model  reported increased seizure susceptibility in CB2 knockout mice  was reported to have an anticonvulsant effect against seizures induced by transcorneal electrical stimulation in mice  and rats1 and CB2 receptors  during kainate-induced SE reduced the atrophy and death of parvalbumin- and cholecystokinin-expressing interneurons . SimilarCDKL5 mutation, childhood infection, and Ohtahara syndrome, in adults (Clinical studies for testing the anticonvulsant effect of CBD in epileptic patients have been conducted since 1980 . Recentln adults  and chiln adults .A meta-analysis regarding the adverse effects of CBD  showed t1 receptor, is likely to be induced by the increased production of endocannabinoids following initial injury; thus, prevention of epileptogenesis by DGLα or CB1 receptor antagonists immediately after the initial insult may be a potential therapeutic candidate. However, the role of endocannabinoid signaling changes from pro-epileptogenic to anti-epileptogenic during epileptogenesis or in epileptogenesis with milder progression such as kindling. Therefore, careful analyses of the changing roles of endocannabinoid signaling in epileptogenesis should be conducted in the future.Endocannabinoid signaling is closely linked to the pathogenesis of epilepsy and is affected by a variety of factors. Generally, seizures cause an increase in the levels of endocannabinoids, especially 2-AG, which has an acute suppressive effect on seizures and can lead to chronic circuit changes. In particular, the transient surge in endocannabinoid signaling during the initial insult promotes epileptogenesis. Homeostatic downregulation of endocannabinoid signaling molecules, such as DGLα and the CB1 receptors—CB1 receptor signaling at excitatory synapses appears to have a suppressive effect, whereas that at inhibitory synapses has a promoting effect on seizures. In addition, 2-AG suppresses seizures through multiple downstream signaling pathways, including those involving the CB1, CB2, and GABAA receptors. In contrast, AEA appears to have a minor role, if any, in suppressing seizures or even exert a promoting effect on ictogenesis due to its action on the TRPV1 receptor.To develop new antiepileptic drugs and novel therapies for epilepsy, we need to understand the effects of endocannabinoids on ictogenesis as well as their mechanisms of action. Endocannabinoids mediate the retrograde suppression of synaptic transmission through presynaptic CB2 receptor signaling to epileptogenesis and ictogenesis? Compared to the studies on the CB1 receptor, very few studies used conditional CB2 receptor knockout mice. Several experimental procedures for ictogenesis and epileptogenesis should be applied to conditional CB2 receptor knockout mice to determine the cell-types responsible for the role of CB2 receptors in ictogenesis and epileptogenesis. Moreover, since precise subcellular localization of CB2 receptors is not known, novel methods such as CRISPR-Cas9 mediated tagging of protein, SLENDR (Three important issues remain unresolved. First, how is the contribution of CB, SLENDR  and vSLE, SLENDR , should 1 receptor expression during epileptogenesis? It is difficult to explain this change from the homeostatic point of view because the increase in CB1 receptor expression seems to occur predominantly at inhibitory synapses. This would lead to the reduction of inhibitory synaptic transmission and exaggerates the hyperexcitability of the epileptic circuit. As mentioned above, involvement of CB1 receptor signaling and that of interleukin-1β signaling seem to be critical to this process (Second, how are the mechanisms underlying the increase in CB process . FurtherThird, how are the detailed time course and cellular origin of endocannabinoid release during epileptogenesis? Taking advantage of endocannabinoid imaging using GRABeCB2.0 , transieIn conclusion, it is hoped that unraveling these issues will advance our understanding of the pathogenesis of epilepsy and will lead to the development of new antiepileptic drugs and disease-modifying therapies for epileptogenesis.YS and MK designed and wrote the manuscript. Both authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


There is strong evidence supporting the contribution of genetic factors to obstructive sleep apnea syndrome (OSAHS) susceptibility. In the current study we analyzed both in a clinical cohort and in silico, four single nucleotide polymorphisms SNPs, rs999944, rs75108997, rs35329661 and rs116133558 that have been associated with OSAHS. In 102 patients with OSAHS and 50 healthy volunteers, genetic testing of the above polymorphisms was performed. Polymorphism rs116133558 was invariant in our study population, whereas polymorphism rs35329661 was more than 95% invariant. Polymorphism rs999944 displayed significant (>5%) variance in our study population and was used in the binary logistic regression model. In silico analyses of the mechanism by which these three SNPs may affect the pathophysiology of OSAHS revealed a transcriptomic network of 274 genes. This network was involved in multiple cancer-associated gene signatures, as well as the adipogenesis pathway. This study, uncover a regulatory network in OSAHS using transcriptional targets of intergenic SNPs, and map their contributions in the pathophysiology of the syndrome on the interplay between adipocytokine signaling and cancer-related transcriptional dysregulation. Obstructive sleep apnea hypopnea syndrome (OSAHS) is a common disorder presenting with recurrent episodes of partial or complete upper airway obstruction that result in sleep disruption and intermittent hypoxemia with variable severity. On the genomic level, this pathophysiological substrate is linked with chronic upregulation of oxidative stress and hypoxia-responsive pathways and genes .Individuals with OSAHS are at increased risk for cardiovascular disease, diabetes, stroke, cognitive impairment and many other disorders ,3, and eThe etiology of OSAHS is multifactorial, including the interplay between obesity, craniofacial structure, upper airway neuronal control, ventilator control and inflammation ,6,7,8.There is strong evidence supporting the contribution of genetic factors to OSAHS susceptibility . Recent 2), rs35329661  and rs116133558 (associated with sleep SpO2), previously identified by Cade et al. [In the current study we aimed to elucidate the role of four intergenic SNPs selected from Cade et al.’s study : rs99994This study was approved by the Institutional Review Board of University Hospital of Larissa (No: 63569-24 December 2018) and written informed consent was obtained from all participants.Our study included consecutive patients with suspected OSAHS who underwent polysomnography (PSG) test in the Clinic of Sleep Disorders of the Respiratory Medicine Department of the University General Hospital of Larissa were invited to participate in this study. All subjects underwent an overnight laboratory-based PSG, and the apnea–hypopnea index (AHI) was measured in all of them. OSAHS was defined as an AHI > 5 events/hr, and daytime symptoms specific for OSAHS. Hypopnea was defined as either (a) a >50% reduction in airflow, (b) a <50% reduction in airflow associated with a desaturation of >3% or (c) a moderate reduction in airflow accompanied by an electroencephalogram (EEG) -defined arousal. Patients were grouped according to the following classification by American Academy of Sleep Medicine (AASM 2007): mild disorder (AHI: 5–15 events/h), moderate disorder (AHI: 15–30 events/h), and severe disorder (AHI > 30 events/h). AHI < 5 events/hr was diagnosed as healthy subjects. A total of 102 Greek patients with OSAHS and 50 non-OSAHS, age- and gender-matched Greek controls were included in this study.® 7900 HT Fast Real–Time PCR System .Genomic DNA was extracted from whole blood by DNA isolation kit, according to the manufacturer’s protocol. The purity and concentration of DNA were measured by a nanodrop spectrophotometer , with absorbance ratios ranging from 1.8 to 2.0 at the length of A260/A280. Genotyping of SNPs rs999944, rs75108997, rs35329661 and rs116133558 was performed using TaqMan single nucleotide polymorphism (SNP) genotyping technique on an ABI PRISMp < 0.05. Deviation from the Hardy–Weinberg equilibrium was assessed using a chi-squared test with one degree of freedom. Statistical significance for categorical variables was assessed by the chi-squared or Fisher’s exact test. OSAHS risk and severity associated with the candidate SNPs were estimated by computing the odds ratios (ORs) and their 95% confidence intervals (CIs) by logistic regression analysis, adjusting for age, gender, and BMI. The analyses were done first per allele  and then per genotype (additive model). Post-hoc power analysis was performed via the Bioinformatics Institute’s Online Sample Size Estimator (OSSE)  [All data analyses were performed with SPSS 23.0 . Statistical significance was accepted at a level of er 2021) .https://www.ebi.ac.uk/gwas, accessed 16 September 2021) [https://www.genecards.org/, accessed 16 September 2021) [SNPs mapped to pseudogenes and the corresponding pseudogenes themselves were analyzed for their potential biological activity in a multistep procedure. First, we determined that said pseudogene produced transcripts by inquiring the NHGRI-EBI GWAS catalog, a database of curated genome wide associated studies maintained by the National Human Genome Research Institute  . This reer 2021)  was useder 2021) ,15 contahttps://data.broadinstitute.org/mpg/snpsnap/, accessed 16 September 2021) was used in order to identify interactions between SNPs, and identify common biological functions affected downstream [The SNPSnap tool , in order to predict its biological functions [Based on the above analyses and the results from the GeneCards database, we constructed a network of putative interactors from (a) SNP associated transcription factors (b) downstream genes (c) ARBB1, the gene mapped to the rs35329661 SNP (3′ UTR variant). This interactome that included a total of 274 genes was dubbed Iunctions .p > 0.05).The main demographic and clinical characteristics of the 102 OSAHS cases and 50 healthy controls that underwent polysomnography are presented in Polymorphism rs116133558, rs75108997 were invariant in our study population, whereas polymorphism rs35329661 was more than 95% invariant . Polymorphism rs999944 displayed significant (>5%) variance in our study population A/G: 20%; G/G:20%) and was used in the binary logistic regression model.A binary logistic regression model adjusting for age, sex, BMI and lipid profile did not detect statistically significant associations between genotype frequency for the rs999944 SNP between OSAHS groups and controls . Post-hoA BLAST analysis of the ±100 kb region containing rs116133558 revealed a hit in pseudogene AC114402.Correspondingly, BLAST analysis of rs75108997 revealed total query cover and sequence similarity with pseudogene AL663058.5. The subsequent GeneCards Query did not reveal any significant transcription factor binding sites, or corresponding gene targets. The rs999944 displayed total query cover and sequence similarity with pseudogene AC007880.2. .A), the putative functional network of these two SNPS. SNPSEA did not reveal direct interaction between the two SNPS  for rs11613358 and rs999944 . Collecttwo SNPS A network  pathways resulting from GSEA on IA via Enrichr  is an established perturbator in the pathophysiology of OSAHS . In animOur findings corroborate the findings of these studies on both the gene- and pathway-level. On the pathway level, the TNF, adipogenesis and adipocytokine signatures that we detected may reflect disruption of adiponectin signalling that has been correlated to adipocyte volume . On the These findings indicate that the mechanism by which both intergenic polymorphisms contribute to OSAHS lies in their interaction with transcription factors and second-order phenomena, such as the disruption of regulatory networks , in contThe epidemiological link between OSAHS and cancer is a complex one, potentially riddled with both clinical and biochemical confounders . The maiOur findings corroborate with the latter study on both the gene- and pathway- level. Specifically, significantly enriched signatures that overlap between our studies included androgen signaling, breast cancer, and leukemia related pathways (see  and SuppWithin this context, our findings support a model of long-range regulation by non-genic SNPs , and potAdipocytokines signaling and cancer, as they arise in our analyses and are corroborated by others ,20,21,26Adipocytokine cascades are well established clinical correlates with cancer , with obOur findings should be interpreted within the conceptual framework of this study’s limitations and strengths. A major limitation of our study is that the clinical cohort did not achieve sufficient sample size, reflected by the invariance of rs116133558 and rs75108997. As such, we were not able to sufficiently detect associations between genotype frequency and OSAHS parameters at the clinical level. Considering that recruitment was greatly affected due to the pandemic, this obstacle could not be overcome within the given timeframe of our study. Another important caveat regarding the clinical cohort is that as a nested study, the reference population is specific and thus any finding we could have drawn would be of reduced generalization. Furthermore, while we reconstructed a regulatory gene network from two intergenic SNPs, we cannot confirm our findings in a prospective cohort. We overcome this limitation by comparing our findings with two of the most comprehensive studies in OSAHS and we managed to validate our major findings both on the genomic and pathway level.This is the first study to uncover a regulatory network in OSAHS using transcriptional targets of intergenic SNPs and map their contributions in the pathophysiology of the syndrome on the interplay between adipocytokine signaling and cancer-related transcriptional dysregulation. Further studies are needed to expand this concept in other intergenic SNPs and outline the non-genic networks governing long-range transcriptional regulation in OSAHS.


To assess the ocular surface and meibomian gland (MG) of patients with obstructive sleep apnea hypopnea syndrome (OSAHS) and to explore the effects of surgery for OSAHS on the ocular surface and MG.Based on the apnea hypopnea index (AHI), 21 patients with mild OSAHS , 20 patients with moderate OSAHS , 62 patients with severe OSAHS  were examined. The ocular surface and MG were evaluated using Keratograph 5M. In addition, detailed Ophthalmic examination including visual acuity, refraction, slit-lamp examination of the anterior segment, corneal fluorescein staining (CFS), ocular surface disease index (OSDI) scoring, Schirmer I test (SIT) and serum lipid measurement was performed. For OSAHS patients with dry eye syndrome (DES) who underwent uvulopalatopharyngoplasty for improving AHI, the conditions of the ocular surface and MG were compared before surgery and 3 months after surgery. Only the data of the right eyes were analyzed.p = 0.015, p = 0.018, p < 0.001, p = 0.022, p = 0.036, p = 0.007, p = 0.019, p = 0.017, p = 0.045, p = 0.013, and p = 0.029, respectively). The SIT in the Group A was significantly higher than in Group B (p = 0.025) and in Group C (p < 0.001). In the correlation analyses, the fNIBUT, avNIBUT, SIT and LLG had negative correlations with the AHI . The BRI, CFS and LRUE were positively correlated with the AHI . Three months after surgery, there were no significant differences in the ocular surface or MG.There were no significantly different in the OSDI score, tear meniscus height (TMH), or loss ratio of the lower eyelid (LRLE) among these groups. The first non-invasive tear film breakup time (fNIBUT), average non-invasive tear film breakup time (avNIBUT), bulbar redness index (BRI), lipid layer grading (LLG), CFS, plugged orifices and distortion in MG, the loss ratio of upper eyelid (LRUE), and the incidence of DES, floppy eyelid syndrome (FES) and meibomian gland dysfunction (MGD) showed significant differences between Groups A and C (Patients with severe OSAHS have poor stability of tear film and are prone to lipid-deficient dry eye as a result of the loss of meibomian gland. By improving the AHI, the ocular surface damage of OSAHS patients cannot be reversed in a short time. Obstructive sleep apnea hypopnea syndrome (OSAHS) is a chronic intermittent hypoxic sleep-disordered breathing disease that is characterized by repeated apnea and hypopnea during sleep . The prePrevious studies have found that OSAHS is associated with reduced tear film breakup time (TBUT) and Schirmer values, and increased ocular surface disease (OSDI) scores and corneal fluorescein staining (CFS), these associations show that ocular surface parameters are impaired in OSAHS and suggest a tendency toward dry eye syndrome (DES) in these patients , 19. MeiThe treatment of OSAHS includes conservative approaches, such as weight loss, avoiding smoking, excessive alcohol and sedatives, continuous positive airway pressure (CPAP) and surgical therapy –34. AlthThis study was conducted in the Department of Ophthalmology and Otorhinolaryngology at the Second Xiangya Hospital of Central South University between August 2019 and April 2021. This study was conducted according to the Declaration of Helsinki and approved by the Ethics Committee of the Second Xiangya Hospital of Central South University (Number: 2021205).Patients who presented with snoring, nocturnal choking, and excessive daytime sleepiness underwent polysomnography (PSG) tests before their enrollment. According to the PSG results, a total of 103 patients (AHI ≥ 5) were included in our study. Based on the AHI, the severity of OSAHS was classified as follows: mild, 5/h ≤ AHI <15/h; moderate, 15/h ≤ AHI <30/h; severe, AHI ≥ 30/h . Twenty-2), which is calculated by the equipment software as the area percentage ratio between the vessels and the rest of the analyzed area. The BRI ranges from 0.0 to 4.0, and the more blood vessels there are, the higher the score , non-invasive break-up time of tear film (NIBUT), lipid layer grading (LLG), bulbar redness index (BRI) and infrared meibography –44. The he score . Infrarehe score .The CFS was performed by placing a wet sodium fluorescein test strip in the lower conjunctival sac, and observed the dye under the blue light from a slit-lamp. The CFS was ranged from 0 to 12, which was the sum of the scores of the four corneal quadrants  scored individually as 0 (no staining), 1 (mild staining with 1–30 dots of stains), 2 (moderate staining between 1 and 3), or 3  .The OSDI questionnaire is composed of three sections, involving eye symptoms, environmental factors and visual function. The score of each item on the questionnaire is 0 to 4. The OSDI score is the sum of the scores of 12 items, multiplied by 25, and then divided by the number of questions answered .After the subjects accomplished the corneal staining, they were given a 30 min rest. The Schirmer I test strip was placed into the lower eyelid one-third of the distance from the lateral canthus and the wetting distance was recorded after 5 min.The diagnostical criteria of lipid-deficient dry eye (LDDE): LDDE is caused by the abnormal quality and quantity of the lipid layer, such as MGD, or various factors causing increased tear evaporation. The tear film stability decreased significantly (FBUT or NIBUT ≤ 5 s), and the tear secretion was slightly abnormal (10 mm/5 min ≤ SIT ≤ 12 mm/5 min), which tended to be considered as lipid-deficient dry eye . The floT-test was applied to compare the preoperative and postoperative differences. Spearman's correlation was applied to analyze the relationship between the variables. P-value <0.05 was considered as statistically significant.Statistical analysis was executed with software package SPSS version 25.0 . Descriptive variables are expressed as the mean ± standard deviation (SD). The normality distribution of the data was tested by the Kolmogorov-Smirnov test. The variables with a non-normal distribution were analyzed by means of a non-parametric test. The variables among the three groups were analyzed through the non-parametric Kruskal-Wallis H-test. The non-parametric Mann–Whitney U test was applied to compare two groups. The enumeration data was analyzed using Chi-square tests, including sex and the incidence of DES, FES and MGD. The paired Student's 2 in severe OSAHS patients, which was significantly higher in Group C than in Group A (p < 0.001). Some patients were taking hypolipidemic drugs or had a lack of results, resulting in the partial loss of serum lipid data (p = 0.014 and p = 0.020)  . The higp = 0.291 and p = 0.287, respectively). The fNIBUT and avNIBUT were significantly different between the group A and Group C. In Group C, fNIBUT and avNIBUT were shorter than in Group A . Similarly, the BRI, LLG and CFS has significant difference among these groups. In Group A, both BRI and CFS were lower and LLG was higher than in Group C . The Schirmer values were 14.7 ± 1.5 mm, 13.7 ± 1.4 mm, and 12.4 ± 1.5 mm, respectively. The Schirmer in the Group A was significantly higher than in Group B (p = 0.025) and in Group C (p < 0.001).The ocular surface parameters are presented in p = 0.007, p = 0.019). In the Group C, the loss ratio of the upper eyelid was more severe than that in the Group A (p = 0.017). However, that of the lower eyelid was much higher but not significantly different. The incidence of DES and MGD was higher in Group C than in the Group A , and all of dry eye was lipid-deficient dry eye (LDDE). The FES was observed more frequently in severe OSAHS patients (p = 0.029)  .R = −0.263, p = 0.006; R = −0.200, p = 0.038; R = −0.200, p < 0.001; R = −0.211, p = 0.029, respectively). Moreover, the BRI, CFS and LRUE were found to be significantly positively correlated with the AHI . The TC and LDL levels were significantly correlated with MGD   .A total of 103 OSAHS patients were enrolled in our study, of these patients, 66 cases were diagnosed with DES. 5 cases who underwent uvulopalatopharyngoplasty for OSAHS were followed up in 3 months, of which 3 cases were moderate OSAHS patients and 2 cases were severe OSAHS patients. The characteristics of the postoperative ocular surface are shown in To our knowledge, this is the first study to evaluate certain parameters of the ocular surface for OSAHS patients by a non-invasive instrument, and to analyze the correlation between the ocular surface and the severity of OSAHS in terms of AHI. In our study, we found that the patients with severe OSAHS had higher BRI and CFS scores, which were positively correlated with the AHI. The BRI may be a potential objective index to estimate the severity of OSAHS in the clinic. In OSAHS patients, long-term chronic intermittent hypoxia has been found to increase oxidative stress, resulting in an upregulation of stress signaling cascades, such as HIF-1, NF-KB and Nrf2 . These pAdditionally, the loss ratio of the upper eyelid MG was higher in severe OSAHS patients, and the incidence of gland distortion, FES and MGD were positively correlated with the AHI. The proportion of OSAHS patients with FES varies from 2 to 40%, and the occurrence of FES in OSAHS patients indicates that the disease severity is more serious . This maFurthermore, the plugged orifices increase the intraluminal pressure, forming a vicious circle that leads to atrophy and dropout of the MG. Finally, another reason could be due to the lower androgen level in OSAHS patients than that in normal people . The MG In 2019, Karaca et al. observed dropout and morphological changes in the MG in OSAHS patients with a slit-lamp biomicroscope . ResearcThe tear film has a complex structure, and it is followed by a lipid layer, aqueous layer, and mucin layer from the outside to inside. The normal function of various tear functional units is vital to a stable tear film and heathy ocular surface . The MG Studies have shown that elevations in TC, TG and LDL, and decreases in HDL in patients with OSAHS, and those alterations may be exacerbated with the increasing of OSAHS severity , 69. A pCurrently, CPAP and surgery are the two major treatment modalities for OSAHS. CPAP is considered as the first-ling treatment for OSAHS, but patient compliance has been notably poor result from mask discomfort, nasal dryness and congestion, and difficulty adopting to the pressure, which decrease the usage and efficacy , 75. In The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Ethics Committee of the Second Xiangya Hospital of Central South University. The patients/participants provided their written informed consent to participate in this study.SLiu and SLi: analysis and interpretation of data and drafting and revising the article. ML and SZ: participate in survey and data collection. LZ and BC: substantial contributions to conception and design and revising it critically for important intellectual content. All authors approved the final manuscript.This work was supported by Natural Science Foundation of Hunan Province (No. 2020JJ5845).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.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.


BackgroundThe deep palmar arch is formed by anastomosis of the continuation of the radial artery with the deep palmar branch of the ulnar artery. With recent advances in microsurgical techniques for vascular repair, the knowledge of variations in the arteries of the hand, as well as the caliber of these arteries, has become more important for surgeons. Additionally, radial artery harvesting for myocardial revascularization is being performed nowadays, for which collateral circulation in the hand through the palmar arches is a prerequisite. Therefore, this study was conducted to study the patterns of the deep palmar arch and perform the morphometry of the arch.MethodologyIn this study, 30 hands (16 right and 14 left) from formalin-fixed adult human cadavers were dissected to observe the completeness, formation, and branching pattern of the deep palmar arch. The length of the arch was measured using a thread and scale. The diameters of the forming arteries and branches of the arch were measured at their origin using a digital vernier caliper.ResultsAll deep palmar arches were complete. The arches were classified into two types based on whether the superior or inferior deep palmar branch of the ulnar artery completed the arch. Another classification was based on the interosseous space through which the radial artery or its branch entered the palmar region to complete the deep palmar arch. The length of the arch was 4.2 ± 0.47 cm on the right side and 4.0 ± 0.6 cm on the left side. The diameters of the deep palmar branch of the radial and ulnar arteries at their origin were 4.02 ± 0.48 mm and 1.90 ± 0.36 mm, respectively. No significant difference was found between the right and left sides.ConclusionsThe anastomosis was found between radial and ulnar arteries in all cases of the deep palmar arch. Therefore, it can be safe to sacrifice the radial artery in procedures such as radial artery harvesting and radial artery flap transfer. The knowledge of variations and morphometry of the arch will facilitate vascular repair surgeries on hands. The deep palmar arch is important for the blood supply of the palm and fingers. It is usually formed by anastomosis between the continuation of the main radial artery and the deep palmar branch of the ulnar artery. When there is no anastomosis, the arch is said to be incomplete. Through its distal, recurrent, and perforating branches, the deep palmar arch ensures the blood supply of the hand .The radial artery is the main artery contributing to the deep palmar arch. The damage to the radial artery in invasive procedures affects the blood flow through the palmar arches. Radial artery catheterization and radial artery harvesting for myocardial revascularization are commonly performed procedures. Transradial access is preferred over transfemoral access for coronary angiography and interventions in patients with acute coronary syndromes . MoreoveIn distal transradial access, the radial artery is approached in the anatomical snuffbox. This approach is advantageous over the traditional transradial access as the superficial palmar branch of the radial artery arises proximal to the access site . HoweverWith recent advances in microsurgical techniques for vascular repair, the knowledge of variations in arteries, as well as the caliber of these arteries, has become more important for surgeons. The pedicled interossei and lumbrical muscle flaps are used in reconstructive surgery of the hand. The lumbricals are supplied by branches from both the superficial and deep palmar arches, and interossei are supplied by the deep palmar arch and dorsal metacarpal arteries .Given the importance of the deep palmar arch in the blood supply of the hand and the contribution of the radial artery in its formation, this study was conducted to study the morphology and morphometry of the deep palmar arch and its branches. This information will help surgeons to plan and perform microsurgeries in this region and propose newer and safer surgical procedures.The present study was conducted in the Department of Anatomy, Maulana Azad Medical College, New Delhi from September 2015 to May 2017 after obtaining approval from the Institutional Ethics Committee . A total of 30 hands (16 right and 14 left) from formalin-fixed adult human cadavers were dissected. Normal as well as variant patterns in the arteries contributing to the arch, completeness of the arch, and the branching patterns were observed and noted, and their percentages were calculated.The length of the arterial arch was measured using a thread and a scale. With the help of digital vernier calipers, the diameters of the forming arteries of the arch were measured at their origin. In addition, the diameters of palmar metacarpal branches were measured at their origin. The mean and standard deviation of the parameters were calculated. The unpaired t-test was applied to compare the values of the right and the left sides. A P-value of less than 0.05 was considered significant. Statistical analysis was done using SPSS version 20 .All deep palmar arches were complete, implying that there was anastomosis between the radial artery and the deep palmar branch of the ulnar artery. The deep palmar arch was classified into two types based on the type of the deep palmar branch of the ulnar artery completing the arch. In the Type 1 arch, the superior deep branch of the ulnar artery was anastomosed with the radial artery to complete the deep palmar arch. It was found in three (10%) hands Figure .Another classification of the deep palmar arch was employed based on the interosseous space through which the radial artery or its branch entered the palmar region to complete the deep palmar arch. In this classification, there were two types. In the Type 1 arch, the radial artery passed dorsally just distal to the radial styloid process, then passing deep to the extensor tendons, it entered the first intermetacarpal space to reach the palmar region. This type was found in 29 (96.7%) hands. The Type 2 arch included only one specimen (3.3%). In this hand, the second dorsal metacarpal artery, which branched from the radial artery, communicated with the deep palmar arch through a perforating artery. This perforating artery completed the arch. The radial artery itself ended by supplying the thumb and index finger and had no communication with the deep palmar arch Figures , 3B.The deep palmar arch was classified into two patterns based on the branching pattern of the arch. In Pattern 1, the branches of the deep palmar arch, which arose from its convexity, were usually three palmar metacarpal arteries (PMAs). The PMAs were named PMA-1, PMA-2, and PMA-3 from the lateral to the medial side. In this study, 29 (96.7%) hands displayed this pattern, but the course and area of supply of these PMAs varied considerably. Pattern 2 included only one (3.3%) hand in which the deep palmar arch gave only two PMAs.Two unique variations were observed in this study. The inferior deep branch usually originated directly from the ulnar artery in 24 hands. However, in a left hand, the deep branch arose from the proper palmar digital artery (PPDA) to the little finger. In two other hands, the deep branch arose from the common trunk dividing into the PPDA and the fourth common palmar digital artery (CPDA). This finding was bilateral . There was no significant difference between the length of the deep palmar arch on the right and left sides (p = 0.617). The mean and standard deviation of the diameters of forming arteries of the deep palmar arch are presented in Table The deep palmar arch develops from a plexus at the terminal end of the original axial vessel of the upper limb. The radial artery establishes communication with the deep palmar arch later in development. The anomalies of the deep palmar arch arise mainly during its formation where the forming arteries may originate from a different artery or pursue a different course .The incidence of the complete deep palmar arch in various studies ranges from 76% to 100% -13. In tThe superior deep branch of the ulnar artery completed the deep palmar arch in 34.5% of cases in the study by Coleman and Anson . GellmanThe inferior deep branch of the ulnar artery completed the deep palmar arch in 90% of cases in our study. Gellman et al. and Coleman and Anson observed it in 44.4% and 49% of hands, respectively . In contSingh et al. described a variant of the deep palmar arch where a deep branch of the ulnar artery divided into the superior and inferior branches, both of which then anastomosed with the radial artery to complete the deep palmar arch. They found this variant in 8% of cases . The intIn this study, the radial artery entered through the first intermetacarpal space into the palmar region to complete the deep palmar arch in 96.7% of cases. In a Brazilian study, the deep palmar arch was completed by the radial artery entering through the first intermetacarpal space in 85% of cases .The deep palmar arch completed by the perforating artery communicating with the second dorsal metacarpal artery was noted in 3.3% of cases in this study. Coleman and Anson described this variant as a type of an incomplete deep palmar arch . Ikeda eThe PPDA to the little finger gave origin to the deep palmar branch of the ulnar artery in 15% of cases in the study by Olave and Prates . In thisIn this study, the branch from the CPDA or PPDA that completed the deep palmar arch was considered the inferior or distal deep palmar branch of the ulnar artery. This nomenclature is consistent with some previous studies ,13. In cAs described in the standard anatomical textbooks ,18, thisAlthough many variant patterns of the palmar arterial arches have been observed in the forming arteries and their branches, anastomosis was found between the radial and ulnar arteries in all cases of the deep palmar arch. This suggests that, from an anatomic perspective, it can be safe to sacrifice the radial artery in procedures such as radial artery harvesting and radial artery flap transfer. Moreover, the radial artery can be used for transradial access in coronary and neuroendovascular interventions. However, it is recommended to use Allen’s test, Doppler ultrasound, and oximetry technique to assess hand circulation before performing any invasive procedures on the radial artery ,20.In this study, anastomosis was found between the radial and ulnar arteries in all cases of the deep palmar arch, implying that all arches were complete. Therefore, the radial artery can be safely sacrificed in procedures such as radial artery harvesting and radial artery flap transfer. Moreover, we observed various patterns of the deep palmar arch and classified them in two ways. This knowledge along with the morphometric data of the arch will undoubtedly help surgeons to perform safe vascular repair surgeries on the hand. However, testing of the hand for vascular insufficiency is recommended before performing any arterial intervention to identify the compromised collateral circulation in the hand.


Germ layer specification and axis formation are crucial events in embryonic development. The Spemann organizer regulates the early developmental processes by multiple regulatory mechanisms. This review focuses on the responsive signaling in organizer formation and how the organizer orchestrates the germ layer specification in vertebrates. Accumulated evidence indicates that the organizer influences embryonic development by dual signaling. Two parallel processes, the migration of the organizer’s cells, followed by the transcriptional activation/deactivation of target genes, and the diffusion of secreting molecules, collectively direct the early development. Finally, we take an in-depth look at active signaling that originates from the organizer and involves germ layer specification and patterning. In 1924, to understand the processes involved in developmental biology, Spemann and Mangold transplanted a blastopore lip between different ectodermal regions of amphibian embryos . When trXenopus laevis, further studied the functions of the organizer and concluded the following. First, the organizer deactivates or activates the surrounding cells to differentiate and start morphogenesis. Second, the three germ layers  of the developing embryo are signaled and affected by the organizer. Third, the three germ layers will respond to the organizer’s signals [Years after the findings of Spemann and Mangold, Harland and Gerhart , using t signals . Since t signals ,7,8,9,10 signals . In tele signals ,13,14. T signals . All ver signals . The org signals . The lit signals ,17. TherIn all vertebrates, the organizer  is functionally conserved. The transplanted Hensen’s node can induce neural tissue in fish, mammalian, and amphibian embryos ,12,18, wgoosecoid (gsc), chordin (chrd), noggin (nog), and Xnrs [Xnr1, Xnr2, Xnr4, Xnr5, and Xnr6 [Xnr5 and Xnr6, acting in combination with Wnt/β-catenin signaling, form the Nieuwkoop center (NC) in the dorsal–vegetal region  [cer) gene will be upregulated, promoting the formation of overlying mesoderm and the establishment of the Spemann’s organizer, during gastrulation, at the dorsal mesoderm of the embryo [The formation of Spemann’s organizer involves a series of complex intercellular events that begin right after fertilization. The overall process of organizer formation can be described by some sequential/parallel embryonic events that can be described as two steps. Cortical rotation is the first intracellular event in the fertilized egg that allows for the shifting of maternal determinants from the vegetal to the animal region of the embryo , which eand Xnrs ,21. The and Xnrs . At the and Xnrs . On the and Xnrs ,6,23,24.and Xnr6 ,25. In pl region  of the b (dkk-1) . Finallye embryo ,25.All vertebrates have a position-specific group of cells (collectively refer as organizers) that are absolutely essential in embryonic development. During embryonic development of the chick, after the mid-streak stage, the top region of the streak thickens and forms the Hensen’s node. Later on, these cells assembled to the midline of the mesoderm to form a notochord . WhereasIn recent years, a wide range of secreted molecules involved in embryonic development have been isolated and identified from the Spemann organizer using several different screening methods  . This ha2+ pathways [2+ pathways, Fzd transduces signals to phospholipase C, which leads to the activation of several intermediate components of Ca2+ signaling [gsc, siamois, and twin in the Xenopus embryo [tcf7, hes-like, kremen2, vegt, fzd10, etc. [The functional role of the Wnt signaling pathway is highly conserved across vertebrates and plays a central role in developmental biology . Wnt sigpathways . In the pathways ,48. Wnt pathways . The nucpathways . In the pathways ,50. In tignaling . Since βs embryo . However10, etc. .chrd transcription by directly binding to ARE (activin response elements) within the promoter region [Transforming growth factor β (TGFβ) comprises 33 members and includes the activin, inhibin, and nodal families of ligands. Typically, the three subunits  dimerize (homo- or heterodimer) in different combinations to produce a functional dimer. Inhibin consists of a common α-subunit and always a second βA-subunit or βB-subunit to dimerize. Therefore, the only two possible dimer combinations are inhibin A (α-subunit and βA-subunit) and inhibin B (α-subunit and βB-subunit) (reviewed in ). Summarr region . Howeverr region ,60,61,62Xenopus 19 ligands have been identified [Xenopus embryos. The expression of fgf4, fgf8, and fgf20 was reported at a high level in the mesodermal region of Xenopus embryos. In addition, several mesodermal markers including xcad2 and xbra showed marked responses to FGF signaling; we refer readers to these particular articles [FGF signaling plays an essential and diverse role in the overall embryonic development of vertebrates. A recent study found that the total number of reported FGF ligands in mice and humans is 22, wherein entified . Furtherarticles ,64,65,662+ concentration is directly modulated by influx (from the extracellular space or endoplasmic reticulum), mediated via several types of Ca2+ channels. The intracellular Ca2+ interacts with and activate a variety of calcium-binding effector proteins ) and Ca2+-dependent protein kinase (CDPK) [2+ is essential for involuting/migrating mesodermal cells [2+ signaling interacts with other pathways and plays an inductive role in neural development in vertebrates; for details, readers may wish to consult the cited articles [The intracellular Cae (CDPK) ,68,69. Ce (CDPK) ,68,69,70al cells ,72. Howearticles ,74,75,76The Spemann organizer is a dynamic and heterogeneous structure composed of distinct cell populations that make it a suitable candidate to serve as a master regulator of embryonic development in vertebrates. The active protein molecules secreted from the organizer are mostly inhibitors of BMP, nodal, Wnt, and other signaling that enable self-differentiation as well as modulate the fate of surrounding cells. During gastrulation, the organizer  cells initiate migration toward the ectoderm layer  to form primary germ layers. These migrating cells contact neighboring cells directly or through the extracellular matrix (ECM) . The ECMdkk-1, Frzb-1, and Crescent), expressed by the organizer, generates a Wnt signaling gradient, also required for mesoderm patterning—especially for notochord formation, but not necessary for trunk muscles [gsc, whereas lower levels induce the notochord marker expression [Xenopus), while higher nodal doses induce the antagonists Chrd, Dkk1, and Cer [gsc and chrd genes’ expression, in a Smad2/3-dependent manner [Once the organizer has been fully formed in the embryo, the tissues that surround the organizer will receive organizer-produced signals that induce transcription factors  and morphogen molecules  and create a signaling gradient of BMPs, Wnts, and nodals. Nodal, BMPs, and Wnt signals crossregulate each other, as nodals induce other nodals, Wnts, and BMPs, as well their antagonists . These f muscles . In this muscles . Lastly, muscles . Amphibi muscles . In an e muscles . The low muscles . In mice muscles ,86. In z muscles . Other s muscles . High lepression . Similarpression ,88. Thes and Cer ,33,89. St manner ,59. xbra and xcad2/3 [gsc, Pintallavis, Xbra, and Xlim1) involved in mesoderm formation [Wnt8 expression [ventx1.1 and ventx1.2 [FGFs have also been demonstrated to induce mesoderm formation. In experiments using mouse, fish, frog, and chick embryos, when FGFs’ function was blocked, the mesoderm development was affected ,91,92,93 xcad2/3 ,96,97,98 xcad2/3 . The FGF xcad2/3 . Besidespression ,101; it pression ,103. Morventx1.2 ,105. Manventx1.2 ,108,109.Xenopus no BMP is required for notochord, low levels of BMP signaling are necessary for muscle, and even higher BMP signaling is needed for the formation of blood and the lateral plate [In the embryo, in the early to middle gastrula stage, besides the dorsal signaling center (Spemann organizer), there is also a ventral signaling center . In the al plate ,114,115.During gastrulation, the Spemann organizer is deeply involved in the patterning and formation of ectoderm and neuroectoderm. Years of research have led to the identification of a large number of genes, molecules, and pathways responsible for the inductive properties of the organizer in neuralizing the ectoderm and patterning the neuroectoderm, critical steps for the formation of the epidermis and central nervous system. During gastrulation in vertebrates, cells of the ectoderm can be induced into distinct fates: cells can become flattened and originate the epidermal progenitors (skin epidermis) on the ventral side or turn elongated and give rise to neural progenitors  on the dorsal side ,116. Thichordino (a Chrd homolog) and ogon (a secreted Frizzled homolog), do not develop a nervous system [Xenopus tropicalis mutant embryos that lack chrd, nog follistatin, and cer fail to develop an anterior brain and neural structures [Msx1 mRNA inhibited the neural tissue formation induced by nog [In the first step, the organizer inhibits BMP by releasing several BMP inhibitors. For the formation of the nervous tissue, the levels of BMP need to be significantly reduced in the dorsal part of the ectoderm, which is regulated by BMP antagonists  . These ms system ,125. Micructures ,126. Cerructures . Moreoveructures . Growth ructures . GDF6 caructures . BMP-tard by nog . Overexpd by nog . Additiod by nog ,131,132.d by nog . The inhd by nog ,133. Thid by nog ,135. Furd by nog ,136,137.d by nog . 2+ channels and cations influx. Increased amounts of intracellular Ca2+ activate Ca2+-mediated signaling pathways and activate neural genes’ expression [In the second step, at the same time the organizer also produces inductive molecules that induce neural-specific genes’ expression, parallel to BMP inhibition. BMP inhibition itself activates some neural specifiers, for example Foxd411.1. Once Foxd411.1 is produced, it drives further neural development . Some inpression ,76. Howepression . Also, wpression . Furtherpression . Moreovepression ,144. Mempression ,146,147.pression ,148. In pression ,139,149.pression ,151. FGFpression . Taken tXenopus embryos, the majority of the endodermal mass elongates along the anterior posterior endodermal axis and forms a primitive gut tube [The endoderm is the innermost germ layer. Similar to in the ectoderm and mesoderm, as a distinct signaling center, the organizer affects endoderm patterning by a gradient of extracellular molecules. During the blastula stage, the NC contains maternal determinants that actively influence the organizer’s formation and at the same time determine endodermal cells’ responses to these signals. Once the organizer cells start migrating, the overlapped endodermal cells internalize with the mesoderm , which tgut tube . During gut tube . In the gut tube . Howevergut tube ,154,155.We have discussed the possible roles of the organizer in the early embryonic development of vertebrates. In the present review, we have focused on embryonic patterning and how several signaling pathways engage in crosstalk to drive proper embryonic patterning in a spatiotemporal manner. The organizer itself regulates the expression of several sets of genes that encode secreted growth factors and antagonists. Collectively, these growth factors/antagonists activate or deactivate the target signaling in the surrounding germ layer in coordination with normal embryonic development. Finally, we collected the integrated signaling cascade that originated from (or was involved with) the organizer and plays an important role in establishing the overall embryonic axes.