Human T-cell lymphotropic virus (HTLV) remains a major safety concern for blood supplies. Despite many HTLV positive cases being reported in southeastern China, the detection of HTLV has not been prioritized in routine blood screening. Additionally, data on the prevalence of HTLV infection among blood donors is also limited. The objective of this study was to investigate the prevalence of HTLV among blood donors in three Chinese provinces through their representative blood centers, to evaluate the feasibility of chemiluminescence immunoassay (CLIA) for blood screening.From November 2018 to March 2019, blood plasma samples were collected from Hebei, Changsha, and Shenzhen blood centers and were screened for the HTLV-1/2 antibody using a CLIA and enzyme-linked immunosorbent assay (ELISA). This was followed by confirmatory tests using INNO-LIA HTLV I/II.p < 0.05). After confirmation, 3 samples were confirmed as indeterminate for HTLV antibodies, and only one sample from the Shenzhen blood center was confirmed as HTLV-1. The overall prevalence of HTLV-1/2 was 1.67 per 100,000 . The HTLV-infected blood came from a 32-year-old first-time female donor with a high school degree, who belonged to the SHE ethnic minority and was born in the Fujian province.A total of 59,929 blood donations were collected and screened for HTLV-1/2. The reactive rate of CLIA and ELISA among donations in the Shenzhen blood center  was higher than Hebei , and Changsha  (In summary, the overall prevalence of HTLV-1/2 among blood donors in the three blood centers in China remains relatively low. However, blood donations with positive or indeterminate results for HTLV antibodies reminded us of the importance of HTLV screening among blood donors in China. The human T-cell lymphotropic virus (HTLV) was the first human retrovirus to be discovered in the early 1980s . HTLV-1/Several developed countries including the US, France, Netherlands, Sweden, Switzerland, and Japan have conducted HTLV screening among blood donors with different screening strategies based on its prevalence. HTLV-1/2 infection has not been included as part of routine blood screening at the national level. In accordance with the requirements of the National Health Commission in China, laboratories in the Fujian, Zhejiang, and Guangdong provinces, which have a high prevalence of HTLV, do HTLV-1/2 antibody screening on all blood donations. In contrast, other provinces or municipalities have been screening only 10% of the donations for HTLV, since 2015. The prevalence of HTLV in Fujian, Guangdong, and Zhejiang provinces was 24.3 per 100,000 , 9.1 perIn China, the data available for HTLV screening among blood donors are limited. Blood screening laboratories conduct HTLV screening using enzyme-linked immunosorbent assay (ELISA), according to the requirement of the Blood Donation Law. The chemiluminescence immunoassay (CLIA), sample pre-processing system, and result analysis system are fully automated and self-contained platforms that minimize operator involvement, have good reproducibility, and can avoid the false positive/negative factors brought by operators , 21. ThiFrom November 2018 to March 2019, plasma samples from Changsha and Hebei blood centers underwent ELISA using the diagnostic kit for HTLV-1/2 antibodies  and blood plasma samples in Shenzhen were screened by Murex HTLV I + II . After ELISA screening, blood donations were randomly selected and screened for the HTLV-1/2 antibody using LUMIPULSE G HTLV-I/II Immunoreaction Cartridges and LUMIPULSE L2400  in their respective blood centers, according to the number of tests. The number of blood donations was equal to the number of blood donors. The sample with initial ELISA and/or CLIA reactivity will perform repeated tests twice using the same reagent. If one of the two outputs was identified as HTLV-1/2 reactive, it was followed up with a confirmatory test using INNO-LIA HTLV I/II ; the final results were analyzed by Auto-LIA 48 automatic system . The study route and criteria for interpreting the results obtained with the INNO-LIA strips were described in Fig. Since laboratories in China have not been performing routine HTLV screening, the donors that were found to be initially reactive for HTLV antibodies using ELISA were not deferred until they were confirmed to be positive for HTLV in National Centers for Clinical Laboratories using western blot or INNO-LIA HTLV I/II, according to the screening algorithm. However, the donation that was detected as reactive in ELISA was discarded.According to the requirements of the National Health Commission in China, all blood donations underwent HTLV screening using ELISA in the Shenzhen blood center, while blood centers of Changsha and Hebei blood screened only 10% of the blood donations. However, during the course of this study, HTLV screening was conducted for all blood donations across all three laboratories. Furthermore, these samples were also screened for Hepatitis B surface antigen, antibody to Hepatitis C Virus, antibody to treponema pallidum, and antibody to human immunodeficiency virus (HIV) and/or HIV-1 P24 antigen using ELISA; donations with reactive results for the serologic markers were not excluded from this study.p < 0.05 was considered statistically significant.The SPSS 21.0 software was used for statistical analysis. Chi-square tests were performed on all the examined outcomes between the three blood screening laboratories; p < 0.05); no significant difference in serologic activity was found between Hebei and Changsha blood centers.A total of 59,929 blood donations  were collected and screened for HTLV-1/2 using CLIA (Table p > 0.05). The true negative population percentage of HTLV-1/2 among blood donors in Hebei was 99.9752% , which was similar to Changsha  and Shenzhen  (p > 0.05). Furthermore, no statistical differences were observed in the HTLV-infected donors in the three blood screening laboratories (p > 0.05). In summary, of the 59,929 donations, 99.9933%  samples were confirmed as HTLV-1/2 negative, and 0.0050%  samples were classified as indeterminate for HTLV-1/2 antibodies. The overall prevalence of HTLV-1/2 was 1.67 per 100,000 .Among the 33 reactive blood donations for HTLV-1/2 by L2400 and/or ELISA, 29 were confirmed as HTLV-1/2 negative, 3 were HTLV-1/2 indeterminate , and only one collected in Shenzhen was positive for HTLV-1 antibodies . Of these, 3 donations with a single gp46 I/II band were identified as negative for HTLV antibodies, while 3 samples with single gp21 I/II were classified as indeterminate for antibodies. Only one donation had the 4 confirmation lines and was confirmed as HTLV-1 positive due to the 2 bands of discrimination (p19 I and gp46 I).The L2400 and INNO-LIA HTLV I/II score among blood donations varied. Out of 32 plasma samples reactive on CLIA, 27 (84.4%) had sample cutoff (S/CO) values between 1.0 and 5.0, and 5 (15.6%) had S/CO values > 5.0. Regarding the confirmatory INNO-LIA tests, seven samples had lines upon confirmation , central (Changsha blood center), and northern regions (Hebei blood center) of China.From November 2018 to March 2019, no HTLV-infected blood donors were found in Changsha and Hebei, and only one blood donor from Shenzhen was positive for HTLV-1 antibodies. Both the CLIA and the ELISA tests detected the one seropositive sample in this study. In addition, there were not many false-positive results on CLIA testing and even less on ELISA testing. In other words, both tests had a high specificity. The prevalence of HTLV-1 among blood donors in Shenzhen was 0.0035%, which was similar to the latest survey on HTLV prevalence (0.0029%) among volunteer blood donors in Shenzhen, conducted by Institute of Blood Transfusion attached with Chinese Academy of Medical Sciences , which fThe Fujian province has highest prevalence of HTLV in China . HoweverOur study did have a few limitations. Firstly, although highly sensitive CLIA can be used for routine blood screening , HTLV scIn summary, the overall prevalence of HTLV-1/2 among blood donors in the three major provincial blood centers in China was 0.0017%, which is lower than Japan, the US, and many European countries that have implemented HTLV donor testing. However, blood donations that had positive or indeterminate results for HTLV antibodies reminded us of the importance of HTLV screening among blood donors in China to prevent the transmission of HTLV from blood transfusion. In the view of HTLV prevalence and cost concerns, we support the view that HTLV screening of blood donors in area with high prevalence is reasonable in China; all the first-blood donors should undergo HTLV screening as a systematic strategy in low prevalence of HTLV. We recommend that the future research based on this study must focus on an expanding sample size and geographical coverage to get a more comprehensive dataset on HTLV prevalence, to ultimately improve blood safety.


Epstein-Barr virus (EBV) is closely associated with multiple human cancers. EBV-associated cancers are mainly lymphomas derived from B cells and T cells ) and carcinomas derived from epithelial cells . EBV can induce oncogenesis in its host cell by activating various signaling pathways, such as nuclear factor-κB (NF-κB), phosphoinositide-3-kinase/protein kinase B (PI3K/AKT), Janus kinase/signal transducer and transcription activator (JAK/STAT), mitogen-activated protein kinase (MAPK), transforming growth factor-β (TGF-β), and Wnt/β-catenin, which are regulated by EBV-encoded proteins and noncoding RNA. In this review, we focus on the oncogenic roles of EBV that are mediated through the aforementioned signaling pathways. As a kind of human pathogen, Epstein-Barr virus (EBV) is closely associated with the development of several cancers. More than 90% of adults have been infected with EBV , but as LMP1 has been confirmed as an oncoprotein that possesses conversion characteristics in vitro and is regularly expressed in EBV-related cancers. The main regulatory functions of LMP1 are mediated by its C-terminal activating regions . CD40 and B cell receptors (BCRs) are simulated by LMP1 and LMP2, respectively . EBNA1 pNuclear factor-κB (NF-κB), a highly conserved family of transcription factors, includes p50, p52, RelA(p65), RelB, and c-Rel . When stChrysanthemum indicum Linné (CIE) can strikingly reduce LMP1-induced NF-κB activation as well as LCL activity but produces no negative effects on human foreskin fibroblasts (HFFs), EBV-negative Burkitt lymphoma cells or HeLa cells. Further evidence suggests that the LMP1-induced IKK2-TPL2 signaling pathway may mediate JNK signaling to effectively regulate the proliferation and survival of EBV-transformed LCLs [NF-κB dysregulation is one of the key steps in the occurrence and development of most tumors. The expression of NF-κB is upregulated in some cancers, such as head and neck squamous cell carcinoma (HNSCC) , colorecmed LCLs . LMP1 camed LCLs . On the med LCLs .EBV-encoded miR-BARTs also have an important impact on cell proliferation and migration. The total phosphorylation levels of TAK1 and IKKα/β/γ in NPC tissue samples increased correspondingly when EBV-miR-BART8-3p was upregulated. Furthermore, EBV-miR-BART8-3p can regulate NPC cell migration by activating NF-κB and Erk1/2 . Xu et aPhosphoinositide-3-kinase (PI3K), an intracellular phosphatidylinositol kinase, is equipped with serine/threonine activity and phosphatidylinositol kinase activity. When signals are received from tyrosine kinases and G protein-coupled receptors, p85 of the PI3K regulatory subunit is recruited to the site around the cytomembrane. Then, protein kinase B (AKT) translocates from the cytoplasm to the cytomembrane and activates AKT with assistance from PDK1 and PDK2 . The PI3The products of EBV can regulate cell proliferation and promote the occurrence of EMT and tumor angiogenesis through PI3K/AKT Fig. . LMP1 isEBV-encoded miRNAs regulate cellular EMT via the PI3K/AKT signaling pathway. Intranuclear accumulation of the oncoprotein β-catenin indicates the initialization of EMT, which can be negatively regulated by GSK-3β. Although GSK-3β and β-catenin are downstream proteins of the WNT signaling pathway, they are often regulated by PI3K/AKT because each signaling pathway does not exist independently. Cai et al.  confirmeHowever, there is no direct evidence that EBV products regulate the proliferation and apoptosis of posttransplant lymphoproliferative disease (PTLD) through the PI3K/AKT signaling pathway. Many studies have shown that PI3K/AKT signaling pathway plays an important role in PTLD infected by EBV. In the study of Sang et al. , severalIn the Janus tyrosine kinase/signal transducer and transcription activator (JAK/STAT) family, there are several members, including JAK1, JAK2 and TYK2, that are commonly expressed in all types of cells. In contrast, JAK3 expression is usually limited to lymphoid cells . The traTo date, 7 independent STAT proteins have been identified that are closely related to apoptosis and immune evasion. On the one hand, evidence suggests that STAT3 and STAT5 control the cell cycle proceeding from G1 to S phase by raising the expression level of cyclin D1 , 40. OthMitogen-activated protein kinases (MAPKs) are involved in helping direct cellular responses to various extracellular stimuli, such as cytokines, neurotransmitters, and hormones, as well as cellular stress and adhesion. In the MAPK signaling pathway, there is a conservative pattern of three kinases, including MAPK kinase kinase , MAPK kinase  and MAPK, which are activated in turn when stimulated. There are 4 major classes of MAPKs, namely, ERK, p38, JNK and ERK5. Among those classes, both ERK1 (MAPK3) and ERK2 (MAPK1) are involved in growth factor signal transmission and cell proliferation and apoptosis .EBV-encoded products share some close associations with the MAPK signaling pathway Fig. . LMP1 noThe JNK/p38-MAPK signaling pathway plays a vital role in cell apoptosis, especially oxidative stress-induced cell apoptosis. In a study on reactive oxygen species (ROS), high expression of CD70 on EBV-transformed B cells could also evoke the stress reaction of the endoplasmic reticulum (ER), and the JNK and p38-MAPK signaling pathways may interact to induce ROS generation and subsequent cell apoptosis . FurtherThe transforming growth factor-β (TGF-β) signaling pathway is involved in many cellular processes of both mature organisms and developing embryos. Such processes include cell growth, differentiation, apoptosis and dynamic equilibrium. TGF-β superfamily ligands may bind with the TGF-βII receptor, while the II type receptor is a kind of serine/threonine kinase receptor that catalyzes the phosphorylation of the I type receptor that regulates Smad protein expression in return. On the other hand, Smad proteins may change the phenotype via regulation and transcription .In studying the regulation of TGF-β on apoptosis and proliferation, EBV-positive NPC cells can resist TGF-β1-mediated growth inhibition and apoptosis, while the growth of EBV-negative NPC cell lines is strictly regulated by TGF-β1 , among wEBV could also strengthen its own infection and transmission through the TGF-β signaling pathway. TGF-β activates Zp through the combination of AP-1 and Smad4. Activated Zp promotes the expression of BZLF1, causing EBV to switch from a latent form of infection to a lytic form of infection . AccordiThe classical Wnt signaling pathway can regulate genetic transcription. As a kind of Wnt signaling pathway, Wnt/β-catenin can signal β-catenin to gather within the cytoplasm, translocate to the nucleus and bind with TCF/LEF family transcription regulatory factors to exert a corresponding regulatory effect. Without Wnt, β-catenin cannot gather inside the cell due to ubiquitylation and degradation by protein complexes . These protein complexes may encourage ubiquitylation of β-catenin first and then transport it to the proteasome for digestion. In contrast, the presence of Wnt promotes the dissociation of the protein complex and loses the ability to ubiquitinate β-catenin, resulting in stable expression of β-catenin .According to previous studies, LMP1 is unlikely to play a vital role in Wnt signaling pathway regulation , but somWith the advancement of medicine and application science, the synergistic effect and interaction at the molecular level are frequently unveiled and confirmed. EBV-encoded products may activate various signaling pathways, such as the NF-κB, JNK and JAK/STAT signaling pathways. These signaling pathways collectively regulate the interactions among specific downstream proteins, providing evidence for the oncogenic mechanism of EBV-encoded products. The synergistic effect between NF-κB and PI3K/AKT in LMP1-promoted aerobic glycolysis, as they interact with each other to enhance the transcription and plasma membrane translocation of glucose transporter 1 (GLUT1) and thus fuel the proliferation of cancer cells . In addiLMP1 could be active in all the signaling pathways mentioned above. From a large number of experiments on LMP1, LMP1 promotes the generation of extracellular vesicles (EVs), which has attracted increasing attention. Therefore, more experiments are needed to understand these mechanisms at the molecular level. LMP1 upregulates the expression of CD63, Alix, Syntenin-1, Hrs, TSG101 and CHMP5 through the endosomal sorting complex required for transport (ESCRT), increasing the production of EV . CD63 isAfter elucidating the mechanism of so many EBV activation signaling pathways, researchers designed inhibitors of certain key proteins in the activation signaling pathway, which has become a method of treating tumors. In the new clinical treatment strategy, the focus is no longer on drug therapy, and cellular immunotherapy has become a hot spot Table . First, There is an urgent need for new strategies for the treatment of EBV-induced cancer in the clinic. Traditional drug treatments often only target cancer but ignore that even the same cancer-induced factors can be completely different. We urgently need to understand the molecular mechanism, develop drugs for abnormal proteins or genes, and pave the way for individualized precision treatment. Moreover, it is a promising strategy to design specific artificially modified T cells to recognize EBV oncoproteins combined with clinical drugs to alleviate or even cure EBV-induced cancer. Unfortunately, the current technology, artificially modified T cells, will produce serious toxicity and side effects in the human body, which is another problem that urgently needs to be solved. However, we believe that in the near future, after we deeply understand the mechanism of toxic and side effects, we can minimize the occurrence of toxicity and side effects, so that artificially modified immune cells become a powerful tool for us to fight diseases. At the same time, combined with our research on the signaling pathways of disease onset, a real era of molecular individual therapy will come. This is also our outlook on the positive attitude of the future.EBV-encoded products greatly affect the cell cycle, proliferation and apoptosis via six major signaling pathways, which exhibit a considerable amount of cross-talk with each other and thereby form a network. Discoveries of these signaling pathways may provide new directions and targets for the prevention and treatment of EBV-associated cancers. Nevertheless, there are certain limitations of studies on the relationships between EBV and JAK/STAT and Wnt/β-catenin, and more evidence is needed to prove the interaction of EBV with MAPK. In this review, we disclosed the regulatory effect of EBV in host cells and cell interactions via multiple signaling pathway networks. It is meaningful for us to further explore the relations between EBV and these signaling pathways to fully understand EBV-induced oncogenesis.


Candida albicans, 5% with C. guilliermondi, 3% with C. lusitaniae and 3% with C. parapsilosis.In this study, 181 healthy individuals, including 29 couples, were analysed regarding oral yeast colonization using a culture-based approach. Results showed that 39% of the individuals were yeast carriers, 89% being colonized with C. albicans strains with only one CAI genotype, while two but similar CAI genotypes inhabited the oral cavity of the remaining 20% individuals. The same CAI genotypes were found in 66.6% of the couples when both were colonized.Sixty-two percent of the couples had at least one member colonized. Colonization and CFU counts were higher in the couples´ group. Eighty percent of the volunteers were colonized with Our results indicate that the intimacy among couples increases the probability of heavy cross-colonization, which is potentiated when one member of the couple is a smoker. Candida, Cladosporium, Aureobasidium, Saccharomycetales, Aspergillus, Fusarium and Cryptococcus being most predominant [Penicillium spp., Aspergillus spp. and Cladosporium, while the most abundant yeasts were Candida spp. and Rhodotorula spp [Candida species were the most prevalent and existed commensally in the oral cavity of up to 70% of healthy individuals [Candida species like C. albicans, C. dubliniensis, C. parapsilosis and C. glabrata belong to the normal microbiota of the skin and mucosal surfaces of healthy individuals, not only in the oral cavity, but also in the gastrointestinal tract and the vagina [Advances in metagenomics allowed a more complete understanding of the different microorganisms that inhabit on or within human tissues and fluids. The number and type of these microbes vary with age, diet and personal hygiene habits, being collectively referred to as the normal microbiota of the human body. In particular, the oral cavity is colonized by a highly diverse set of microbes from different species, including bacteria, protozoa and fungi, and also by viruses ,2. They dominant . In cultrula spp . In thesividuals ,7. In fae vagina .Candida opportunistic infection, leading to a spectrum of oral mucosal disorders, from simple to chronic candidosis [Despite its relatively low abundance, the impact of the mycobiome in human health and disease is well established [ndidosis . In sevendidosis ,11,12.Candida spp. and the appearance of strains resistant to conventional treatment, led to the development of new approaches to effectively identify different Candida spp., among which microsatellite typing was used [C. albicans microsatellite CAI was first described in 2003 and has proved to be an efficient method for strain differentiation with a discriminatory power of 0.97 [The increasing number of infections caused by was used ,14. The  of 0.97 .C. albicans in the human oral cavity have been performed in individuals with different pathologies or belonging to risk groups. It is widely described that C. albicans predominates among Candida spp. in the oral cavity, but little is known about its genotypic diversity, stability and transmissibility between individuals. Hence, the two main goals of the present study were to determine yeast colonization in the oral cavity of healthy individuals and to evaluate patterns of C. albicans transmission between couples, and their stability over time. Moreover, correlations with gender and smoking habits were also studied.Most studies on the prevalence of C. albicans in the first sampling and continued participant availability.One hundred and eighty-one healthy individuals volunteered to participate in this study, including students and staff of the University of Minho. The study had been approved by the Ethics Committee for Research in the Life and Health Sciences of the University. All the participants signed an informed consent, and data regarding food habits, oral hygiene and smoking habits were registered. The ages ranged from 18 to 60 years, with 116 females and 65 males. Exclusion criteria included antibiotic or steroid therapy within the 3 months preceding the collection. To maintain the anonymity of the donors a number was assigned to each. Members of a couple received the same number, being distinguished only by the use of the letters ‘a’  and ‘b’ . To assess individual variation of oral yeast colonization over time, a follow-up of 10 participants was carried out approximately 1 year after the first sampling. The selection criteria for the follow-up participants included identification of A saliva sample (approximately 1 mL) from each participant was collected between 10 a.m. and 12 a.m., to avoid variation in salivary flow rates, and directly plated and spread on Yeast extract glucose chloramphenicol agar (YGC) with 50 mg/L chloramphenicol to inhibit bacterial growth. The plates were incubated at 37°C for 5 days. The cultures were examined every day, and the number of fungal colonies was recorded in colony-forming units per millilitre (CFU/mL).Candida yeast species. Following this preliminary phenotypic characterization, isolates identified on the CHROMagar as C. albicans and the non-albicans species were further analysed through the use of molecular techniques. From each individual, a maximum of eight C. albicans colonies were randomly selected for CAI analysis, and one non-albicans colony of each different colour was chosen for ITS species identification. Bacteria isolates were not identified in this study.The yeast colonies  were sub-cultured on CHROMagar Candida to facilitate the presumptive identification of C. albicans were genotyped with the CAI species-specific microsatellite marker. CAI locus was amplified with primers 5´-ATG CCA TTG AGT GGA ATT GG-3´ (forward) and 5´-AGT GGC TTG TGT TGG GTT TT-3´ (reverse), according to [Before DNA isolation, cells were cultivated overnight on Sabouraud medium at 30°C and DNA was extracted according to . Isolaterding to . PCR prording to .albicans isolates was performed by sequencing the internal transcribed spacer (ITS) regions of ribosomal RNA genes. Sequence analysis was carried out using primers ITS1 (5ʹ TCCGTAGGTGAACCTGCGG 3ʹ) and ITS4 (5ʹ TCCTCCGCTTATTGATATGC 3ʹ), according to [Molecular identification of non-rding to , and PCRrding to  and compComparisons between categorical variables were performed using the Chi-square statistical test with Yates correction to compare between different conditions. Variables were compared using a 2-tailed t-test in order to evaluate significance associated with higher or lower CFUs values. A p value <0.05 was considered as significant. To evaluate if the statistically significant difference was correlated with helpful information in decision-making, the Cohen´s d value was calculated . A d valC. albicans CAI genotypes were compared according to their Shriver´s genetic distance, using PowerMarker v3.25 software [The software . A distasoftware . Comparisoftware . Markov software . These csoftware .As previously reported, 181 healthy donors participated in this study, including students and staff of the University of Minho, among which 29 were couples. Results showed that 39% (70 out of 181) of the individuals carried yeasts in the oral cavity. The number of CFUs found in saliva samples was variable, with eight individuals showing a countless number of colonies (>300 CFUs) in the saliva, while others presented only one or two colonies. The majority of the individuals (55.7%) presented between one to 20 colonies .Figure 1From the population studied, 116 were females and 65 were males. Although the number of males and females per classes of CFUs was different , the perEighteen percent (n = 34) of the participants were smokers. When correlating colonization with smoking habits , the resTo assess whether the intimacy results in cross-transmission of microorganisms, 29 couples were analysed. Interestingly, 11 couples (37.9%) showed no yeast colonization, nine (31.0%) presented colonization in only one member , and nine (31.0%) in both members of the couples.Results were particularly significant when comparing colonized and non-colonized individuals between the couples and the remaining population . Also, in the couples´ group, the average CFU number was 31.7, while in the remaining single individuals it was 13.9 CFUs . CFU counts were also higher in the couples´ group with smoking habits (CFUs average = 26.3) than in single individuals (CFUs average = 6.1) with smoking habits , contrary to CFUs number in non-smokers between the two groups . These results indicate that the probability of colonization, together with high amount of yeast cells in the oral cavity, is moderately higher within the couples, but is largely potentiated by smoking habits. Colonization was likely not associated with hygiene habits or diet, because all the participants declared to follow regular oral hygiene habits and balanced diet.C. albicans isolates formed yellow-green to blue-green colonies, while the remaining species presented a wide range of colours, from white to dark purple. However, since the colours may differ according to the strain, sequencing of the ribosomal internal transcribed spacer region was performed to identify non-albicans isolates, while C. albicans isolates were amplified with a CAI species-specific CAI marker [C. albicans alone, 5.7% (n = 4) a mixed culture of C. albicans and other yeast species, 5.7% (n = 4) non-albicans species only, 2.8% (n = 2) C. albicans and bacteria, and in only one individual (1.4%) C. albicans co-inhabited the oral cavity with other yeast species and bacteria. Regardless of the presence of chloramphenicol in the culture medium, bacteria isolates were identified in five individuals, and from those, three also presented yeast colonization.Differentiation of yeast isolates was performed on CHROMagar Candida medium. In this medium, I marker . The resCandida guilliermondi, C. lusitaniae, C. parapsilosis, and Rhodotorula mucilaginosa were among the other yeast species identified  showed isolates with the same CAI genotype, 33.3%  presented isolates with different CAI genotypes, and only one couple  presented a mix of genotypes derived from slippage events, such as microvariations (Fifty-three participants (80%) were colonized by strains with only one CAI genotype and 13 (20%) with two genotypes. The different genotypes isolated from the same individual were probably due to rearrangements at the CAI locus, such as slippage  or loss of heterozygosity . The slippage is observed when one or two microsatellite repeated units are added or reduced in one or both alleles, as observed in strains isolated from individual S148, while the LOH is observed when one of the alleles is missing, as shown in strains isolated from the individual S031 . Consideriations .Table 2.C. albicans, only the S054 couple also shared the non-albicans species, C. guillermondii. Couples S015 and S095 did not share the non-albicans species, C. parapsilosis or C. lusitaniae . Interestingly, in couples colonized with species other than sitaniae .C. albicans colonization is stable over time, 10 C. albicans carriers were selected for a second sampling, approximately 1 year after the first analysis. The collected isolates were again identified and C. albicans CAI genotypes compared with the first sampling. Results showed that the CAI genotypes of the colonizing strains were stable over 1 year  among yeast carriers, which is also widely reported in the literature [C. albicans was isolated alone and in 10% in a mixed culture, including chloramphenicol resistant bacteria. Curiously, C. albicans was identified together with C. guillermondii and C. lusitaniae, but not with C. parapsilosis or R. mucilaginosa. A lower competitiveness between C. guillermondii and C. lusitaniae with C. albicans may account for this result. Candida tropicalis and C. glabrata are frequently identified in oral samples, however, in our survey, these species were not found. Indeed, it is described that C. glabrata is innately resistant to antifungal agents [In the present study, we observed that terature . Indeed,l agents , so the l agents .C. dubliniensis, but this species was also not isolated in our study. However, to the best of our knowledge, C. dubliniensis has not been identified yet in oral samples in Portugal [Another species frequently identified in oral samples is Portugal ,36.C. albicans is essentially clonal, it is described that variations in biological properties may be traced by only one variable marker [C. albicans, analysis of loci associated with known biological properties would provide more accurate data [RLM1 [C. albicans colonized volunteers with the CAI marker identified a total of 22 different alleles and 39 distinct genotypes. Different studies have correlated strains presenting CAI alleles with 30 or more CAA/CAG repetitions with resistance to stress agents, virulence in the mouse model, and severity of human vulvovaginal candidiasis [Since the mode of reproduction of e marker . Howeverate data ,38. CAI ta [RLM1 , and hasta [RLM1 ,39,40, tdidiasis ,39,40. HResults showed that the majority of the volunteers were colonized with the same CAI genotype, but some were colonized by two distinct genotypes that could result from a microevolutionary step, such as an LOH or slippage event . This isC. albicans genotypes in the same individual were identified by using two molecular markers (Hist3 and CAI) [In hospitalized patients without oral infections, up to nine different and CAI) . Analysiand CAI)  study, 7C. albicans CAI genotype or microvariations of the same CAI genotype is predominant in the oral cavity. However, the difference between the two studies may indicate that hospitalized patients are more immunocompromised, disturbing the host-fungus interaction, enabling different CAI clones to inhabit the oral cavity. In CIn immunocompromised individuals the host-microorganism relationship changes from commensal to opportunistic and may eventually lead to the appearance of oral diseases [The results of the present study corroborated these findings, suggesting that in healthy individuals, only one diseases ,43,44.C. albicans strains between couples is not a dominant phenotype, but the intimacy among couples increased the probability of heavy cross-colonization. It has been reported that a massive transmission of microbes may occur through kissing [C. albicans strains, the same or similar CAI genotype is predominant, suggesting an exogenous origin followed by CAI stabilization due to constraint sharing of microorganisms.In the couples group, it was interesting to observe that 37.9% were not colonized, 31.0% showed colonization in only one member of the couple, and only 31% in both members of the couple, indicating that transmission of  kissing , so, rel kissing . HoweverC. albicans strains are stable over time in the oral cavity, despite its continuous exposure to the external environment. In all individuals the same CAI genotypes persisted after 1 year, except one case with two CAI genotypes in which only the CAI genotype with a high molecular weight allele persisted. In agreement with this, it has been described that high molecular weight CAI alleles could confer higher adaptability to certain niches, such as mucosal surfaces, enabling specific clones to persist [40et al. 2018. Our results also indicate that the cross-colonization between the two members of the couple is potentiated when the mates are smokers.One important observation of the present study was that  persist 4046, CarC. albicans strains, the stability of the present genotypes over time. Nevertheless, we acknowledge the existence of some limitations regarding the number of couples included in the study and the need for further information about the yeast isolates, for instance, their antifungal susceptibility profiles.Overall, our study presents interesting new findings regarding yeast colonization in healthy individuals and, as regards Click here for additional data file.


The WHO established targets for 2030 to globally reduce new viral hepatitis B and C infections by 90% and deaths by 65% and recommends searching for coinfections that increase the progression of chronic liver infections towards cirrhosis and hepatocellular carcinoma.This study aimed to add information concerning the influence of human T-lymphotropic virus type 1 (HTLV-1) and type 2 (HTLV-2) infections in hepatitis B and C, since in Brazil, these human retroviruses are endemic but neglected. Serum samples from 1,910 patients with hepatitis B and 1,315 with hepatitis C from São Paulo, southeast Brazil, that were previously tested and grouped for HIV and HTLV-1/-2 coinfections were analyzed for hepatitis B virus (HBV) and hepatitis C virus (HCV) loads measurements and subsequent clearance using data from laboratory records.p<0.05). In contrast, higher HCV VL was detected in HCV/HIV, HCV/HIV/HTLV-1/-2 coinfected patients , and the lowest HCV VL was detected in HCV/HTLV-2 coinfected patients. Curiously, 61.1% of the patients with HBV/HTLV-2 coinfection had an undetectable HBV VL at the beginning of the study versus 21.4% in the patients with HBV/HTLV-1 coinfection. Although the percentages of undetectable HCV loads in HCV/HTLV-1 and HCV/HTLV-2 coinfected patients were quite similar, during follow-up, more HCV clearance was detected in patients with HCV/HTLV-2 coinfection .Briefly, the lowest HBV viral load (VL) was detected in HBV/HTLV-2 coinfected patients, regardless of whether they were infected with HIV  and type 2 (HTLV-2) are endemic and neglected in Brazil, and although these viruses were considered to have prognostic value when associated with HIV, e.g., HTLV-1 has been associated with fast progression and death to AIDS and more cases of lymphoma and neurological disorders, and HTLV-2 has been associated with slow progression to AIDS, their impact on hepatitis B virus (HBV) and hepatitis C virus (HCV) outcomes remain unknown. The present study analyzed the influence of HTLV-1 and HTLV-2 coinfection on HBV and HCV virological outcomes  in serum samples from 1,910 patients with hepatitis B and 1,315 patients with hepatitis C from São Paulo, southeast Brazil. The results obtained confirmed the positive impact of HTLV-2 on HBV and HCV virological outcomes  and the opposite effect of HTLV-1; these findings are similar to the effects observed in HIV/AIDS patients. Taking into consideration these results and the differential impact of HTLV-1 and HTLV-2 in viral hepatitis B and C, we suggest including the serology of HTLV-1/2 in the follow-up of such patients in Brazil. Viral hepatitis infections, mostly those caused by hepatitis B virus (HBV) and hepatitis C virus (HCV), are major global health problems. HBV and HCV can cause chronic infections, and a significant number of chronically infected individuals will develop cirrhosis and hepatocellular carcinoma –3. In 20Unfortunately, human T-lymphotropic virus type 1 (HTLV-1), although endemic in Brazil, is responsible for at least two diseases of high morbidity and mortality  ; howeverTwo years ago, we started studies on the prevalence and impact of HIV, HTLV-1 and HTLV-2 in patients with viral hepatitis B and C from São Paulo, southeast Brazil, and disclosed alarming results in hepatitis C, including high percentage of HCV/HTLV-1/-2 coinfection (5.3%) , and assThe Instituto Adolfo Lutz (IAL), a Public Health Laboratory located in São Paulo City, is a reference laboratory for viral hepatitis, HIV, HTLV-1, and HTLV-2 infections. The IAL is responsible for the diagnosis and surveillance of these viruses and for assessing trends of infections and coinfections. Blood samples are sent to IAL from several Specialized Health Centers in the state of São Paulo, i.e., STI/AIDS and viral hepatitis centers and gastroenterology and/or hepatology services. A retrospective study was conducted using data obtained from cross-sectional studies previously described that utilized plasma samples collected from 1,910 patients analyzed for HBV VL at IAL during two periods: from June to November 2014  and fromAll samples were first analyzed for HBV and HCV VL measurements at the IAL Viral Hepatitis Laboratory using Abbott Real-Time HBV and Abbott Real-Time HCV assays, with a lower limit of detection of 10 IU/mL and 12 IU/mL, respectively, and HCV genotyping using Abbott Real Time HCV Genotype II, . All assays were conducted according to the manufacturer’s instructions. Furthermore, the samples were tested for HIV-1, HTLV-1 and HTLV-2 coinfections at the IAL HTLV Research Laboratory using currently available assays for the analyses. Briefly, HIV-1 infection was evaluated using an immunochromatographic assay  and enzyme immunoassays , as previously described ,15. AntiSix groups were categorized according to the results (positive or negative) for the following HIV-1 and HTLV-1/-2 serological assays. In hepatitis B: HBV mono-infection ; HBV/HIV-1 coinfection (n = 140), HBV/HTLV-1 coinfection (n = 7), HBV/HTLV-2 coinfection (n = 4), HBV/HIV/HTLV-1 coinfection (n = 7), and HBV/HIV/HTLV-2 coinfection (n = 14). Of note, because of the small sample size of the HBV/HTLV coinfection groups, primarily the HBV/HTLV-2 coinfection group (n = 4), four groups were categorized for the statistical analysis: HBV, HBV/HIV, HBV/HTLV-1 and HBV/HTLV-2 (the last two groups were irrespective of their HIV-1 status), although data of all groups were presented. In hepatitis C, initially six groups were categorized and statistically analyzed: HCV mono-infection ; HCV/HIV-1 coinfection (n = 127), HCV/HTLV-1 coinfection (n = 28), HCV/HTLV-2 coinfection (n = 9), HCV/HIV/HTLV-1 coinfection (n = 9), and HCV/HIV/HTLV-2 coinfection (n = 15). Subsequently, four groups were considered for clearance analysis: HCV, HCV/HIV, HCV/HTLV-1 and HCV/HTLV-2 (the last two groups were irrespective of their HIV-1 status).10 transformed), as well as the clearance results of HBV and HCV during two years of follow-up, were abstracted from laboratory records and analyzed according to the type of viral infection or coinfection.HBV and HCV VL  and 95% confidence intervals (CIs). The analysis was performed using SPSS 21 .Differences in the numbers of males and females in each group were evaluated statistically using the Chi-square test. GraphPad Prism software version 5.03  was used for age and HBV and HCV VLs comparisons among three or more groups using Kruskal-Wallis analysis of variance (ANOVA), complemented with Dunn’s multiple-comparison test, and the Mann-Whitney U-test for comparing two groups. Results with a The study was approved by the IAL Ethics Committee for Research CTC#21I-2016 under Ministry of Health protocol number CAAE– 55837316.0.0000.0059. The data were analyzed anonymously.The characteristics of the study populations according to group (mono-infection and coinfection) and the results of the HBV and HCV VL measurements detected in samples from patients with hepatitis B and hepatitis C during the first cross-sectional analysis are presented in p<0.0001). The patients with the oldest median age belonged to the HBV/HTLV-1 coinfection group (median age of 64 years) (p<0.05) and HBV/HIV coinfection groups of patients . Results with statistical significance detected by Mann-Whitney U-test were depicted in Briefly, in patients with hepatitis B, more men were coinfected with HIV and HIV/HTLV-2 when compared to the other groups  , with st10 IU/mL), which was 1.03 log10 lower than the VL value of the HBV mono-infected group (2.64 log10 IU/mL) , and the results with significance obtained by Mann-Whitney U-test were presented in In relation to HBV VL, a minor HBV VL was detected in HBV/HTLV-2 coinfected patients irrespective of their HIV status (1.61 logp<0.0001) , and HCV/HIV with HCV/HTLV-1 coinfected patients (p = 0.0019), 10 IU/mL, and the VL was 0.28 log10 higher in men than in women. Higher HCV VL values were detected in HCV/HIV, HCV/HIV/HTLV-1, and HCV/HIV/HTLV-2 coinfection groups, with the highest values observed in the HCV/HIV/HTLV-1 coinfected patients (6.82 log10 IU/mL) (10 IU/mL)  . Concernp≤0.001, . By Mann0 IU/mL) , Fig 2B.0 IU/mL) , Fig 2B.When we analyzed the number of samples that resulted in VLs that were detectable or under the detection limit of the applied assay (VL undetectable) at the first evaluation, a larger percentages of HBV undetectable VL samples were observed in HBV/HTLV-2 individuals (61.1%), contrasting with the lowest value observed in HBV/HTLV-1 coinfected individuals (21.4%). Using univariate logistic regression analysis the HBV/HIV and the HBV/HTLV-2 coinfected individuals presented more odds to undetectable HBV VL measurements than the HBV mono-infected counterpart , When the same analysis was conducted in HCV patients, no difference in the percentage of undetectable VL levels was observed between the HCV/HTLV-1 patients (18.9%) and HCV/HTLV-2 patients (25.0%). However, in contrast, during follow-up, 50.0% of the HCV/HTLV-2 coinfected patients converted to an undetectable HCV VL, contrasting with 35.1% in HCV/HTLV-1 coinfected patients. The univariate and multivariate regression analysis confirmed the benefit of HTLV-2 infection on HCV clearance  when compared HCV/HTLV-2 coinfected patients with HCV mono-infected counterpart .Of note, using univariate analysis, male sex and the age of ≤50 years were factors associated with HBV/HIV and HBV/HTLV-2 coinfections . The samNotably, according to laboratory records, the most prevalent HCV genotypes identified in samples of individuals with hepatitis C were genotype 1a (42.8%), followed by genotypes 1b (28.4%), 3 (14.1%), and 3a (6.0%). No considerable differences in genotypes according to groups (HCV mono-infection or coinfection) were detected (data obtained from laboratory records).To reach the 2030 WHO goal to reduce viral hepatitis B and C infections by 90% and death by 65%, a search for coinfections (mostly HIV) that could increase the progression of liver chronic infections towards cirrhosis and hepatocellular carcinoma has been recommended, but HIV is not the only retrovirus associated with liver disease progression in viral hepatitis. Some studies from Japan and elsewhere have reported notably worse virological and clinical outcomes in hepatitis C patients coinfected with HTLV-1, i.e., higher HCV viremia, lower HCV sustained virological response to α-interferon treatment, increased risk of cirrhosis and greater liver cancer mortality when compared to their counterparts with HCV infection alone –18. No eAlthough there is a lack of information relating to the impact of HTLV-1/2 on HBV disease progression and clearance, the present study discloses important results. In hepatitis B, we first confirmed more HIV and HIV/HTLV-2 coinfection among men, which could be explained, in part, by men having a greater number of sexual partners during their lifetime; additional, there are more IDUs among males. In fact, corroborating this hypothesis, HTLV-2 has been detected and associated with IDU mostly in male HIV-infected patients in São Paulo (southeast Brazil) and in Londrina (southern Brazil) ,20. AddiConcerning the impact of HTLV-1 and HTLV-2 on HBV virological outcomes, in HBV/HTLV-1 coinfected patients from Salvador, a higher prevalence of HBsAg (evidence of persistent HBV infection or reduced spontaneous clearance of HBV) was detected when compared with HBV mono-infected patients . AnotherOn the other hand, the present study confirms, for the first time, the benefit of HTLV-2 infection on HBV clearance. In fact, at the beginning of the study, more patients coinfected with HBV/HTLV-2 had spontaneous clearance of HBV compared with the HBV/HTLV-1 coinfected patients, regardless of their HIV status. The mechanism by which HTLV-2 affects HBV VL and clearance is unknown and deserves further study. However, we could speculate that the increase in the number of cytotoxic CD8 T lymphocyte responses in HTLV-2 infection could control HBV replication, as reported in HIV and in HCV replication control in studies conducted elsewhere ,26.In relation to hepatitis C, as expected among retrovirus coinfected patients, males predominated. This could be explained by the same risk factors described for HBV and mostly by the IDU, since HCV has been strongly associated with this route of virus transmission ,19–21. IConcerning HCV virological outcomes in mono-infected and coinfected individuals, the results obtained herein confirmed the negative impact of HIV and/or HTLV-1 on HCV VL and clearance, as well as the higher VL levels in males than in females, as previously described , and addIn the present study, we were able to analyze and compare HCV VL and clearance in 787 HCV-infected, 90 HCV/HIV coinfected, and 48 HCV/HTLV-1/2 coinfected individuals from São Paulo . We confirmed higher HCV VL and viremia and lower HCV clearance during follow-up among HCV/HTLV-1 coinfected patients than in HCV mono-infected and HCV/HTLV-2 coinfected patients.Of interest, although lowest HCV VL values were detected in HCV/HTLV-2 coinfected patients, when the patients were also infected by HIV, the HCV VL increased, showing that HIV takes advantage of HTLV-2 coinfection in patients with hepatitis C, probably during the acute or primary HIV infection. However, after treatment  and duriOther factors, such as the genetic background of individuals, the subtype of HTLV-2 strain, the Tax 2 protein, and the antisense protein APH-2, among others, could also be implicated in the benefit of HTLV-2 in hepatitis C, as occurs in HIV/AIDS ,14,16,26Additionally, the results described herein concerning the HCV genotypes detected among patients corroborate the genotypes that are prevalent in Brazil , and no http://id.who.int/icd/entity/1043229589).Remarkably, some Brazilian public health policies concerning HTLV were implemented in recent years in Brazil due to the pressure of clinicians, researchers, HTLV-infected individuals and data from the literature. All of these policies stressed the importance of the correct diagnosis of HTLV-1 and HTLV-2 for monitoring and adequately treating such individuals. They included the recommendation of HTLV-1/2 serology at the first clinical visit for HIV-infected individuals of regions where HTLV-1 is endemic ; the useFinally, the major limitations of the present study was the low number of HTLV-1 and HTLV-2 coinfected patients in each HBV and HCV subgroup analyzed, but we have to consider that the samples came from the Viral Hepatitis Laboratory and not from HTLV out-patients clinics. Thus, the numbers of HBV/HTLV-1/2 and HCV/HTLV-1/2 coinfected individuals although low, are in accordance with the HTLV-1/2 numbers detected in high-risk populations, such as in HIV/AIDS patients ,34, and In conclusion, taking into consideration the results obtained and the different impact of HTLV-1 and HTLV-2 on HBV and HCV loads and clearance, together with the WHO plan for success in Brazil, we suggest including HTLV-1/2 serology in the battery of tests used in the follow-up of patients with viral hepatitis B and C in this country.S1 Checklist(DOC)Click here for additional data file.


Pre-activation amplitudes of PL and TA were assessed with surface electromyography (EMG) during a dynamic landing test. Center of pressure (CoP) displacement and sway variability in anterior-posterior (AP) and medio-lateral (ML) directions were measured with a force platform during a single leg balance test (SLBT). Measures were obtained prior to a single DN intervention, immediately after, at 48 h, and 1 month after. The DN group displayed a significant increase in PL and TA pre-activation values, which were maintained 1 month later. Significant reductions in the ML and AP displacements and sway variability of CoP were found for the DN group. These results showed improvements in feedback/feed-forward strategies following DN, including enhanced neuromuscular control and static postural control, with the potential to become a convenient and accessible preventive treatment in CAI subjects.This study aimed to compare the effects of dry needling (DN) versus placebo DN applied to the peroneus longus (PL) and tibialis anterior (TA) on neuromuscular control and static postural control in basketball players with chronic ankle instability (CAI). A single-blinded randomized controlled trial was conducted. Thirty-two male and female basketball players with CAI were randomly assigned to receive either DN ( After an initial ankle sprain, anatomical changes such as laxity, impaired arthrokinematics, or synovial changes can lead to joint insufficiencies that predispose to recurrent ankle sprains ,2,3,4. GAs a result, a wide variety of altered feedback/feed-forward mechanisms has been shown in subjects with CAI, but it remains uncertain whether these deficits are due to local or spinal/supraspinal conditions . StudiesThese changes that occur in people with CAI may be correlated with the presence of myofascial trigger points (MTrPs) . MTrPs aDry needling (DN) is a technique that aims to diminish persistent peripheral nociceptive inputs by targeting MTrPs ,23. EnhaThus, the primary objective of this study was to evaluate the short and medium-term of DN applied on latent MTrPs in PL and TA on EMG pre-activation amplitudes of these muscles immediately before the initial foot contact during a dynamic landing maneuver performed by basketball players with CAI. The second objective was to analyze CoP displacement and sway variability during a single leg balance test (SLBT) as a representative measure of static postural control. We hypothesized that DN would be effective both in the decrease of CoP displacement measures during the SLBT and in the increase of PL and TA pre-activation during the landing maneuver in basketball players with CAI.A randomized, third-party, single-blinded (subjects and statistician), parallel, controlled trial was conducted following approval from the Committee for Research and Animal Experimentation Ethics of the University of Alcalá, Spain (CEIM/HU/2015/18). The study was prospectively registered in the Australian New Zealand Clinical Trials Registry (ACTRN12616000386437). The study was designed following Consolidated Standards of Reporting Trials (CONSORT) criteria. Ethical principles for clinical research in humans displayed in the Helsinki Declaration were considered. All subjects signed the informed consent and their rights were protected. The study population included basketball players aged 18 and over with CAI  meeting selection criteria for the diagnosis of patients with CAI  see Tab and presThe Spanish Version of the Cumberland Ankle Instability Tool (CAIT)  and the The sample size was obtained using GPower 3.0.18 software. Considering pre-activation as the primary outcome, an effect size (ES) of 0.25 was considered and the correlation between repeated measurements was assumed at 0.5. By setting four measurements in two treatment groups, sphericity correction determined a total sample size of 24, with a statistical power of 0.80 and an alpha level of 0.05. Considering a potential 20% dropout, 32 patients were recruited (16 per group)   = 6.877, p < 0.013; η2 = 0.18]  = 16.152, p < 0.001; η2 = 0.34 and F = 8.331, p < 0.007; η2 = 0.21 respectively]. In both cases, large ESs were displayed. Within-group differences for these variables can be found in Differences in ML and AP sway variability were obtained between baseline and the rest of follow-up measurements [Fp < 0.001). Additionally, statistically significant improvements in static postural control measures (seen as both decreased sway variability and CoP displacement) were achieved in those who received DN (p < 0.001), unlike in those who did not. These findings, which were maintained up to one month after the intervention, support changes both in feedback and in feed-forward strategies following DN of PL and TA latent MTrPs.After a single session of DN of latent MTrPs within the TA and PL muscles in basketball players with CAI, there was a significant increase in muscle pre-activation noted for PL and TA in favor of the DN group during a landing task (p < 0.001) only achieved by the experimental group after latent MTrPs removal, with large ESs (η2 = 0.53 and η2 = 0.29 respectively).Neuromuscular dysfunctions and postural control deficits observed in people with CAI have been correlated with the presence of MTrPs after suffering multiple ankle injury episodes ,37. In tSimilarly, Salom-Moreno et al.  obtainedThese findings might have important clinical implications given that research has found that in the absence of a direct preparatory stimulus, people with CAI displayed decreased muscle pre-activation and activation values of the entire lower extremity during the unidirectional landing phase when performing a side hop task . In agrep < 0.001). Whereas previous research has pointed out that lower TA/PL co-contraction indexes (CIs) in the frontal and sagittal planes are common in athletes with CAI [Dynamic joint stiffness (DJS) is defined as the joint constraint provided by the musculoskeletal system  in dynamic conditions . As withwith CAI , these rwith CAI  and Tretwith CAI  found grAlthough changes in feed-forward neuromuscular behavior in the CAI population remain controversial given the heterogeneity of selection criteria, the different tasks considered for EMG analysis, or the choices of EMG measures , this stp < 0.05). These two measures have been identified as some of the most representative metrics of postural control, where larger values are related to lesser stability [In this sense, DN also was effective in reducing ML and AP CoP displacement and sway variability of basketball players with CAI, who showed a significant improvement of feedback stabilization strategies in favor of the DN group  at increasing pre-activation of ankle stabilizer muscles (PL and TA), both in the short and medium- term. Static postural control also improved following DN, resulting in lower CoP displacement and sway variability in AP and ML directions during a SLBT. These initial results show the potential value of DN in terms of improving feedback and feed-forward strategies, which could be considered within a comprehensive rehabilitation program for people with CAI, inclusive of proprioception and strengthening exercises.


Plasmodium falciparum into liver cells. As a potential malaria vaccine candidate, the genetic diversity and natural selection of PfTRAP was assessed and the global PfTRAP polymorphism pattern was described.Thrombospondin-related adhesive protein (TRAP) is a transmembrane protein that plays a crucial role during the invasion of 153 blood spot samples from Bioko malaria patients were collected during 2016–2018 and the target TRAP gene was amplified. Together with the sequences from database, nucleotide diversity and natural selection analysis, and the structural prediction were preformed using bioinformatical tools.PfTRAP sequences were amplified successfully. On Bioko Island, PfTRAP shows its high degree of genetic diversity and heterogeneity, with π value for 0.01046 and Hd for 0.99. The value of dN–dS  hinted at natural selection of PfTRAP on Bioko Island. Globally, the African PfTRAPs showed more diverse than the Asian ones, and significant genetic differentiation was discovered by the fixation index between African and Asian countries . 667 Asian isolates clustered in 136 haplotypes and 739 African isolates clustered in 528 haplotypes by network analysis. The mutations I116T, L221I, Y128F, G228V and P299S were predicted as probably damaging by PolyPhen online service, while mutations L49V, R285G, R285S, P299S and K421N would lead to a significant increase of free energy difference (ΔΔG > 1) indicated a destabilization of protein structure.A total of 119 Bioko PfTRAP gene from Bioko Island and other malaria endemic countries is highly polymorphic , which provided the genetic information background for developing an PfTRAP-based universal effective vaccine. Moreover, some mutations have been shown to be detrimental to the protein structure or function and deserve further study and continuous monitoring.Evidences in the present investigation supported that The online version contains supplementary material available at 10.1186/s12936-021-03664-8. Plasmodium falciparum is the parasite that cause 99.7% malaria cases in African regions [Malaria is a major public health threat in many parts of the globe and is responsible for half a million deaths annually. According to the World Malaria Report 2019, an estimated 228 million persons suffered from malaria worldwide, with 435,000 malaria deaths in 2018 [The sub-Saharan African country, Equatorial Guinea has a total population of 1.31 million 2018). Bioko, an island of Equatorial Guinea off the coast of Cameroon, with historically high malaria transmission. The Bioko Island Malaria Elimination Project (BIMEP) is a fusion of two long-standing anti-malaria programmes  in Equatorial Guinea, with Medical Care Development Institution (MCDI) as the lead implementing partner 018. Biok. RecentlAnopheles mosquitoes take their blood meal and inject sporozoites into the host (human) skin. Sporozoites quickly pass into the liver, where they infect hepatocytes. Thrombospondin-related adhesive protein (TRAP) is the most extensively studied Plasmodium transmembrane protein and it would be released on the surface when the sporozoite into contact with the host cell [Plasmodium TRAP also assists the sporozoite in several pivotal functions, such as sporozoite gliding motility, hepatocyte invasion and establishment of infection in the vertebrate host [P. falciparum TRAP (PfTRAP) extracellular domain (ECD) consists of three domains/motifs that include the A-domain (similar to the A-or I-domain which is found in integrins), the TSP  and a proline-rich segment at the C-terminus [P. falciparum population of Gambian and Thailand. In their studies, McDonald–Kreitman test showed that the ratio of the number of nonsynonymous to synonymous SNPs within P. falciparum was significantly higher than that of the number of nonsynonymous to synonymous fixed sites between P. falciparum and Plasmodium reichenowi. Furthermore, the value of Tajima’D test and Fu and Li’s test also suggested that the TRAP gene is under diversifying selection in the P. falciparum population in Gambian and Thailand [P. falciparum in other geographic regions of sub-Saharan Africa.Malaria infection in humans starts when infected female ost cell . Plasmodate host –8. The Pterminus . The preterminus  revealedThailand . HoweverP. falciparum and to elucidate how TRAP gene is differentiated among P. falciparum populations. This research would be helpful not only for understanding the molecular evolution of the TRAP gene in P. falciparum but also for the improvement of peptide vaccines based on the TRAP antigen.The aims of the present study were to investigate whether the TRAP gene is under diversifying selection in Bioko www.mcdinternational.org) in Bioko Island.This study was carried out in Malabo Regional Hospital, in private diagnostic clinics (PDCs) in different regions of Bioko Island, and in the clinic of the Chinese medical aid team to the Republic of Equatorial Guinea. Bioko is an island 32 km off the west coast of Africa, and the northernmost part of Equatorial Guinea. The island has a population of 334,463 inhabitants  and a humid tropical environment. The launch of the BIMCP has had a marked impact on malaria transmission, with the decrease of parasite prevalence from over 45% in 2004 to 8.5% in 2016 and the reduction of entomological inoculation rate (EIR) from more than 1000 before 2004 to 14 in 2015 . Dried blood spots were collected on day zero of enrollment through finger prick bleeding spotted onto Whatman 903® filter paper  for future use. Laboratory screening for malaria was done using rapid diagnostic test (RDT) and confirmed using microscopic examination of blood smears. For quality control, archived malaria-positive microslides were re-examined, and parasite density was recorded; The Plasmodium species were identified by a real-time PCR followed by high-resolution melting (HRM) [Plasmodium species, P. falciparum, Plasmodium ovale, Plasmodium malariae and Plasmodium vivax were used as control. In this study, although only clear non-superimposed signals of the sequences were included from electropherograms for further analysis, these sequences could derive from either monoclonal infections or the most predominant clones in these isolates.A total of 153 blood spot samples were collected from the patients with uncomplicated malaria during January 2016–December 2018. Consents were obtained from all participating subjects or their parents and the ethical approval was obtained from the Ethics Committee of Malabo Regional Hospital. Included patients were aged between 4 months and 80 years, were residents on Bioko Island. Malaria patients were classified into uncomplicated malaria states according to World Health Organization (WHO) criteria, which were defined as positive smear for ng (HRM) . The pGEParasite genomic DNA was extracted from dried filter blood spots by Chelex-100 extraction method described in a previous article . The DNAThe full-length TRAP gene (NCBI Gene ID: 814170) was divided into two segments and amplified by nested PCR. The primers designed for nested PCR are presented in Table PfTRAP were analysed using EditSeq and SeqMan in the DNASTAR package . The PfTRAP sequence of the laboratory-adapted P. falciparum strain 3D7 (NC_004331.3) was included in the alignment for comparison as a reference sequence. The values of segregating sites (S), the number of haplotypes (H), haplotype diversity (Hd), and nucleotide diversity (π) were calculated using DnaSP version 5.10.00 [PfTRAP, the rates of synonymous (dS) and nonsynonymous (dN) substitutions were estimated and were compared using the Z-test (P < 0.05) in MEGA6 program [The nucleotide and deduced amino acid sequences of  5.10.00 . In orde program  using Ne program  with the program  were perPfTRAP among global P. falciparum isolates, a total of 1287 sequences from 13 malaria endemic regions  were acquired by mining the MalariaGEN Pf3k Project database (release 5) [PfTRAP haplotypes, the haplotype network for 1406 full-length sequences of PfTRAP from Bioko and other countries listed above was constructed by Network 10.1.0.0 program using Median-Joining method [In order to analyse the genetic diversities and natural selection of lease 5) , 17 usinlease 5)  and vcftlease 5) . Geneticg method .PfTRAP (3D7 isolate) was predicted and modeled by I-TASSER online server (https://zhanglab.ccmb.med.umich.edu/I-TASSER/) [The 3-dimensional structure of TASSER/)  and presTASSER/) . PolyPheTASSER/)  online sTASSER/)  in YASARTASSER/)  to prediPfTRAP amplicons for sequencing and deposited to NCBI Genbank (MK981410–MK981530). Finally, 119 monoclonal sequences were applied in the further analysis while 2 polyclonal sequences  were excluded.Of the 153 blood samples extracted from Bioko Island, 121 yielded suitable PfTRAP on Bioko Island, the minimum number of recombination event (Rm) and the probability of recombination between adjacent sites (Rb) was detected as 22 and 119, respectively, which shows relatively high level among the 14 countries or areas included in this analysis.As the result of genetic polymorphism and natural selection analysis shown in Table PfTRAP. 1287 global sequences mined from Pf3K database , among them there were 42 SNPs appeared only once. Due to the uncertainty, these single SNPs were not included in the following analysis  using NETWORK software. A total of 661 haplotypes were detected among 1406 isolates  and only several haplotypes  were shared between two continents isolates  was calculated and shown in Table p < 0.05), which indicated a greater genetic differentiation. Generally, the differentiation of PfTRAP among African countries is less pronounced, and the same phenomenon was found among Asian countries, but the high degree of genetic differentiation between African and Asian countries cannot be ignored (p < 0.05).For further exploration of the relationship of haplotypes, a haplotype network was constructed based on global tes Fig. , among tPfTRAP-based vaccine clinical trials, the following mutation effect prediction analysis was focus on the variations at T cell epitopes. In Table In this study, all the proven T cell epitopes, B cell epitopes, as well as nonsynonymous substitutions were marked and presented in Fig. PfTRAP was predicted and modeled by using I-TASSER server and displayed in YASARA application  structure of full-length 3D7 ion Fig. . Based oion Fig. .Fig. 4PrPfTRAP was the potential candidate for anti-malarial vaccine and there are several PfTRAP-based vaccines undergoing the clinical trials [PfTRAP gene data of Bioko Island, Equatorial Guinea was presented and submitted to public database, which had improved the global malarial database. Overall, with the polymorphism analysis, Bioko PfTRAP exhibited the high polymorphism, which is consistent with PfTRAP from other African countries but significantly distinct with the relatively low polymorphic Asian PfTRAP. These phenomena consistence with the previous report about P. falciparum circumsporozoite protein (PfCSP) gene [As l trials –27, the SP) gene , which aSP) gene –30. ThesPfTRAP, the results obtained by the two different analytical methods are not consistent. The result of dN–dS is 6.2231 (p < 0.05), which is significantly hinted at a natural selection, while the value of Tajima’s D is − 0.41438 (p > 0.05), which is not significant based on Tajima’s D significance levels. For these two results are different, it cannot be concluded with certainty that the PfTRAP on Bioko island has been affected by natural selection, but continued monitoring is still recommended.As for the natural selection analysis of Bioko Island Anopheles, the host of P. falciparum, caused by the geographical separation. But interestingly, though Bioko Island is an island separated from African mainland by the Atlantic Ocean, its PfTRAP gene shows low genetic differentiation with other African mainland countries. This result might be explained by the work of Guerra et al. [PfTRAP-based vaccine.In the sight of the haplotype distribution and relation network, haplotypes of Bioko and other African countries distributed scattered while Asian ones are tended to cluster. This phenomenon is in line with the polymorphism result, which shows more mutations appear in African area and thereby lead to the abundant haplotypes. Moreover, the vast majority of these haplotypes are presented as singletons and the high prevalence of singleton is probably associated with the intensity of transmission or rapid expansion of population. Even so, the genetic differentiation between African countries shows limited and so do Asian countries, but an obvious genetic differentiation is found between countries which come from different continents. It might be explained with the population segregation of a et al. , 32, whia et al. , 32. In PfTRAP from clinical malaria cases [Antigen polymorphism has been a major obstacle in the way of developing effective vaccines. Recent studies have highlighted the importance of protective roles of CD8+ T-cell and memory T-cell responses to ia cases , 34. Mutia cases –8, thus Nowadays, several malaria vaccines encoding the pre-erythrocytic antigen ME-TRAP, which often coupled with different adjuvants such as Chimpanzee adenovirus (ChAd63) or modified vaccinia Ankara (MVA), had been developed and issued by researchers have entered the clinical trial stage , 27. StiPfTRAP and African PfTRAP shows no significant difference. The PfTRAPs from the same continent shows more homogeneity while the ones from different continents shows more heterogeneity. Taken together, results of the present investigation showed that global PfTRAP gene is highly polymorphic  and some mutations shows destructive to the protein structure or function, which may lead to a change in the affinity of these epitopes to immune molecules. Moreover, evidences in this analysis supported that the global PfTRAP gene is under natural selection. Although TRAP related vaccine clinical trials have not been deployed on Bioko Island, in this paper, polymorphisms and natural selection of PfTRAP are analysed to provide relevant genetic background information for future deployment of clinical trials.The overall trend of Bioko Additional file 1. Global PfTRAP SNP detail information.Additional file 2. Geographical distribution of haplotypes.Additional file 3. Haplotype information.Additional file 4. 1287 global PfTRAP sequences from Pf3K Database.Additional file 5. Original file for haplotype network.Additional file 6. Detail information of CD8+ T cell epitopes of PfTRAP.


Functional neurologic disorders (FNDs), also called conversion disorder , can show almost all the symptoms of other neurological diseases, including both physical  and psychological  symptoms. In spite of our general knowledge about emotional processes and developmental defects in the formation of these somatic symptoms, there is still no systemic and comprehensive research on the effects of emotional developmental variables in FND. Recently, both experimental and theoretical emotion studies have been greatly increased, such as prediction error, conceptual act model, basic emotional theory, and monoamine neuromodulator based three primary emotions. In addition, a large amount of evidence has confirmed the role of psychosocial adversity  as an important risk factor for FND. Here, we review recent advances about emotional stress on FND, and pay special attention to the effects of monoamine neuromodulators, such as how norepinephrine and serotonin affect behaviors. Then, we discuss the significance of these changes for FND, which may contribute to clarifying the pathogenesis of FND, and thus provide potential therapeutic drug targets or psychological intervention methods in the future. Functional neurologic disorders (FNDs) are common sources of disability and the second most common referral to neurological outpatients . FND covAlthough reference to the psychological origin of FND has been removed from the criteria list in DSM-5, many theories still regard FND as physical disturbances that generally occur along with malicious thoughts, emotions, or health-related concerns . Or FND Functional neurologic disorder is defined by neurological symptoms that encompasse functional movement disorders, functional weakness, functional numbness, psychogenic non-epileptic seizures etc. FND accounts for approximately 6% of neurological outpatients and the presumptive community morbidity at a rate of 4–12 per 100,000 per year. About 10% of cases are combined with neurological diseases. This disease is more common in women, especially those between the ages of 35 and 50 , which mThe importance of psychosocial adversity in FND cannot be underestimated given that rates of early life and proximal adverse events have been repeatedly found to be higher in FND samples, and stressful life-events including abuse/neglect, ongoing relationship disturbances, occupational stress, and caring responsibilities are commonly reported . FND is Several etiological models have been proposed in the last century. Bio-psycho-social medical model frameworks acknowledge a variety of predisposing , precipitating , and perpetuating (illness belief/expectation) factors that can contribute to FND . HoweverFunctional neurologic disorder symptoms are varied and include abnormal control of movement, episodes of altered awareness resembling epileptic seizures and abnormal sensation and are often comorbid with chronic pain, fatigue, and cognitive symptoms. Many studies suggest that FND is emotional expressions of distress . In theiEven though the social-psycho-biomedical perspective highlights psychological abnormalities and emotional problems, the psychosocial etiology for FND is still unclear. A recently developed Bayesian predictive coding framework offers an explanation for FND . EdwardsThe predictor error theory suggested that the brain perceives the sensor input with past sensorial experiences, which is also called “predictive coding,” and then categorizes the sensations to evoke a specific action plan; the error between the prediction and the actual input is propagated and used as a feedback to update the internal model . ContempConsistently, Similar to the prediction error, the constructionist model, which is also called the “conceptual act model,” suggests that we all predict about the new sensation with knowledge of prior experiences . For exa“Conceptual act” is a kind of unconscious process that automatically and effortlessly using previous knowledge to predict current sensations. However, if the immediate sensation is different from the prediction, or if there is the prediction error, some forms of interception sense from the body, such as somatic, visceral, can be evoked. These interceptive senses are also called “core affects,” which means the bodily changes  . “Core aSimilar to the predictive coding model, the appraisal theory also proposes that emotions are innate states which are activated by stimulation events. In many appraisal models, the assumption is that the brain contains a series of specific cognitive appraisal mechanisms. Indeed, many studies have established the role of the monoamine neuromodulators in valence and arousal. Mesolimbic DA system in processing reward and pleasure , and 5-Hjoy, sadness, fear, and anger; which are biologically basic and inherited , serotonin (5-HT) , or noreEmotion is as complicated as the colors. If not for the physiological study that there are three kinds of color cells in the retina, we will never believe that there are three kinds of primary colors. It might be also true for the emotions, the three monoamine neuromodulators are the substrates for basic emotions . DA givejoy, sadness, stress (fear and anger).In all, there are considerable evidences suggesting that monoamine  are the neural basis for emotions . TherefoThe three monoamines norepinephrine (NE), dopamine (DA), and serotonin (5-HT) might be the neural basis for the three basic emotions, and represent the three poles on the emotion dimensions , 3. WhilThe major function of DA has been suggested to be reward, or reinforce natural rewarding behavior; or DA is implicated in goal-directed behaviors . DA is tThe synthesis of NE is mainly carried out in the adrenal medullary chromaffin cells (AMCCs). Tyrosine in the blood is taken up by the cytoplasm of adrenergic nerve endings, and converted into DA under the catalysis of tyrosine hydroxylase and decarboxylase, and then catalyzed by dopamine β-hydroxylase to synthesize NE, which is stored in the capsule bubble. When the nerve impulse reaches the nerve terminal, the vesicle approaches the presynaptic membrane and releases NE into the synaptic cleft in the form of cleavage and efflux, which stimulates the corresponding receptors on the post-synaptic membrane to produce a series of physiological effects . The resThe LC-NE system can activate amygdala, which responds by sending signals to the hypothalamus, which in turn stimulates the PNS NE activity. “Core” FND symptoms include weakness, seizures or paralysis, other movement disorders , and sensory disorders  , as wellThe neuromodulator serotonin (5-HT) has been implicated in a large number of affective and executive functions, such as depression or sleep. Recently, more and more work highlighted its role in aversive processing , anotherNeurons containing 5-HT in the midbrain directly innervate the corticotropin releasing hormone (CRH) cells located in the paraventricular nucleus of the hypothalamus. The serotonergic input into the paraventricular nucleus mediates the release of CRH, leading to the release of adrenal cortex hormones, thereby triggering the secretion of adrenal cortex glucocorticoids. 5-HT1A and 5-HT2A receptors are the main receptors that mediate serotonergic stimulation of the hypothalamic-pituitary-adrenal (HPA) axis . This coEmotion is a kind of internal drive, which can be expressed as external behaviors. Emotion induced external behaviors are genetically hardwired and are crucial for animal’s survival. Several major categories of behaviors are developed, such as feeding, reproduction, aggression and sleep, which are observed across animal species. These instinct behaviors are robust, fluent and adaptive to an animal’s internal and external context . Most ofStress is closely associated with most mental disorders, either through early life trauma as a presumed “vulnerability factor” or through late life events prior to symptom onset as a “precipitating factor” . Many scThe relationship between arousal or stress and functional symptoms has been examined to investigate physiological measures of arousal. It is showed that patients with mixed active FND symptoms compared with those with anxiety disorders or healthy volunteers had greater baseline arousal levels, as measured by spontaneous fluctuation in skin resistance along with failure to habituate skin conductance to repeated auditory stimuli . FND patThe fight-flight-freeze response is a natural reaction to danger, and it is a type of response that helps the individual reacts to perceived threats, like an oncoming car or growling dog. Specifically, fight-or-flight is an active defense response for the individual to fight or flee. The heart rate gets faster, which increases oxygen flow to major muscles, and the pain perception drops, and hearing sharpens. These changes help the individual to act appropriately and rapidly. Freezing is fight-or-flight on hold, where the individual further prepares to protect himself. It’s also called reactive immobility or attentive immobility, which involves similar physiological changes, but instead, the individual stays completely still and get ready for the next move. The fight-flight-freeze response is a natural reaction to threat, and it is a kind of behavior that helps the individual to react to perceived threats. The term “fight or flight”  are developed to react to the changes that occur in response to perceived threat for our ancient ancestors. It is first described by an American physiologist Walter Bradford Cannon . The theIn addition to “fight or flight,” freezing is a kind of reactive immobility or attentive immobility, which involves similar increase in heat rate and blood flow, but body stays completely still. This is an automatic reaction, which might work through amygdala, and the amygdala responds by sending signals to hypothalamus, and the hypothalamus works by stimulating sympathetic nervous system . When thSevere fear can cause freeze behavior that happens normally in both healthy people and FND patients. Indeed, behavioral inhibition is a personality type, like shyness, that shows a tendency toward nervousness in new environment. Similarly, FND patients usually show body trembling, shaking, tremors and vibrating and also anxiety disorders, including generalized anxiety, social anxiety, panic disorders etc. Many healthy people experienced body tremors when they are stressed. Tremors activated by the stresses cause body-wide adrenaline changes to boost the energy in the body, and prepare the body for fight or flight, for which freeze is prepared. Tremor induced by tightening the muscle to be more resilient to damage, stimulating the nervous system to run faster, or to prepare for fight or flight. All the changes that cause the body to tremble is an “emergency boost of resources” to deal with the threat (fight-flight-freeze). When stresses are too frequent, the body becomes hyper-stimulated, and tremor can occur without reason or involuntarily. Trembling, and shaking symptoms are the most common types of symptom in FND patients. Tremors can develop into spasms, jerking movements, even looking like Parkinson’s disease, or seizures . Sometimes, the response is overactive, which is common in people who have experienced traumatic stress before. In this case, the brain reacts to related events with overactive response.Many studies have focused on the role of behavioral inhibition in sadness and depression . Our undCaenorhabditis elegance (C. elegance stops moving forward (Serotonin (5-HT) in the CNS is thought to be the substrate of behavioral inhibition. Indeed, 5-HT has been shown to induce inhibition of locomotion, stimulation of egg laying, and pharyngeal pumping in elegance . Similar forward ; another forward . The for forward . ConsistAcute stress can induce fight-or-flight, while long-term chronic stress might induce tiredness and weakness, which might be due to decreased activity of NE and increased release of 5-HT. Mechanisms of weakness in FND patient might also be similar to those involved in hypnotic suggestion. Hypnosis is an alteration in consciousness with heightened suggestibility and decreased awareness, and it is well known that the major function of NE is waking , while tChronic pain can happen in FND patients, especially women, and it is characterized by widespread pain, accompanied with sleep problems, profound fatigue, and fatigue syndrome. Sometimes they also accompany with other symptoms, such as morning stiffness, headaches, and tingling and numbness in limbs, even irritable belly. These symptoms will not recover with rest, instead they are due to emotional trauma.Functional neurologic disorder Symptoms occur as a result of problems in the brain, which fails to send and/or receive messages correctly, and result in a variety of sensory and movement disturbances. In a lot of cases symptoms can be extremely disabling, but the brain problems are only functional for emotions. The neural basis that works for emotions has been intensively studied in recent years. And most of the studies suggest that specific basic emotion can be located in one specific brain nucleus . Indeed,In addition to the monoamine neuromodulators, other hormones and neurotransmitters may also be involved in a secondary way. For example, corticotropin-releasing hormone, which was named the stress hormone, might be a pathway for central norepinephrine (NE). The response to stress is mediated by two main pathways: the autonomic sympathetic response with rapid adrenaline/norepinephrine secretion and the slower response of the HPA axis with cortisol secretion. The relationship between stress, HPA axis and clinical pathology is highly complicated. In an experiment of 18 FND seizure patients and 19 healthy controls, the basic diurnal cortisol levels of seizure patients increased significantly . AlthougExcessive secretion of cortisol in response to stress can cause hippocampal damage and disrupt negative feedback, leading to uncontrolled secretion and further damage. Hypercortisolemia and changes in synaptic plasticity, decreased neurogenesis, neuronal atrophy, trigger hippocampal changes, which can lead to nerve cell death . The HPAFunctional neurologic disorders are neurologic malfunctions which are induced by psychological distress, and are expressed in the form of physical symptoms. These symptoms, however, have no underlying physical cause and are often associated with an emotional or psychological crisis. In the original formulation of hysterical conversion by psychodynamic theories, emotions play a crucial role in the etiology of FND. It is suggested that FND is the body expressing the unprocessed stress in an extreme way. However, recent studies suggested a multi-model for its etiology, for example, there is increasing evidence that patients with FND exhibit activation of the monoamine neuromodulators. We believe that stress changes can directly cause FND symptoms through the monoamine neurotransmitters . For chrFunctional neurologic disorder is a neglected but possibly reversible source of disability. Monoamine neuromodulation products and HPA axis hyperactivity are possible pathological changes of FND. The limitations of this article include the moderate amount of literature. There is controversy about how to conceptualize FND, including whether the disease is classified as stress-related, and whether emotional stress directly affects monoamine neuromodulation and causes FND. First, multiple core symptoms and related symptoms mean that a single core FND symptom should not be assumed to be the most significant aspect of the disease. Therefore, other simultaneous neuromodulation changes are also important to explore the mechanism of FND symptoms. FND is a neuropsychiatric disease with highly variable semiotic manifestations, multiple comorbidities and related social and psychological factors. A single simple mechanism index may not be the best choice. Is the HPA axis hyperfunction and monoamine neuromodulation turbulence summarized as the possible pathogenesis of FND obsolete, or is there new hope? In any case, it is time for psychiatry to stop consciously or unconsciously suppressing this important underlying disease.QX and FW wrote the first draft. MJ, FL, RF, SJ, BY, and TW made major revisions of this article. SX, FW, and JH provided the critical revisions. All authors approved the final version of the manuscript for submission.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.