To achieve the objective of this study, we conducted a narrative review on physical therapeutic modalities applied to prevent functional losses associated with human T-lymphotropic virus 1 (HTLV-1) infections to promote health education and viable and accessible alternatives in the development of health education technology adapted to the home environment. This study comprised a qualitative stage of theoretical development to construct a digital booklet with an observational basis based on studies that reiterate themes about educational technologies as tools to conduct a home protocol of guided exercises without the direct supervision of professional physical therapists. Results indicate a lack of research on the development of health education technologies to assist patients with HTLV-1 without tropical spastic paraparesis or HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP). We believe that this narrative review can initiate a theoretical framework to conduct a home exercise program aimed at people with HTLV-1 who have subtle symptoms, and also at people without the clinical definition of HAM/TSP, helping to train human resources for care and research on the subject and increase scientific production in physical therapy. The human T-lymphotropic virus 1 (HTLV-1) is a retrovirus in the Retroviridae family that affects human blood T lymphocytes and can cause neurological disorders. This infection is characterized by silent, long-term persistence in the host. Despite its irregular distribution, estimates suggest that at least 20 million people are infected with HTLV-1 worldwide ,4,5, wheThe development of serious diseases has been pointed out in association with the virus, such as adult T-cell leukemia/lymphoma (ATL) and tropical spastic paraparesis or HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP). The latter is characterized by the installation of classic motor disabilities in patients and the slow, progressive, and non-remitting inflammation of the spinal cord, which affects 4 to 5% of infected subjects, causing more proximal motor weakness, spasticity of the lower limbs (LLLL), pain and bladder, intestinal and sexual dysfunctions, and, consequently, functional limitations such as impaired walking, ascending and descending stairs, washing, dressing, and urinary continence .Faced with these significant motor disabilities, physical therapy has been prescribed for neurological complications associated with HTLV-1 because it improves functional status, reduces symptoms, and positively impacts patients’ quality of life ,9,10. CoSuch protocols are envisaged as auxiliary strategies for patients with difficulties attending rehabilitation centers as they propose to enable their performance with the use of low-cost materials, promote autonomy and confidence, resume social roles, and seek to provide general data of health conditions associated with HTLV-1 in this population since the levels of evidence and the strength of recommendation for these protocols are yet to be well-established.Observing the presence of neurological signs and symptoms in HTLV-1 carriers living in the municipality of Belém (PA)  in unfavTherefore, it is important to conduct a narrative review on how and which physical therapy modalities are applied to prevent functional losses associated with HTLV-1 that can contribute to a safe and supported home clinical practice and highlight new paths in the production of health education technologies.This is a qualitative narrative literature review with an observational basis. This research was submitted to the Ethics Committee for Research Involving Human Beings (CEP) of the Oncology Research Center of the Federal University of Pará, following the Declaration of Helsinki and the norms of Resolution 466/12 of the National Health Council regarding research on human beings (CAAE: 36688020.1.0000.5634).To conduct this review, the guiding question was first identified, descriptors were selected, and inclusion and exclusion criteria were constituted. Then, the following steps were taken: the sample was selected by searching databases, the information extracted from the selected works was summarized, studies were evaluated, results were interpreted and discussed, and, finally, the review was described and the produced knowledge was synthesized .The guiding question of this study was “What physical therapy approaches can help people affected by HTLV-1 with problems of rehabilitative interest and how?” The construction of the question involved the acronym PICO , i.e.,: The following databases were used: Scientific Electronic Library Online (SciELO); Latin American and Caribbean Literature in Health Sciences (Lilacs); US National Library of Medicine (PubMed); and Google Scholar. Data were collected in institutional repositories of theses and dissertation. The inclusion criteria were: (a) articles with full text; (b) drafts in Portuguese or English; (c) exercise protocols aimed at HTLV-1 carriers. No restrictions were set on the sample to maximize search results. The following were excluded: (a) monographs; (b) annals of events; and (c) duplicates. Data were extracted by a standardized form containing information on the method, sample, intervention, markers, and outcomes of the chosen studies.The following controlled descriptors (indexed to the MeSH terms) were used: human T-lymphotropic virus 1; problems and exercises; physical therapy modalities; Boolean operator “E”. These descriptors in English were also used: “Problems and Exercises”; “HTLV-1”; “HTLV I Associated Myelopathy”; “Physiotherapy Modalities”. A combination of descriptors with the Boolean operator “AND” was used for each of the selected databases due to their specific characteristics, with the guiding question and established inclusion criteria as the guiding principle of this search, without the use of filters.The search was carried out using online access and considering the period from 2006 to 2022. To select the studies, the recommendations of PRISMA  were folOf the sixteen chosen studies, thirteen are scientific articles, two are doctoral theses, and one is a master’s dissertation. The types of studies in this review include six analytical interventions, two literature reviews, a case report, a short communication, two theses, and a dissertation with an observational descriptive study.Following the chronological order of the selected study , we obseIn urinary incontinence associated with the virus, results also point to reduced symptoms after the implementation of behavioral therapy, kinesiotherapy, and electrical stimulation, increasing perineal strength and improving urodynamic parameters  .Regarding the evaluation, the use of ICF codes showed a greater functional independence and quality of life in patients after therapy, emphasizing the effectiveness of physical therapy in controlling spasticity and the value of ICF as a tool to analyze spasticity in patients with HAM/TSP  .PNF increased lower limb ROM, reduced hypertonia/spasticity, and restricted ambulation  . RegardiIn comparative studies between PNF and outpatient physical therapy, results point to a decrease in low back pain and an increase in functional independence in both treatments  .The findings of the literature reviews address the importance of implementing specific exercise programs that seek to improve flexibility, range of motion, muscle strengthening, and postural control, as well as the discussion about perspectives to develop knowledge in the area  ,27.Figueiredo et al. (2013)  evaluateBy assessing balance in people with HAM/TSP, Patrício et al. (2020)  point ouMota (2017) , who evaFacchinetti (2013)  evaluateFor Vasconcelos et al. (2019) , the subFinally, for Costa et al. (2022) , balanceAlthough Brazil has a prominent place in scientific production in physical therapy for people with HTLV-1, this production is still in its infancy, mainly testing therapeutic procedures.A scientometric study on the subject only found 68 studies involving physical therapists, 21 of which were interventional . The mosTherapeutic exercise protocols must be improved, especially regarding dosage and progression. On the one hand, individualized exercises, as in PNF, positively reduce spasticity and improve movement control and functionality levels, but they are isolated cases, as in Costa et al. (2018)’s work , which rIn view of this, the three modalities of therapeutic exercises should be tested in randomized clinical trials with a larger sample size and more detailed protocols, considering a reasonable follow-up time to enable the measurement of a larger effect size, produce better levels of recommendation, and provide greater security in its reproducibility.Home care has become one of the main pillars of providing services at different levels of health as it meets the needs of patients with chronic health conditions, improves quality of life by controlling signs and symptoms, and decreases the risk of complications. Thus, the effectiveness of the practice of home exercises after an injury demands that patients, family members, and caregivers understand the importance of therapy, thus reaching an adequate process with greater possibilities of good results .Studies have been using the home approach for physical exercise, considering feasibility and long-term maintenance ,39,40,41Home exercises remove the need for accessibility to training facilities , is costThus, gathering evidence with a broad review should precede actions that help prevent functional declines associated with HTLV-1, such as the implementation of public health programs aimed at HTLV-1 carriers without defined HAM/TSP.More studies on physical therapy modalities aimed at people affected by HTLV-1 must be developed and tested in randomized clinical trials with a larger sample size and more detailed protocols. We believe that this narrative review can contribute to a safe and evidence-based home clinical practice and point out new paths in the production of health education technologies that are sensitive to the reality of this population.


Rhinella group, which includes species that present an osseous palmar sesamoid and climb bushes or trees to avoid depredation or escape dangerous situations, and can exhibit scansorial and arboreal behaviors. We also add data on the bony sesamoids of 170 anuran species to study the anatomy and evolution of the osseous palmar sesamoid within this amphibian group. Our objective is to bring an overview of the osseous palmar sesamoid in anurans, unveiling the relationship between this element of the manus, its phylogeny, and the anuran habitat use.Sesamoids are generally regarded as structures that are not part of the tetrapod body plan. The presence of a palmar sesamoid is assumed to serve as a distribution point for the forces of the flexor digitorum communis muscle to the flexor tendons of the digits, which are embedded in the flexor plate. It has been considered that the palmar sesamoid is present in most anuran groups, and it has been suggested that it acts by inhibiting the closing of the palm, preventing grasping. Typical arboreal anuran groups lack a palmar sesamoid and flexor plate, a pattern shared with other tetrapod groups, which can retain a reduced sesamoid and flexor plate. We focus on the anatomical structure of the Rhinella were cleared and double-dyed to describe the sesamoid anatomy and related tissues. We review and describe the palmar sesamoid of 170 anuran species from CT images downloaded from Morphosource.org, representing almost all Anuran families. We performed an standard ancestral state reconstruction by optimizing two selected characters  along with the habitat use of the sampled taxa, using parsimony with Mesquite 3.7.Skeletal whole-mount specimens of Leptobranchium, all strongly terrestrial and burrowing species, though with exceptions. The osseous palmar sesamoid is always present in Bufonidae, but varies in form and size, depending on the mode that they use their manus, such as in the Rhinella margaritifera which has a cylindrical one and also grasping abilities that involve closing the manus. The scattered presence of the bony palmar sesamoid among anuran clades raises the question whether this sesamoid can be present with a different tissular composition in other groups.Our primary finding is that sesamoid optimization in the anuran phylogeny revealed that its presence is associated with certain clades and not as widespread as previously anticipated. Additionally, we will also be delving into other important outcomes of our study that are relevant to those working in the field of anuran sesamoids. The osseous palmar sesamoid is present in the clade Bufonidae-Dendrobatidae-Leptodactylidae-Brachicephalidae that we named as PS clade, and also in the archeobatrachian pelobatoid  Sesamoids have been considered structures that do not belong to the tetrapod body plan . They are.g., the patella in mammals , though these arboreal species can retain a reduced sesamoid and flexor plate  sesamoids of Lissamphibia , Sauropsor plate . It has or plate . As far or plate .In spite of this intriguing relationship between the palmar sesamoid presence or absence with arboreality, there are no studies that deepen this issue within the anuran’s groups.Rhinella group, which includes species that climb bushes or trees to avoid depredation or escape dangerous situations, and can exhibit scansorial and arboreal behaviors, such as the veraguensis, festae, and margaritifera groups  and L. Ponssa’s personal collection  were not cleared and used for anatomical descriptions of muscles and tendons. Specifically, we considered the variation of the sesamoid shape and its relationship to the distal carpal, the flexor plate, and the related muscles , and the other on the postaxial edge of the distal carpal. These processes are not always evident, such as in talensis . More deritifera , Truebelrrestris , showingineensis , or as itelzneri . In Rhin process  and 3C. indrical . It fitsRhinella margaritifera and Frostrius, exhibit a modified shape of the palmar sesamoid. This clade presents some reversions to the ancestral state without palmar sesamoid within the mostly arboreal Hyloydea clade in the dendrobatid Minyobates minutus, in the odontophrynids Proceratophrys bioei and Macrogeniaglottus alipioi; in the hylodid Crossodactylus gaudichaudii and C. trachystomus. Other taxa exhibiting reversions are the cycloramphids Zachaenus parvulus and Cycloramphus asper; the miobatrachid Crinia signifera, and Hadromophryne, a Heleophrynidae, the sister clade of Hyloidea+Ranoidea. Among ranoids, the palmar sesamoid is exhibited in the hemisotid Hemisus guineensis; the microhylids Chiasmocleis crucis, Gastrophryne carolinensis, Syncope antenori, and Melanobatrachus indicus; the pyxicephalids Cacosternum boettgeri and C. namaquense. The only taxon with a palmar sesamoid among Archeobatrachia belongs to the Pelobatoidea clade, Leptobrachium hasseltii.The optimization of the bony palmar sesamoid in the anuran phylogeny  shows thLymnodinastes dorsalis can be seen in The shape of the distal carpal ventral surface shows no clear relationship with the presence/absence of the osseous palmar sesamoid. The presence of the parallel crests on the distal carpal, as edges of a concave surface, is independent of the palmar sesamoid presence , maybe related to the anuran habitat use. Interestingly, the terrestrial habitat use optimizes as ancestral to the anuran group, which allows us to suppose that the osseous palmar sesamoid absence may indicate a palmar sesamoid of another tissue composition. Bufonidae-Dendrobatidae-Leptodactylidae-Brachicephalidae (PS clade), clearly united by a common ancestor, present a bony palmar sesamoid and share a terrestrial habitat use, inhabiting the forest floor litter and lowland rainforests. of frogs , and it of frogs . The re-Rhinella margaritifera and R. paraguas, which possess an osseous palmar sesamoid and exhibit scansorial behavior, enabling them to ascend shrubs and small trees (Rhinella margaritifera’ s palmar sesamoid has a convex surface that articulates with the deep concave depression of the carpal distal 3+4+5, like a hinge joint. This kind of articulation enables the movement of closing the manus around a thin object, such as a small branch, and the sesamoid, in this case, has a cylindrical shape. Curiously, the Bufonidae osseous palmar sesamoid, which can be big or small, has a particular drop shape, and lays superficial to the distal carpals, being usually flat or with a slight depression limited by two crests (R. margaritifera. Thus, this association between the palmar sesamoid shape and the carpal surface can be proposed as an exaptation that led to a grasping manus.Among bufonids, almost all species examined have osseous palmar sesamoid and primary terrestrial habitat use, which would be the ancestral state according to ll trees . Our dato crests  and 3. OLeptobranchium. These species are all strongly terrestrial and burrowing, though there are exceptions. Bufonidae always has a bony palmar sesamoid, but its form and size vary depending on how the species uses its manus, such as in Rhinella margaritifera, which has a cylindrical one and the ability to grasp through closure of its manus. The scattered presence of the bony palmar sesamoid among different anuran clades raises the question of whether this sesamoid can exist with different tissue compositions in other groups.The optimization of sesamoids in the anuran phylogeny revealed that an osseous palmar sesamoid is strongly associated with specific clades, contrary to what was previously thought. The presence of a bony palmar sesamoid can be observed in the clade made up of Bufonidae, Dendrobatidae, Leptodactylidae, and Brachicephalidae, which we have named the PS clade, as well as in the archeobatrachian pelobatoid 10.7717/peerj.15063/supp-1File S1Click here for additional data file.10.7717/peerj.15063/supp-2Supplemental Information 2Rhinella genus.Comparative table of the palmar sesamoid and associated anatomical systems in 4 species of Click here for additional data file.10.7717/peerj.15063/supp-3Supplemental Information 3Character matrix used in Mesquite 2.7  through Click here for additional data file.10.7717/peerj.15063/supp-4Supplemental Information 4We selected those species that have a bony palmar sesamoid and described it and the distal carpal anatomical context. Some details were included to extend the usefulness of our data to anatomists working in other topics.Click here for additional data file.10.7717/peerj.15063/supp-5Supplemental Information 5The muscles, flexor plate and the sesamoid were removed to show the distal carpal 3+4+5 form. DC distal carpal 3+4+5; DCc distal carpal 3+4+5 parallel crests; DC hole distal carpal 3+4+5 hole; DC2 distal carpal 2; U ulnar; R radial; U-R radio-ulna; Pp prepollex; Y Y element. Digits are enunciated in roman notation as II, III, IV, and V.Click here for additional data file.


This review summarises the current literature regarding infertility in women with chronic kidney disease (CKD), describing the epidemiology, pathophysiology, investigations, and management options. The pathophysiology is multifactorial, with proposed mechanisms including disruption of the hypothalamus−pituitary−ovarian axis, chronic inflammation, oxidative stress, psychological factors, and gonadotoxic effects of medications such as cyclophosphamide. Diagnostic investigations in CKD patients seeking to conceive should be considered earlier than in the healthy population. Investigations should include hormonal profiling, including markers such as Anti-Mullerian Hormone and imaging such as ultrasound, to evaluate ovarian reserve and identify gynaecology pathology. Treatment options for infertility in CKD patients include GnRH agonists to preserve ovarian function during cyclophosphamide treatment, as well as assisted reproductive technologies including in vitro fertilisation and ovulation induction. However, these treatments must be tailored to the individual’s health status, comorbidities, fertility requirements, and CKD stage. In conclusion, fertility is an important consideration for women with CKD, necessitating early investigation and tailored management. Early discussions regarding fertility are important in order to understand patients’ family planning and allow for prompt referral to fertility services. While challenges exist, ongoing research aims to clarify the underlying mechanism and optimise treatment strategies, which are crucial for improving quality of life and overall health outcomes. Chronic kidney disease (CKD) is defined by the ‘Kidney Disease: Improving Global Outcomes (KDIGO) CKD 2012 Guideline’ as either a reduction in kidney function below defined thresholds of the estimated glomerular filtration rate  for more than three months or people with structural kidney damage, and is associated with increased morbidity and mortality . ConcurrAccording to the most recent cross-sectional survey conducted by the National Health and Nutrition Examination survey (NHANES) in the USA, approximately 15% of patients with CKD are less than 50 years old, whereas a systematic review by Hall et al. estimated this proportion could be as high as 25.7% worldwide ,7.Infertility is the disease of the male or female reproductive system defined by the failure to achieve pregnancy after 12 months or more of regular unprotected sexual intercourse . PregnanThe pathophysiology of how CKD impacts fertility is poorly understood, but there are several proposed mechanisms, and it is likely that more than one may be contributory.The kidneys play an important role regulating the hypothalamus−pituitary−ovarian (HPO) axis. It is hypothesized that in women with CKD there is loss of the pulsatile release of Gonadotrophin releasing hormone (GnRH), which impairs follicle-stimulating hormone (FSH) and luteinizing hormone (LH) production and leads to low oestrogen and loss of ovulation. The loss of LH surge results in a lack of ovulation and subsequently oligomenorrhoea . As eGFRThe impact of CKD on the HPO axis is based on a small study published over forty years ago on samples derived from 17 premenopausal women on haemodialysis with 15 normal controls . Three tPrevious research has focused on the impact on fertility in the late stages of CKD. It is proposed that the effect of CKD on menstruation and fertility is proportional to the degree of renal dysfunction; however, the relationship between less severe kidney disease and fertility has not been established ,12.Patients with CKD have been shown to have high levels of inflammatory and oxidative stress markers . StudiesFemales with primary ovarian failure have also been demonstrated to have an increased expression of interferon-γ and tumour necrosis factor alpha (TNF-α). These cytokines can induce major histocompatibility complex (MHC) class II antigens, which have been shown to be present in higher levels in ovarian tissue from these patients compared with the healthy controls . It is tMoreover, patients with endometriosis, who are well known to have lower levels of fertility, have been shown to have higher concentrations of macrophages, as well as expressions of IL-1, IL-6, and TNF-α in their peritoneal fluid . Pro-infIt has been hypothesized that low-grade chronic inflammation associated with CKD could negatively impact fertility in women with kidney disease. However, the association between inflammation and infertility in women with CKD has not been well investigated and work is ongoing, using proteomics, to examine the role of these inflammatory markers further.n = 10). In addition, those receiving high-dose IV cyclophosphamide (≥6 g) did show a significant decline in Anti-Mullerian Hormone (AMH) titres [Cyclophosphamide is a medication commonly used to treat rapidly progressive glomerulonephritis and systemic lupus erythematosus, which are more prevalent in reproductive-aged patients. However, its gonadotoxcity effects are well established ,19. In f) titres , while wFor reproductive-aged females who wish to conserve their fertility there are therapeutic options available, including oocyte cryopreservation via ovarian stimulation or cryopreservation of ovarian tissue. These will be covered later in this review. However, patients are often too unwell to undergo these treatments or do not have enough time prior to starting cyclophosphamide, as this often requires urgent commencement. Moreover, fertility-sparing treatments are frequently needed urgently, and are not well understood by nephrologists and thus are not discussed until later in the patient’s journey .Reduced libido, difficulty with arousal, dyspareunia, and anorgasmia are thought to be common in pre-dialysis female patients with CKD, with low levels of oestrogen leading to reduced vaginal lubrication, resulting in pain during sexual intercourse ,24. A stThe extent to which low fertility rates in women with CKD is related to reproductive choice versus impaired fertility remains unclear. A survey of Dutch nephrologists reported that 88% advised their female patients not to become pregnant . A systen = 76) in a recent systematic review [It has been suggested that patients with CKD should be investigated for infertility earlier than that of the healthy population. Wiles et al. suggested that a female of reproductive age with CKD should be referred to a specialist fertility centre after six months of trying to conceive rather than one year, as advised in the healthy cohort . As withc review . Tubal fc review ,35,36.It is important to ask the patient about current and previous medications, including doses, as there is often a dose-dependent relationship between gonadotoxic medications and fertility . ConsidePatients with genetic conditions that cause kidney failure, such as autosomal dominant polycystic kidney disease (ADPKD), may wish to have pre-implantation genetic testing (PGT) to ensure their offspring are unaffected. In these cases, they should be informed of the fertility treatments available to them early in the disease process and referred to specialist centres when they show an interest in conceiving.A hormonal profile can be important to ascertain the cause of infertility. For example, a raised FSH (over 30 IU/L) together with raised LH and low serum oestradiol levels indicates hypergonadotropic, hypoestrogenic anovulation caused by ovarian failure. If the patient is less than 45 years old, these results suggest primary ovarian insufficiency as the cause of infertility. High prolactin concentrations, as discussed previously, are commonly seen in CKD due to reduced renal clearance and increased secretion .AMH is a glycoprotein, which has a role in folliculogenesis. It is synthesised in the granulosa cells of the ovaries. It is probably the most studied reproductive hormone in women with CKD because it is thought to be the most stable biomarker of ovarian reserve ,40. It in = 27) compared with 600 age-matched controls [Wiles et al. analysed AMH according to the stage of CKD . They recontrols . InteresMenses is frequently restored within a few months of successful kidney transplantation; hence, it could be postulated that post-transplantation AMH titres would return to similar concentrations as the general population. However, a study of 60 women showed that serum AMH concentrations remained reduced in patients who had a renal transplantation . The autIt remains difficult to draw firm conclusions regarding the clinical role of AMH concentrations in women with CKD patients as studies have tended to have had small samples sizes and concentrated on the latter stages of CKD; hence, more research needs to be conducted to identify trends.Ultrasound is the first line imaging modality in the assessment of female fertility. To date, there is only a single prospective study published in 1997 investigating the prevalence of gynaecological disorders in 100 women with CKD using pelvic ultrasound as part of their assessment. The authors reported that 58% of the cohort had menstrual disorders . OvarianAMH and AFC are the best predictors of ovarian response to ART ,52. TheyPathologies such as endometriosis, adenomyosis, and fibroids can be diagnosed upon transvaginal ultrasound. This helps with further assessing the causes of infertility and subsequent management. If surgical management is required, Magnetic Resonance Imaging (MRI) can be useful in surgical planning, particularly if fibroids or endometriosis are present. A summary of all the investigations which can be useful in diagnosing infertility and identifying the cause is demonstrated in The management of infertility is primarily dependent on the cause of infertility and is complex and beyond the scope of this review. The main treatment options available, and what considerations are required in patients with CKD, are outlined.Cyclophosphamide, as described previously, can cause ovarian damage. To counteract this, GnRH agonists (GnRHa) can be used to preserve ovarian function and subsequently avoid infertility . They inARTs include ovulation induction (OI), intrauterine insemination (IUI), egg freezing, in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI). OI involves the use of either oral agents or injectable gonadotrophins in order to promote the growth of antral follicles to ovulatory ones. Oral agents include selective oestrogen-receptor modulators and aromatase inhibitors, such as clomiphene or letrozole, which increase the endogenous production of follicle-stimulating hormone (FSH) from the pituitary. In contrast, injectable gonadotrophins bypass the pituitary and act directly on the ovary and its follicles. These medications are typically given in the first part of the cycle to stimulate one or two dominant follicles that will ovulate . OI can IVF is where high concentrations of FSH-containing gonadotrophins are injected into the patient to stimulate the ovaries to produce more than one mature oocyte. The oocytes are collected from the ovaries via a needle passed through the vaginal wall and are fertilised with sperm in vitro ,51,61. CAlthough fertility treatment is generally very safe, there are risks and potential complications. Ovarian hyperstimulation syndrome (OHSS) is a potential serious complication of fertility treatment caused by an over response to gonadotrophin intake. A systematic review of women with CKD undergoing IVF reported that 7.4% of women developed OHSS, of which AKI occurred in three cases (out of 54). This is higher than the incidence in the general population undergoing IVF, which is 3–6% , but theIt is well recognised that females with CKD can have a strong desire to have children, but they can also feel that their fertility status is being overlooked in their management . The pro


Numerous vaccination research experiments have been conducted on non-primate hosts to prevent or control HTLV-1 infection. Therefore, reviewing recent advancements for status assessment and strategic planning of future preventative actions to reduce HTLV-1 infection and its consequences would be essential.MEDLINE, Scopus, Web of Science, and Clinicaltrials.gov were searched from each database's inception through March 27, 2022. All original articles focusing on developing an HTLV-1 vaccine candidate were included.A total of 47 studies were included. They used a variety of approaches to develop the HTLV-1 vaccine, including DNA-based, dendritic-cell-based, peptide/protein-based, and recombinant vaccinia virus approaches. The majority of the research that was included utilized Tax, Glycoprotein (GP), GAG, POL, REX, and HBZ as their main peptides in order to develop the vaccine. The immunization used in dendritic cell-based investigations, which were more recently published, was accomplished by an activated CD-8 T-cell response. Although there hasn't been much attention lately on this form of the vaccine, the initial attempts to develop an HTLV-1 immunization depended on recombinant vaccinia virus, and the majority of results seem positive and effective for this type of vaccine. Few studies were conducted on humans. Most of the studies were experimental studies using animal models. Adenovirus, Cytomegalovirus (CMV), vaccinia, baculovirus, hepatitis B, measles, and pox were the most commonly used vectors.This systematic review reported recent progression in the development of HTLV-1 vaccines to identify candidates with the most promising preventive and therapeutic effects.The online version contains supplementary material available at 10.1186/s12879-023-08289-7. Deltaretrovirus genus. The number of infected individuals is currently estimated at approximately 5–10 million globally ) OR (Human T-lymphotropic virus 1[Title/Abstract])) OR (Human T lymphotropic virus 1[Title/Abstract])) OR (HTLV*[Title/Abstract])) AND ((((("Vaccines"[Mesh]) OR (vaccines [Title/Abstract])) OR (vaccin*[Title/Abstract])))). Studies not identified by the above databases were included by evaluating the reference sections of relevant studies , case series/reports, and congress and conference abstracts as a source of grey literature. The following criteria were used as our inclusion criteria; original research articles focusing on developing a HTLV-1 vaccine candidate, whether using an experimental animal model, a human-based model, or in-vitro studies investigating HTLV-1 vaccine development. The title and abstract of the studies were assessed based on the inclusion criteria after duplicate papers were removed. Finally, a thorough screening of the full texts took place. The selection was carried out independently by the two authors. Two researchers independently extracted the following data: author, year, country, type of study, number of participants (if applicable), host, vaccine type, vaccine, construct, vaccine dose, vector, route of administration, prescribed number, adjuvant, laboratory method, and study’s main findings. A third reviewer resolved disagreements.Based on our search, we retrieved 1700 citations. After removing duplicates, a total of 1250 articles were screened based on title and abstract. Furthermore, the hand-searching of other studies revealed 7 studies that met the inclusion criteria and were included after assessing their full texts. Overall, 47 articles were included in this systematic review Most of the included studies investigated the role of protein-based vaccines in developing the HTLV-1 vaccine –75.Peptid vaccines were investigated in 26 studies including 16 in-vivo, 3 in-vitro, 2 in-vivo/in-vitro and 5 in-silico studies. All in-vivo studies were animal model with animals such as mouse, rat, rabbit, and monkey. The major protein vaccine constructs assessed in these studies were comprised of Tax peptide in 15 studies , 73–75, Lairmore et al. examined inoculation of chimeric B- and T-cell epitopes of HTLV-1 env-gp46 (SP2 and SP4a) with promiscuous T-cell epitopes (from tetanus toxin and MVF protein) in mice and rabbits. They showed connecting viral peptides with promiscuous epitopes promoted specific helper T-cell responses. MVF-SP2 and SP4a-MVF constructs were efficient to overcome genetic-restricted immunity . VaccinaSundaram et al. found a multivalent vaccine constructed of three HLA-A ∗ 0201 restricted CTL epitopes  that induced cellular immunity in HLA-A ∗ 0201 transgenic mice. Splenocyte lysis response was elicited by Tax11–19 (32%), Tax178–186 (34%), and Tax233–241 (≈6%) epitopes. Results demonstrated that Tax11–19 and Tax178–186 epitopes invoked significant CTL response and IFN-γ release in HHD mice (NSG-HLA-A2/ HHD mutant immunodeficient mice). However, Tax233–241 epitopes elicited IFN-γ release but not a significant CTL response . In anotAnother study found a novel multi-immunodominant vaccine. The vaccine constructed of sequences of HTLV-1-Tax epitope (11–19 and 178–186) and SP2 and P21 with His-tag or mouse-Fcγ2a fusion  was examined in BALB/c mice challenging with HTLV-1-MT2 cell line by Shafifar et al. . Higher In-vivo vaccination regimen of priming with recombinant vaccinia virus expressing whole HTLV-I envelope (gp46 and gp21) or just gp46 as a surface env protein with boosting of entire HTLV-I envelope gene, expressed in a baculovirus non-fusion vector system, demonstrated enhanced anti-env-antibody production. Neutralizing antibody level increment was shown in response to priming with recombinant vaccinia virus expressing only gp46 or with an admission of an adjuvant constructed out of mycobacterial cell wall extract .Eight studies investigated if adjuvants or encapsulation particles differed in the immune response to HTLV-1 vaccine constructs , 56, 66.n = 10 out of 12) and mice (n = 9 out of 9). Enhanced reactivity to viral antigens, viral-mediated fusion inhibition, and whole viral preparations recognition were revealed. Interestingly, the construct was not protective efficiently against cell-associated viral challenges in rabbits [Frangione-Beebe et al. examined a vaccine (MVFMF2) comprising HTLV-1-gp46 (aa 175–218) linked by GPSL turn to MVF (aa 288–302). They demonstrated antibody response in mice and rabbits in the admission of N-acetyl glucosamine-3yl-acetyl-L-alanyl-D-isoglutamine (nor-MDP) adjuvant. They found promoted immunogenicity of MVFMF2 in PLGA-encapsulated form without the need for boosting and adjuvant. Anti-MVFMF2 antibodies, predominantly IgG2  in mice, recognized HTLV- envelope protein in rabbits  and trimethyl chitosan (TMC) nanoparticles demonstrated good immunoadjuvant potential in admission with a vaccine comprising env23 and env13, recombinant proteins of gp46. IgG1 and IgG total levels were demonstrated higher than antigen levels in SC injection. IgG2a titer and IgG2a/IgG1 ratio were significantly higher due to nasal delivery of env23 than SC injection. Env23 induced more potent cell-mediated immunity compared with env13 .4 adjuvant. They found seven peptides derived from env-gp46, pol, gag-p19, and tax proteins invoked specific CTL responses in HLA-B*3501 transgenic mice. However, adjuvant-stimulated bulk cultures didn't show a specific CTL response.Furthermore, Schönbach et al.  investigImmunization with HLA-A*0201-restricted HTLV-1 Tax-epitope encapsulated with oligomannose-coated liposomes (OML⁄Tax) induced HTLV-1-specific CTL and IFN-γ responses, against no IFN-γ release in only peptide epitope inoculation. Moreover, dendritic cell 48 h exposure to 1 µg/ml of OML⁄Tax invoked increased CD86, MHC-I, MHC-ll, and HLA-A02 expression, in comparison .Vaccination by chimeric peptide comprising HLA-A*0201-restricted HTLV1 Tax-epitope/hepatitis B virus core (HBc) particle induced HTLV-1-specific CD8 + T-cells, antigen-specific IFN-γ reaction, and anti-HBc IgG level in HLA-A*0201-transgenic mice, against only peptide inoculation. Dendritic cell 48 h-exposure to HTLV-1/HBc chimeric particle resulted in CD86, HLA-A02 and TLR4 increased expression in a dose-dependent manner .4 adjuvant didn't show a specific CTL response.Totally, studies showed nor-MDP, PLGA, ISCOMATRIX, oligomannose-coated liposomes, chitosan and trimethyl chitosan promoted immunogenicity of vaccines, in comparision with the constructs without adjuvants. However C-Ser-(Lys)n = 2) vaccinated with a construct of Tax 180–188 and ISS-ODN adjuvant and showed tumor suppression elicited T cell immunity compared to the control group (n = 2). Moreover, in vivo inoculation of CTLs specific to Tax 180–188 (as a dominant recognized epitope) demonstrated tumor suppression (n = 2), too. Interestingly, equal antitumor effects of CD4 + and CD8 + T Cells were shown in this study as unfractionated T cells.Vaccines with anti-tumoral effects4 studies in design of in-vivo and in-vitro assessed tumor suppression/regression of their vaccines , 53, 54.Furthermore, Fujisawa et al. reported 2 leukemia survival in 5 Tax-peptide vaccinated infected hu-NOG mice with restricted number and growth of infected T cells. Vaccination before infection elicited IL-12 release and Tax-specific CD8 T-cell induction . Helper Totally, these studies showed tumor suppression and leukemia survival. Main effective epitopes were found Tax 180–188 (with ISS-ODN adjuvant) , Tax191–Investigation of designing possible Multi-Epitope Based Vaccine (MEBV) is an important progress in vaccinology as they can evoke both humoral- and cell-mediated immunity , 77. PreTariq et al.  construcAlam et al.  predicteAll DNA plasmid vaccines in this literature review were in-vivo animal studies Table . Armand Dendritic cell-based constructs were suggested as therapeutic vaccines that induced specific CD8-T cells , 65, 70 The use of vaccinia virus as a tool for developing vaccines is evident in literature . PreviouKuo et al. have used a recombinant surface glycoprotein (gp46) attached to the Fc region of human IgG (sRgp46-Fc), which lead to a significant rise in the antibody (Ab) response . FurtherThe use of ATLL patients own peripheral blood mononuclear cells (PBMC) were also suggested to have an immunogen activity against the virus through activating Tax- specific CTLs . ExpressIn a study by Fujii et al., an anti gp46 antibody was used for a possible induction of passive immunization in two pregnant rats . In theiThis is, to the best of our knowledge, the most comprehensive systematic review that thoroughly reviewed the available evidence regarding multiple efforts to create a well-developed vaccine against HTLV-1. In this paper, we reviewed the findings from 47 studies which used several different methods to design the aforementioned vaccine, including peptide/protein, DNA-based, dendritic-cells-based, and recombinant vaccinia virus. Most of the included studies were peptide or protein based experimental models, which mostly used Tax, Glycoprotein (GP), GAG, POL, REX, and HBZ as their peptides to develop the vaccine. Dendritic cell-based studies were more recently published and achieved their immunization through an activated CD-8 response. The first attempts to create an HTLV-1 vaccination relied on recombinant vaccinia virus and most results sound positive and efficacious, albeit there hasn't been much focus regarding this type of vaccine lately. Most of the studies were experimental studies performed on animal models, although few investigations were done on humans. CMV, vaccinia, baculovirus, hepatitis B, measles, pox, E. coli, and adenovirus were among the most commonly used vectors in the studies  to gather recent progression and future perspectives regarding the evaluation of the HTLV-1 vaccine in clinical trials. The most recent randomized controlled study protocol by Suehiro et al. is registered in the Japan Registry of Clinical Trials and aims to evaluate the effectiveness of autologous dendritic cell vaccine therapy in adult T-Cell Leukemia/Lymphoma (ATLL) patients. The main population were pre-treated ATLL patients and positive for any of HLA-A*0201, *2402, *1101, or *0207. The three times with a two-week interval at a dose of 5.0 × 106 cells vaccine will be subcutaneously injected and patients’ progression-free survival, the vaccine safety and effectiveness will be reported. Moreover, another protocol submitted by Suehiro et al. was aimed at studying the effectiveness of autologous dendritic cell vaccine pulsed with Tax peptides in ATLL patients. However, this study was terminated. A few other protocols were available, but none of them reported their results. Therefore, the authors of this systematic review urge further investigation into the potential use of these suggested vaccines to prevent and treat HTLV-1 infection in humans based on their efficacy in animal models.Previous reviews are also available in the literature regarding developing an efficacious HTLV-1 vaccine –86. The Our study has several limitations. First, due to the heterogeneous results and methodology of each study, meta-analysis was not carried out and the result section was presented in narrative form. Second, because the number of studies evaluating the effects of the proposed HTLV-1 vaccine in humans was insufficient, the applicability of the efficacy of the experimental animal models is unknown. Finally, little information was available regarding the comparison of the effects of the different proposed vaccine types to each other.In conclusion, this systematic review summarized recent assessments of HTLV-1 vaccine candidates. There are numerous constructs with potential immunogenicity investigated in in-silico, in-vitro, and in vivo studies. Cell-mediated immunity, tumor suppression, leukemia regression, and humoral response with antibody secretion were reported in reviewed studies. HTLV-1-Tax epitopes  and gp46 and gp21 were the most used epitopes in different immunogen vaccines. Some dendritic-cell-based and Tax epitope (180–188)-based vaccines showed reducing risk of the development of ATL in vivo. Although human clinical trials for HTLV-1 vaccines remain rare yet, a 3-individual-human trial showed the therapeutic efficacy of autologous dendritic cells for ATL patients. Recent in silico studies predicted the highest immunogenic T- and B-cell epitopes for efficient HTLV-1 vaccine. Further wet lab and in vitro investigations are required to authorize their vaccines. Elevated cell immunity appeared to be associated with Tax-specific CTL responses and protection from illness. Encapsulation of the vaccine with some nanoparticles (such as PLGA) showed the same immunity without the need for adjuvants or boosting. This study will address the essential need for a potential HTLV-1 vaccine to prevent and or treat ATLL and other HTLV-1 immune-related disorders. It is difficult to determine which approach is the most promising for developing an HTLV-1 vaccine, as each approach has its own advantages and disadvantages. Additionally, each approach may work differently in different populations and may have different safety and efficacy profiles. However, some of the approaches that have shown promising results in preclinical studies include the use of peptide vaccines, virus-like particle (VLP) and adenoviral vector vaccines encoding HTLV-1 proteins. These approaches have been shown to induce strong immune responses against HTLV-1 in animal models. It is important to note that while preclinical studies are promising, the safety and efficacy of these approaches in humans is not well known. Further clinical trials are needed to determine the safety and effectiveness of HTLV-1 vaccines in humans.Additional file 1: Supplementary Table 1. PRISMA 2020 checklist. Supplementary Table 2. Search strategies for online databases. Supplementary Table 3. Full characteristics of the included studies.


Background: Recent years have seen a dramatic increase in new “tic” cases in teens and young adults. These individuals often present with fulminant onset of symptoms not commonly seen in Tourette syndrome (TS) and are often diagnosed with Functional Neurological Symptom Disorder (FND-tic). However, some authors have questioned whether this illness truly differs from typical Provisional Tic Disorder (PTD) and TS. Previous studies have compared FND-tic, usually a few months after symptom onset, to patients with TS, usually years after symptom onset. We sought to test whether the presenting symptoms of FND-tic differ substantially from those in patients at a similar duration of symptoms who are later diagnosed with TS.Methods: This comparative study examines clinical features summarized from published reports of FND-tic with novel data from a longitudinal study of PTD. This study came from a referral center for TS and tic disorders and included 89 children with tics whose first tic occurred a median of 3.6 months earlier, nearly all of whom were diagnosed with a chronic tic disorder at follow-up. Specifically, we examine clinical features identified in a recent literature review as supporting a diagnosis of FND-tic, including symptom characteristics, course, severity and comorbidity.Results: Several clinical features dramatically distinguish the patients diagnosed with FND-tic from those diagnosed with typical PTD. For example, coprophenomena are reported at or shortly after symptom onset in over half of FND-tic patients, whereas even several months after onset, coprophenomena had occurred in only 1 of 89 children with PTD. Six clinical features each have a positive predictive value over 90% for FND-tic diagnosis if prior probability is 50%.Conclusions: These new data provide strong evidence supporting the diagnostic validity of FND-tic as distinct from TS. For instance, echopraxia and coprolalia occur in more than half of these individuals at symptom onset. The nature and characteristics of these symptoms, and the onset age and course of illness have led experienced clinicians to differentiate these cases from TS and to diagnose instead Functional Neurological Symptom Disorder (FND). FND with tic-like symptoms (hereinafter “FND-tic”) has been reported previously, but prior to 2019 was considered rare, occurring in < 2% of tic or tic-like cases at five major referral centers from three continents.Recent years have seen a dramatic increase in new “tic” cases in teens and young adults. Perhaps, for instance, echopraxia is present early in the course of TS much more often than has been recognized. We concur with these authors that clearly differentiating a new diagnosis from existing diagnoses is a key component of diagnostic validity. Substantial published data describe typical clinical features of chronic tic disorders, but almost no prospective data have been published on symptoms in the first year after tic onset., This evidence gap is crucial because most FND-tic patients at clinical centers have had symptoms for only a few months (mean 0.4 years in one study). Here, we directly address this concern by providing for the first time substantial data on relevant clinical features during the first few months after symptom onset in children ultimately diagnosed with TS.Some experts have expressed skepticism as to whether a new diagnosis (FND) is needed for these patients, positing that the previous understanding of TS may have been too narrow. Children are assessed using multiple informants . The diagnosis in this situation is Provisional Tic Disorder (PTD), and nearly all these children (77 of 79) were diagnosed with TS (70) or a persistent tic disorder (7) when they returned at the one-year anniversary of their first tic. Here we report the prevalence and timing from the New Tics sample of various features that occur commonly in FND-tic patients.The New Tics study is a prospective, longitudinal study that enrolled 89 children ages 5–10 years whose first tic occurred in the past 9 months (median 3.6 months). The comparison data for FND-tic patients comes from 26 published reports, with pertinent data in 17 reports,– describing a total of 336 patients (data file available asUnderlying data). For quantitative variables, the weighted mean is provided (weighted byN in each report), along with the median and range of the summary values reported in each relevant publication.The feature list was drawn from a recent review of FND-tic, a narrative review that included all primary data publications on FND-tic known to its authors as of August, 2022. impairment item at screening. Details on other such choices are given in footnotes toMost of these features thought to suggest FND-tic were recorded prospectively in the New Tics study, including age, sex, premonitory urges, tic suppression, coprophenomena, and family history. However, since the New Tics sample was enrolled almost entirely before the recent FND-tic upsurge, some of these clinical features were recorded indirectly. For instance, to match “severe symptoms at onset,” defined differently in various reports on FND-tic, we conservatively chose from the New Tics sample all patients with emergency department visits or disability prior to the screening visit, or a high score on the Yale Global Tic Severity Scale’sFisher’s exact test was used to find the probability of differences in frequency of features between the two populations (fisher_exact from SciPy (RRID:SCR_008058) 1.9.1).The New Tics study was approved by the Washington University Human Research Protection Office , all participants assented to participation, and a parent or other legal guardian provided written documentation of informed consent. Movements or vocalizations that were dramatically worse in the presence of othersversus when alone occurred in 47% of FND-tic patients, but in none of the New Tics PTD sample. Symptoms dramatically and persistently disrupted intended actions in 65% of FND-tic patients, but in only 2% of PTD. The prevalence of prolonged tic attacks was 65% in FND-tic, but 0–2% in PTD. Other features that differed substantially include lack of premonitory urges (53%vs. 4%) and severe symptoms at onset (48%vs. 3–6%).Stark differences in presentation distinguish the FND-tic patients from typical PTD . For exa Clinical equipoise about a given participant’s diagnosis is represented by a prior probability of 50%, for instance if one knows that a referring clinician is ambivalent about whether the patient has PTD or FND-tic, but one has not yet read the chart nor seen the patient. Features thought to be less common in FND-tic are listed with a negative predictive value (NPV), equivalent to PPV for the absence of the given feature.(p<.0001), but its absence only raises the probability of FND-tic from 50% to 57%.In a patient with recent onset of tics, coprophenomena at onset, or any one of the other features named above, raises the probability of a non-TS diagnosis from 50%  to over 90% . Other f, but not to a large PTD sample. We also provide for the first time quantitative estimates of the diagnostic significance of individual clinical features previously suggested to indicate FND-tic. This approach addresses a current debate, by showing that some features are significantly more common in patients diagnosed with FND-tic, yet individually do not substantially raise the likelihood of an FND-tic diagnosis.We demonstrate conclusively that patients with functional tic-like symptoms differ notably from typical tic patients at the same stage of the disorder, namely in the first few months after symptom onset. Previous reports have compared FND-tic to TS,,, The PTD cases were volunteers willing to participate in a rather intensive research study, and were ascertained by a variety of methods  rather than by clinical care-seeking. However, at the screening visit for the study, over 60% of them had sought clinical care for the tics or were planning to. The two FND-tic reports from Calgary, Alberta (child and young adult) were from a prospective registry of all patients seen for tics at their center, which is the only specialty center in their region. FND-tic cases were defined by “rapid onset of complex tic-like behaviors, with escalation to peak severity within hours to days.” In other words, these reports are selected only for being seen at a specialty center for tic-like phenomena. Yet their clinical features are similar to those of the FND-tic literature overall (or even more different from the PTD group). For instance, 95% of the Calgary FND-tic child patients were of female sex, only 25% had ADHD, and only 5% had OCD. We can conclude that potential bias from selecting more interesting, severe or classic cases for published case series does not substantially alter our results. Perhaps most importantly, there are no larger published sources for data about FND-tic nor about PTD. Nevertheless, ideally the results presented here should be confirmed in a new, independent sample.The primary concern with the validity of these conclusions arises from the different potential sources of ascertainment bias in the two groups. Fortunately, these differences may not be as problematic as one might suppose. The FND-tic group is older, and if one’s information were limited to this study alone, one might posit that the natural history of tic disorder included different early symptoms at different ages of tic onset. However, the literature includes decades of previous clinical information on typical tic disorders. Retrospective studies of TS and a prospective study of PTD in siblings of TS probands all found peak tic onset before age 10 years old; adult onset of tics is quite uncommon.We note that 22% of the patients reported in the FND-tic papers in fact had a prior history of typical tics, and many of them exhibited both tics and functional tic-like symptoms at the time they presented due to the latter. We have structured our results around whether FND-tic can be diagnosed, not whether PTD can also be diagnosed. In other words, when a patient presents with a typical history for TS but also new symptoms, the features above would allow more confidence in diagnosing FND-tic in addition to TS. Unfortunately, we have no prospectively collected data from the PTD group on exposure to others with similar symptoms.Other features in addition to those studied here may also be important for diagnosis. For instance, exposure to tic-like symptoms on social media was a common feature discussed in the papers discussing FND-tic in the past few years.The data presented here do not prove the etiology of the tic-like symptoms diagnosed in the cited reports; hence the limited claim that these symptoms represent a different illness than PTD/TS. However, the marked difference in presentation these data demonstrate is an important argument adduced in the cited reports to support the diagnosis of functional neurological symptom disorder. Diagnosing FND-tic is important, since to the extent of our current knowledge, its prognosis and optimal treatment differ from those of TS.In conclusion, these new clinical data about the first few months after tic onset prior to diagnosis of TS provide strong evidence supporting the diagnostic validity of functional tic-like symptoms as distinct from PTD and TS. The authors have responded adequately to my critiques. I appreciate this important contribution to the study of tic disorders.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?YesAre all the source data underlying the results available to ensure full reproducibility?YesIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?PartlyAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:Meta-analysis, psychopharmacology, tic disorders, OCDI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Thank you to the authors for their response to all my queries and for the clarification. I would like to approve this article as a helpful addition to this field.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?PartlyAre all the source data underlying the results available to ensure full reproducibility?YesIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?PartlyAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:Paediatric Neurology , Movement Disorders and TourettesI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. The authors, all highly experienced 'Tourettologists', have approached this topic in an interesting and novel manner to try and provide some evidence for the ability to differentiate functional tic like behaviours from those seen in provisional tic disorders, usually related to Tourettes at follow up. This is a complex area, with some researchers proposing some shared mechanisms and overlapping neurobiology in the presentations. This paper uses some usefully collected detailed  clinical data of children with PTD within a few months of presentation to compare characteristics demonstrating some useful distinguishing features. The presentation of the statistics could benefit from a little more expansion and explanation, especially for the non-expert, as it seems an important aspect of this paper. For example, table 2 is not that clearly explained and could do with more detail. There are some limitations, but these have been clearly highlighted by the authors, such as the difference in ages of the two groups. I therefore would support this paper as it represents a useful contribution to the ongoing exploration of the functional tic-like phenomenon. I do wonder whether the dichotomy of subjects is a problem and would welcome wider discussions by the authors, on the situations seen commonly in the clinic in which young people, demonstrate both Tourette-related tics and functional tic-like behaviours together. This paper raised a question in my mind, as to whether the authors could have included distinguishing factors for the concept of provisional or transient functional disorder, especially when appearing in the context of exposure to social media or influencers. Thank you for an interesting contribution.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?PartlyAre all the source data underlying the results available to ensure full reproducibility?YesIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?PartlyAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:Paediatric Neurology , Movement Disorders and TourettesI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. We thank Dr. Hedderly for her thoughtful and expert critique. Below we respond to each comment in turn.The presentation of the statistics could benefit from a little more expansion and explanation, especially for the non-expert, as it seems an important aspect of this paper. For example, table 2 is not that clearly explained and could do with more detail. 1. Thank you. We agree. The new text in 'Results' reads as follows: "Table 2 illustrates the clinical value of these comparisons, viewing each clinical feature as a “test” for FND-tic, with its associated sensitivity and specificity. We also provide the positive predictive value (PPV) for each feature thought to indicate FND-tic. The PPV represents how confident one can be of a FND-tic diagnosis given the presence of the listed feature. The PPV depends on the prior probability of the FND-tic diagnosis, or its likelihood before one knows whether a given patient has that feature. We provide PPV for each feature based on two prior probabilities, 2% and 50%. The first, 2%, represents the approximate rate before the pandemic of functional tic-like symptoms at clinical referral centers. 4  Clinical equipoise about a given participant’s diagnosis is represented by a prior probability of 50%, for instance if one knows that a referring clinician is ambivalent about whether the patient has PTD or FND-tic, but one has not yet read the chart nor seen the patient. Features thought to be less common in FND-tic are listed with a negative predictive value (NPV), equivalent to PPV for the absence of the given feature." I do wonder whether the dichotomy of subjects is a problem and would welcome wider discussions by the authors, on the situations seen commonly in the clinic in which young people, demonstrate both Tourette-related tics and functional tic-like behaviours together. 2. We agree the discussion did not address this issue previously. The discussion now includes this additional paragraph: "We note that 22% of the patients reported in the FND-tic papers in fact had a prior history of typical tics, and many of them exhibited both tics and functional tic-like symptoms at the time they presented due to the latter. We have structured our results around whether FND-tic can be diagnosed, not whether PTD can also be diagnosed. In other words, when a patient presents with a typical history for TS but also new symptoms, the features above would allow more confidence in diagnosing FND-tic in addition to TS."This paper raised a question in my mind, as to whether the authors could have included distinguishing factors for the concept of provisional or transient functional disorder, especially when appearing in the context of exposure to social media or influencers. 3. The reviewer raises a very interesting question that appears to include two concepts: diagnostic utility of exposure to social media and nosology. et al. (2022)Frey andet al. (2022)Malaty). Unfortunately, we have no prospectively collected data on this question from the PTD group. Anecdotally, I can report that although over a third of our New Tics study participants had a parent or sibling with tics, only once or twice was there any suggestion that the child's first tic may have appeared to be prompted by the family member's similar tic. We have added to the discussion the following paragraph:  a) The exposure to social media or other examples that the new symptoms appear to recapitulate is an important diagnostic clue. We and others have discussed that issue elsewhere  Traditionally, functional neurological symptoms have not been diagnosed differently based on duration of the defining symptoms. The closest analogy I can think of is Briquet's syndrome , which required not only atypical, medically unexplained symptoms starting before midlife but also numerous symptoms over time, affecting a variety of organ systems. Personally I would not favor creating a new diagnosis to represent "presumed functional symptoms in the first year since onset". I do not believe the primary limitation of the manuscript is really acknowledged in the current draft. Mainly that the FND cases are drawn from the existing literature (where there is likely a large degree of reporting bias) versus a Provisional Tic Disorder sample that is much more general. Basically, there is quite a strong possibility that there are other characteristics associated with group difference other than diagnosis.Please consider providing statistical tests in table 1 as well as sensitivity, specificity in table 2.I think in the conclusion the authors should discuss the importance of testing the potentially meaningful differentiators in an independent dataset.It would also be very worthwhile in further studies to use individual participant data to determine the PPV of multiple predictors to engage in a diagnostic distinction.If possible, a histogram exploring age and gender differences between the two groups would be helpful.This manuscript compares the clinical characteristics of the sample of patients with Functional Neurological Disorder (FND) described in the literature, witha well-characterized sample of Provisional Tic Disorder. Strengths of the manuscript include the clinical importance and novelty of the data as well as the expertise of the authors and the well-written manuscript. Overall, I think this is a manuscript worthy of indexing, although I have several critiques that could potentially improve the manuscript with revision.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?YesAre all the source data underlying the results available to ensure full reproducibility?YesIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?PartlyAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:Meta-analysis, psychopharmacology, tic disorders, OCDI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. We thank Dr. Bloch for his thoughtful and expert critique. Below we respond to each comment in turn.I do not believe the primary limitation of the manuscript is really acknowledged in the current draft. Mainly that the FND cases are drawn from the existing literature (where there is likely a large degree of reporting bias) versus a Provisional Tic Disorder sample that is much more general. Basically, there is quite a strong possibility that there are other characteristics associated with group difference other than diagnosis. 1. We agree and have edited the ms. to reflect this point. However, the disparity is smaller than one might think. Here is our new text in the discussion: "The primary concern with the validity of these conclusions arises from the different potential sources of ascertainment bias in the two groups. Fortunately, these differences may not be as problematic as one might suppose. The FND-tic group is older, and if one’s information were limited to this study alone, one might posit that the natural history of tic disorder included different early symptoms at different ages of tic onset. However, the literature includes decades of previous clinical information on typical tic disorders. Retrospective studies of TS and a prospective study of PTD in siblings of TS probands all found peak tic onset before age 10 years old; adult onset of tics is quite uncommon. 7 , 8 , 33 The PTD cases were volunteers willing to participate in a rather intensive research study, and were ascertained by a variety of methods  rather than by clinical care-seeking. However, at the screening visit for the study, over 60% of them had sought clinical care for the tics or were planning to. The two FND-tic reports from Calgary, Alberta (child and young adult) were from a prospective registry of all patients seen for tics at their center, which is the only specialty center in their region. FND-tic cases were defined by “rapid onset of complex tic-like behaviors, with escalation to peak severity within hours to days.” In other words, these reports are selected only for being seen at a specialty center for tic-like phenomena. Yet their clinical features are similar to those of the FND-tic literature overall (or even more different from the PTD group). For instance, 95% of the Calgary FND-tic child patients were of female sex, only 25% had ADHD, and only 5% had OCD. We can conclude that potential bias from selecting more interesting, severe or classic cases for published case series does not substantially alter our results. Perhaps most importantly, there are no larger published sources for data about FND-tic nor about PTD. Nevertheless, ideally the results presented here should be confirmed in a new, independent sample."Please consider providing statistical tests in table 1 as well as sensitivity, specificity in table 2. 2. Done.I think in the conclusion the authors should discuss the importance of testing the potentially meaningful differentiators in an independent dataset. 3. We agree. The discussion now includes: "ideally the results presented here should be confirmed in a new, independent sample." It would also be very worthwhile in further studies to use individual participant data to determine the PPV of multiple predictors to engage in a diagnostic distinction. 4. That's an excellent idea. We have supplied individual participant data for the New Tics group as a supplementary file. If possible, a histogram exploring age and gender differences between the two groups would be helpful. 5. We do not have individual participant data for the FND-tic group (which came from 17 different publications), so we can't do this.


Usnic acid (UA) is a compound with multiple biological activities that make it useful in various industries, e.g., pharmaceutical, cosmetic, dentistry, and agricultural sectors. Lichens are the primary source of UA, which is primarily extracted using acetone. This study aimed to investigate the solubility of UA in numerous natural deep eutectic solvents (NADESs) and use a mixture of thymol and camphor as a NADES in the optimization of the UA extraction process with the design of experiments method. For numerical optimization, the following parameters were employed in the experiment to confirm the model: a camphor-to-thymol ratio of 0.3, a liquid-to-solid ratio of 60, and a time of 30 min. The obtained experimental results aligned well with the predicted values, with the mean experimental value falling within the confidence interval, exhibiting deviations between 11.93 and 14.96. By employing this model, we were able to optimize the extraction procedure, facilitating the isolation of approximately 91% of the total UA content through a single extraction, whereas a single acetone extraction yielded only 78.4% of UA. Alectoria, Cladonia, Evernia, Lecanora, Parmelia, Ramalina, Usnea, and Xanthoparmelia) as a yellow cortical pigment [Usnic acid (UA) is a phenolic compound with a dibenzofuran structure occurring in the form of two enantiomers  1] in s in s1] i pigment ,3,4,5,6. pigment , antitum pigment , photopr pigment ,10. Cons pigment .2) [2 [However, for UA to be used in industry, it must be isolated from lichen thallus, because the use of a synthetic compound increasingly fails to meet the expectations of modern consumers, does not comply with the tenets of “green chemistry”, and the use of plant raw material requires its standardization and is associated with the introduction of other metabolites into the product as well. The values of the LogP coefficient 2.88)  and topo2)  evidence2) ,18,19,202) ,22,23,242) , n-hexan2) , and hep2) . Methano2) ,29, as t.88  and 2) [2  and solv2) [2 , glycero2) [2 .Cladonia uncialis (L.) Weber ex F.H. Wigg. , which consist of common plant metabolites such as carbohydrates, amino acids, simple organic acids , or compH. Wigg. .Among the tested NADES systems, the lipophilic mixtures of thymol with borneol and thymol with camphor  turned oHydrophilic NADESs were undoubtedly much worse solvents and showed a significantly lower UA extraction ability compared to lipophilic NADESs . Only a Cladonia uncialis was used for the determination of UA, and acetone was used as a standard extractant to perform a total UA extraction. However, the exhaustive extraction of UA with acetone required multiple cycles using fresh portions of the extractant, and acetone did not seem to be the best extractant of this compound (compared to the NADESs used in this experiment). Ten-fold extraction with acetone made it possible to determine the content of UA in the C. uncialis at the level of 14.5 ± 0.1 mg/g (exhaustive extraction), while three-fold extraction, commonly used in the isolation of plant metabolites, resulted in the isolation of 93.6% of UA   molar ratio, the NADES:sample/liquid:solid (X2) ratio, the temperature of extraction (X3), and the time of extraction (X4), were tested for the optimization of UA extraction from the lichen thallus (3) did not show a significant impact on the UA yield, this factor was removed from the model. The camphor:thymol ratio and, partially, the time (p = 0.051) exerted a significant linear and quadratic effect (1) had a negative impact (−0.92), while X4 exerted a positive linear effect on the UA extraction yield. Surprisingly, not only the temperature of extraction (X3), but also the liquid:solid ratio (X2) did not exhibit a significant linear effect on the response. In turn, the X2X4 interaction effect was significant and X1X2 was close to significance (p = 0.059).The four independent variables, including the camphor:thymol , which indicated that the model was adequate for prediction. In turn, a ratio of signal-to-noise above 4 (Adeq Precision) indicated that the developed model had an adequate signal level and high ability to predict properties within the whole designed space [The constructed polynomial model was highly significant and exhibited good fitting statistics with a determination coefficient ed space .In conclusion, it should be highlighted that the NADESs used extracted UA very efficiently already in a single extraction process. A similar or even higher efficiency of extraction from various plant compounds using different NADESs compared to classically used extractants has already been repeatedly reported in other studies ,34,36,40Chelidonium majus [um majus . This efOur unpublished studies suggest that mixtures of UA and thymol melt at a much lower temperature than UA alone; however, the exact explanation of this phenomenon requires further research. In addition, it was shown that, with the decreasing camphor:thymol ratio, the obtained NADES had lower viscosity from 18.0 to 16.6 mPa/s for 1.5 and 0.3 molar rates, respectively, which is known to have a positive effect on the kinetics of the extraction process. The positive effect of high values of the liquid:solid ratio a and timThe optimal set of factors that exerted a significant impact on the response were determined by maximization of the extraction yield. The results of the numerical optimization are presented in Considering the numerical optimization, the following parameters: camphor:thymol ratio—0.3, liquid:solid ratio—60, and time—30 min were used in the experiment for confirmation of the model . The exp® 3UV–R .β-Alanine, sucrose, L-proline, L-(+)-tartaric acid, citric acid, D-sorbitol, choline chloride, myristic acid, levulinic acid, lauric acid, DL-menthol (≥95%), (±)-camphor (≥95.5%), (−)-borneol (97%), lactic acid (90%), glycerol anhydrous, methanol (HPLC), acetonitrile (HPLC), UA (98%) were purchased from Sigma-Aldrich . Betaine was provided by Sigma Aldrich ; glucose, maltose, and D-fructose were purchased from POCH S.A. ; urea from Chempur ; and propanediol from EcoSpa . Water was deionized and purified using ULTRAPURE Milipore Direct-QC. uncialis lichen thalli were collected from Sobibór Forest, Poland . The samples were identified by Prof. Hanna Wójcik and deposited at the Department of Analytical Chemistry, Medical University of Lublin, Lublin, Poland (voucher specimen no. C.u.1/2022). The air-dried lichen was stored in a dry and dark place until use in the experiments. Then, it was mortar-ground to a homogeneous powder and sieved (1.6 mm sieve).Wild-growing All lipophilic NADESs were obtained by heating the mixed components in a water bath without additional mixing. Initially, all NADESs were heated for 30 min at 50 °C. This made it possible to obtain liquids in thymol:camphor, thymol:lactic acid, thymol:lactic acid:choline chloride systems and in menthol: lactic, lauric, and myristic acid systems. The mixtures of borneol:thymol, menthol:thymol, and menthol:camphor were further heated for 30 min at 60 °C. To obtain a homogenous liquid of borneol:thymol, additional heating for 30 min at 70 °C was applied.The hydrophilic NADESs were dissolved in an excessive amount of water in a previously weighed round-bottomed flask. Then, the samples were evaporated under reduced pressure (10 mBa) in a rotary evaporator with a water bath (50 °C). Further, the flasks were placed in a desiccator for five days until constant weight was achieved. The mass difference between samples before and after water addition was considered as water bound in the NADES structure. The samples that crystallized during evaporation, drying in the desiccator, or storage at ambient temperature did not qualify for further experiments.An excess amount of UA was added to 1 mL of samples (lipophilic and hydrophilic NADESs) in 2 mL Eppendorf tubes. The tubes were transferred to an ultrasonic bath. Ultrasound at a frequency of 35 kHz  was applied at ambient temperature in three cycles (each of 15 min).The samples were centrifuged  after the ultrasonic bath. Afterward, the samples were allowed to settle for two weeks at 20 °C to attain equilibrium.After that, the saturated UA solutions of NADESs were diluted in water (hydrophilic) or methanol (lipophilic solvents) in adequate ratios, depending on the UA content in the sample . Subsequently, the samples were analyzed by HPLC. The concentrations of UA in the samples were transformed to the solubility value. The solubility of UA in one-component solvents was assessed similarly.v/v) with 0.025% of trifluoroacetic acid as the mobile phase at a temperature of 20 °C and an eluent flow rate of 1.2 mL·min−1. The sample injection volume was 10 μL. The UA retention time was determined as tR = 8.42 min. The concentration of UA in the samples was determined from the area under the curve at 281 nm with a calibration curve obtained with the methanolic solution of UA . All analyses were repeated three times.An EliteLaChrom chromatograph with a PDA detector and EZChrom Elite software  was used for chromatographic analysis. The samples were analyzed on a C18 reversed-phase core–shell column   using a mixture of acetonitrile and water  using an ultrasonic bath at 30 °C (10 × 15 min). After each extraction step, the sample was centrifuged, and the supernatant was poured into 2 mL volumetric flasks. The flasks were topped up with acetone and mixed thoroughly. The extracts obtained were analyzed by HPLC according to the methodology described in C. uncialis.1) molar ratio, NADES:sample/liquid:solid ratio (X2), temperature of extraction (X3), and time of extraction (X4) on the yield of UA extraction from Cladonia uncialis. A Box–Behnken design was used for the generation of the design of the experiment (p < 0.05). Additionally, the adequacy of the models was checked by calculation of the fit statistics, including R2, adjusted R2, predicted R2, and adequate precision. Based on the developed model, numerical optimization was performed. Finally, the model was confirmed using the experimental (n = 3) and predicted values. All statistical calculations were performed using Statistica ver. 13.3.03  and Design Expert ver. 13 .The design of experiments methodology was used to investigate the influence of four independent numerical factors: camphor:thymol . Then, 1.5 mL of various mixtures of camphor and thymol were added to the tubes. The samples were extracted in an ultrasonic bath for the assigned time and at a controlled temperature. The detailed conditions of all the conducted experiments are presented in In order to perform the design of experiments, three different ratios  of the camphor:thymol mixture  were pre®, Warsaw, Poland).Viscometric measurements of the camphor:thymol mixtures  in a temperature range of 22–40 °C were performed using an IKA ROTAVISC lo-vi viscometer with an ELVAS-SP spindle, a small sample adaptor, and a temperature sensor (IKAR2 over 0.71. The model is suitable for prediction, has an adequate signal level, and has good ability to predict properties across the design space. Considering the numerical optimization, the following parameters: camphor:thymol ratio—0.3, liquid:solid ratio—60, and time—30 min were used in the experiment to verify the model. The experimental results and the predicted value corresponded well, with the mean experimental value falling within the confidence interval with deviations between 11.93 and 14.96. The model allowed optimization of the extraction procedure, whereby a single extraction yielded approximately 91% of the total UA content, while only 78.4% of UA were isolated in the single acetone extraction. The mechanistic explanation of this phenomenon requires further research, but it can be assumed that thymol and UA form a eutectic solvent.This study presents the results of UA solubility evaluation in 10 single-component solvents and 16 lipophilic and 51 hydrophilic NADESs, demonstrating the greatest potential of lipophilic NADESs as solvents for this compound. The solubility of UA is much higher in the mixtures of lipophilic NADESs than in single-component solvents and hydrophilic NADESs. Based on the use of the mixtures of thymol and camphor to optimize the UA extraction process, a polynomial model was constructed, which is highly significant and exhibits good fitting statistics with a determination coefficient


Signaling pathways play critical roles in executing and controlling important biological processes within cells. Cells/organisms trigger appropriate signal transduction pathways in order to turn on or off intracellular gene expression in response to environmental stimuli. An orchestrated regulation of different signaling pathways across different organs and tissues is the basis of many important biological functions. Presumably, any malfunctions or dysregulation of these signaling pathways contribute to the pathogenesis of disease, particularly cancer. In this review, we discuss how the dysregulation of signaling pathways  modulates chromatin modifications to regulate the epigenome, thereby contributing to tumorigenesis and metastasis. Cell signaling is the mechanism by which cells respond to environmental stimuli and initiate appropriate action by turning on or off different signaling pathways; thus, these pathways are crucial for regulating biological processes. Typically, the binding of ligands to membrane-bound receptors activates the signal transduction processes and triggers a cascade of signaling activities through numerous signaling molecules. Ultimately, signaling molecules coordinate with activators, coactivators, transcription factors, and chromatin remodelers to regulate downstream gene expression, and initiate appropriate physiological or cellular responses. These responses include development, cell proliferation, apoptosis, differentiation, cell cycle arrest, cell migration, epithelial–mesenchymal transition (EMT), cellular homeostasis, tissue repair, metabolism, and immunity . It is nChromatin is a higher-order, complex structure of DNA and histone proteins. A nucleosome—the fundamental unit of chromatin—is composed of approximately 145–147 base pairs of DNA wrapped around a histone octamer; this octamer is composed of 2 copies of each histone protein: H2A, H2B, H3, and H4. The nucleosomes are assembled into a compact structure—chromatin—that is further stabilized by the linker histone H1. This creates high-order structures known as chromosomes  phosphorylate LRP5/6 of the FZD-LRP5/6 complex; this triggers the recruitment of Dishevelled (Dvl) proteins to the plasma membrane . Dvl and2+ signaling, Wnt-ROR2 signaling, Wnt-RAP1 signaling, Wnt-PKA signaling, Wnt-GSK3-microtubule (MT) signaling, Wnt-aPKC signaling, and Wnt-mTOR signaling [The noncanonical Wnt signaling pathways are diverse and less distinct, often defined as β-catenin–independent Wnt- or FZD-initiated signaling  ; this interaction stabilizes both proteins. This Wnt/β-catenin/Dnmt1 complex alters DNA methylation patterns on a specific locus and drives tissue differentiation . In colon cancer . Moreoven cancer . Overalln cancer . The C-tn cancer . Moreoven cancer . In stemn cancer , 78.In the absence of Wnt signaling, LEF1 interacts with HDAC1 and recruits the NuRD complex to repress the transcription of Wnt target genes. However, when Wnt signaling is activated, β-catenin removes HDAC1 from the HDAC1-LEF1 complex and attenuates the deacetylase activity of HDAC1. β-catenin then forms the dimeric β-catenin-LEF1 complex that activates the transcription of Wnt target genes . AlthougGATA-3 expression during helper T cell differentiation [The Wnt signaling downstream effector β-catenin acts as a molecular switch to regulate global gene activation by interacting with transcription factors and chromatin-remodeler complexes. For instance, the chromatin organizer special AT-rich binding protein 1 (SATB1) recruits β-catenin and p300 acetyltransferase to induce ntiation . The preThe Notch signaling pathway is a conserved master intracellular pathway that regulates diverse developmental processes, including organ formation, tissue function, and tissue homeostasis through cell-to-cell communication , 84. In The dysregulation of Notch signaling can be involved in proliferation and growth arrest during differentiation, either survival or death pathways, and is largely dependent on the physiological conditions and protein–protein interactions; thus, it is not surprising that Notch signaling shows mixed, and contradicting, effects across tumor types. A growing body of emerging evidence supports the idea that Notch signaling is a major player in tumor initiation and progression in different cancers, including small cell lung cancers , peripheMyc; this might be an important event in several human tumors, including T-ALL [In recent years, a growing body of the literature suggests that the interaction of effector proteins  with chromatin-remodeler complexes is responsible for the activation of the NOTCH-targeted genes , 94. It ng T-ALL , breast ng T-ALL , and manng T-ALL , 104.Hes1/Hes5 to suppress Notch-mediated transcription [MAD4, a MYC repressor, resulting in the elevation of MYC expression and oncogenic functions [Chromatin remodeling mediated by Notch signaling, and the subsequent changes in gene expression caused by the chromatin remodeling, remain contentious. Genetics and phenotypic studies have shown that activated Notch and its binding partner, RBP-JK, recruit the SWI/SNF chromatin-remodeling complex, which positively regulates Notch-targeted transcription activity , 106. Hocription . Recentlunctions .Hey1 expression, which in turn makes lymphoma cells aggressive and chemoresistance [Notch signaling is activated through cell-to-cell contact, and cancer cells take advantage of elevated expression of Notch ligands for the activation of Notch signaling in endothelial cells to activate angiogenesis, an indispensable process for sustainable tumor growth and progression –112. Lymsistance . Under hsistance  in seversistance , bladdersistance , and pansistance . Hence, Thus, it is conceivable that the Notch signaling pathway serves as a platform for transcription activators and corepressors to regulate target genes in accordance with the physiological condition. This suggests an extremely dynamic, multifunctional role for Notch signaling in oncogenic processes. In the near future, we expect more scientific evidence to delineate the diverse roles of Notch signaling in different physiological conditions; this information is essential if we hope to develop therapeutic strategies to modulate Notch signaling.The PI3K/AKT/mTOR signal transduction pathway is one of the most critical pathways as it is involved in numerous biological processes, including cell proliferation, migration, adhesion, invasion, metabolism, and survival . AberranEpigenetic silencing of tumor suppressor genes or activation of oncogenes is frequently observed during tumorigenesis. DNA and histone modifications can lead to the epigenetic silencing of genes. Hypermethylation of DNA is often associated with gene silencing. For example, promoter methylation causes the suppression of the retinoblastoma gene (Rb) in retinoblastoma-tumors . On the Mounting evidence suggests that PI3K/AKT signaling-mediated chromatin regulation (histone modifications) by chromatin-remodeler complexes induces transcriptional activation to promote tumorigenesis. AKT phosphorylates methyltransferase EZH2, a member of PRCs, that trimethylates promoter-associated histone H3 Lys27 (H3K27me3) to suppress transcription . ActivatPI3K/AKT signaling regulates p300/CBP-mediated histone acetylation of lysine residues to activate transcriptional activity has been implicated in tumorigenesis and metastasis in different cancer types . Upon acAKT promotes PRC1 complex-mediated H2A ubiquitination to repress chromatin at specific genomic loci for transcriptional inactivation. Specifically, E3 ubiquitin ligase RING1A containing PRC1 complex monoubiquitinates nucleosomal histone H2A at lysine 119 and subsequently recruits PRC2, which catalyzes the addition of methyl groups to histone H3 at lysine 27 (H3K27me3). This contributes to polycomb-complex dependent epigenetic gene silencing . AKT-medOverall, the PI3K/AKT signal transduction pathway has emerged as a critical signal transducer that is most frequently dysregulated in virtually all solid tumors and hematological malignancies. The downstream effector of this signaling pathway, AKT, phosphorylates over 200 substrates , 142 andSignal transduction pathways are a critical means of cellular communication; these pathways allow cells to perceive extracellular signals/stimuli and transmit those signals into precise cellular functions, thus maintaining cellular and organismal homeostasis. Understanding the detailed molecular mechanisms that contribute to cell signal transmission from the cell membrane to the nucleus and that regulate chromatin-remodeler complexes, transcriptions activators, and cofactors to control gene expression is critical if we hope to understand disease mechanisms. For example, HDAC1 and HDAC2 deacetylate over 50% of global histones acetylation marks and take part in 3 different histone deacetylase complexes: SIN3/HDAC, NuRD, and CoREST. How stimuli-dependent and context-dependent cellular signaling contributes to the distribution of HDAC1 and HDAC2 in those chromatin-remodeler complexes in normal and diseased conditions is critical to devise therapeutic interventions in human cancers.phosSMAD4-NuRD complex. The above-mentioned evidence suggests that nRTKs-mediated dysregulation of signal transduction pathways is associated with tumorigenesis and metastasis. Thus, a comprehensive profiling of nRTK is urgently needed to identify the members of the nRTK family that change signaling pathways, as these proteins will be key targets for drug discovery.A subgroup of tyrosine kinases, known as non-receptor tyrosine kinases, relay intracellular signals and is indispensable in cell signaling . ElevateIn conclusion, chromatin-modifying complexes and associated proteins are at the core of chromatin regulation corresponding to gene expression for organismal homeostasis. Aberrant activation or dysregulation of signal transduction pathways causes miscommunication that alters epigenetic modulators, resulting in unsubstantiated gene expression that contributes to cancer development, progression, and metastasis. In this review, we discussed several main signal transduction pathways: (1) TGF-β signaling, (2) Hippo signaling, (3) Wnt signaling, (4) Notch signaling, and (5) PI3K-AKT signaling. Those pathways are frequently dysregulated, and this dysregulation modulates chromatin-modifying complexes, leading to oncogenic genes regulation, and the promotion of tumorigenesis and metastasis. A comprehensive understanding of signaling pathways and their communication with chromatin modulators in healthy and diseased conditions is essential for the therapeutic intervention of human cancer.


Evidence on neonatal withdrawal syndrome following antidepressant intrauterine exposure is limited, particularly for antidepressants other than selective serotonin reuptake inhibitors (SSRIs).To ascertain whether maternal antidepressant treatment may be associated with withdrawal syndrome in neonates, investigating the comparative reporting between individual antidepressants and classes.We performed a case/non-case pharmacovigilance study, searching reports of withdrawal syndrome in newborns in the VigiBase, the WHO database of suspected adverse drug reactions. Disproportionality analysis was performed, estimating reporting odds ratio (ROR) and the Bayesian information component (IC). Antidepressants were compared to all other medications, to methadone, and within each class of antidepressants  and other antidepressants). Antidepressants were ranked in terms of clinical priority, based on a semiquantitative score.We retrieved 406 reports of neonatal withdrawal syndrome in 379 neonates related to 15 antidepressants. Compared to all other drugs, disproportionate reporting was detected for antidepressants altogether , for TCAs , other antidepressants  and SSRIs . All antidepressants showed a significant disproportionality, apart from bupropion (figure 1). We did not find any disproportionate reporting for any antidepressant compared to methadone. The clinical priority ranking showed moderate clinical priority for all antidepressants, with the exception four, that had a weak one (figure 1). Most frequently reported symptoms were respiratory symptoms (n=106), irritability/agitation (n=75), tremor (n=52) and feeding problems (n=40).Image:Exposure to antidepressants in utero is associated with moderate signals of disproportionate reporting for neonatal withdrawal syndrome for most antidepressants. Clinicians should pay extra attention to neonates with antidepressant-treated mothers.C. Gastaldon: None Declared, E. Arzenton : None Declared, E. Raschi: None Declared, O. Spigset: None Declared, D. Papola: None Declared, G. Ostuzzi: None Declared, U. Moretti: None Declared, G. Trifirò Grant / Research support from: he was the scientific director of a Master program on pharmacovigilance, pharmacoepidemiology and real-world evidence which has received non-conditional grant from various pharmaceutical companies; he coordinated a pharmacoepidemiology team at the University of Messina until Oct 2020, which has received funding for conducting observational studies from various pharmaceutical companies . He is also scientific coordinator of the academic spin-off “INSPIRE srl” which has received funding for conducting observational studies from contract research organizations ., Consultant of: has served in the last three years on advisory boards/seminars funded by SANOFI, Eli Lilly, AstraZeneca, Abbvie, Servier, Mylan, Gilead, Amgen, Speakers bureau of: has served in the last three years on advisory boards/seminars funded by SANOFI, Eli Lilly, AstraZeneca, Abbvie, Servier, Mylan, Gilead, Amgen, C. Barbui: None Declared, G. Schoretsanitis Consultant of: Dr. Schoretsanitis has served as a consultant for HLS Therapeutics and Thermo Fisher Scientific.