Myxovirus resistance (MX) proteins are pivotal players in the innate immune response to viral infections. Less than 10 years ago, three independent groups simultaneously showed that human MX2 is an interferon (IFN)-stimulated gene (ISG) with potent anti-human immunodeficiency virus 1 (HIV-1) activity. Thenceforth, multiple research works have been published highlighting the ability of MX2 to inhibit RNA and DNA viruses. These growing bodies of evidence have identified some of the key determinants regulating its antiviral activity. Therefore, the importance of the protein amino-terminal domain, the oligomerization state, or the ability to interact with viral components is now well recognized. Nonetheless, there are still several unknown aspects of MX2 antiviral activity asking for further research, such as the role of cellular localization or the effect of post-translational modifications. This work aims to provide a comprehensive review of our current knowledge on the molecular determinants governing the antiviral activity of this versatile ISG, using human MX2 and HIV-1 inhibition as a reference, but drawing parallelisms and noting divergent mechanisms with other proteins and viruses when necessary. One of the first cellular defenses against viral infection is the production of interferons (IFNs). IFNs are cytokines with pro-inflammatory and immunomodulatory activities, which induce the upregulation of IFN-stimulated genes (ISGs) ,2,3. TheMX2, which arose from an ancient duplication event. This has resulted in two different lineages, the MX1-like and the MX2-like lineage. Interestingly, rodent Mx2 is similar to human MX2 (hMX2/MXB), only by name, since the rodent Mx2 gene is a paralog of Mx1, while the human-like Mx2 was lost during evolution. Similarly, fish, birds, and reptiles do not have a human-like Mx2 gene  different viral families are inhibited by the same MX2 protein, highlighting the important role of this protein on the IFN response to infection, and (ii) the viral and MX2 determinants governing this inhibition are diverse, with the only commonality of the direct interaction between MX2 and a viral component. Therefore, hMX2 interacts with the capsid (CA) of HIV-1 ,36,37, tA summary of all existing data linking MX2 proteins with the viruses they restrict can be found in hMX1 and hMX2 proteins belong to the family of large dynamin-like GTPases and share a 63% sequence identity at the amino acid level. Due to its earlier recognition as an important viral restriction factor, hMX1’s structure was resolved over a decade ago ,60, as rOwing to their similarity, the hMX2 structure resembles that of hMX1. Therefore, G domain, BSEs, and stalk domain are distributed analogously B 35,62],6235,62]Comprehensive structural and biochemical characterizations of hMX2 have determined the existence of four different interaction interfaces. Interface II, located on the stalk domain, is essential for dimerization and includes residues Met574 or Tyr651, whose mutation renders monomeric forms of hMX2 ,62,63,64hMX2 exists as two isoforms of ~76 and ~78 KDa, both IFN-inducible, due to the presence of an alternative start codon at position 26 ,68. ThisSome important features for the NTD antiviral function have been identified. A stretch of three arginines spanning positions 11 to 13 is critical for the HIV-1 inhibitory activity of hMX2 and the mutation of these residues to alanine or lysine produced inactive proteins . The speIn contrast, the triple-arginine motif is not required for HSV-1 inhibition  and, theAs discussed before, MX proteins form large oligomers owing to the presence of different interaction interfaces. By analyzing the antiviral activity of interface II mutant proteins such as M574D or Y651D, it was shown that monomeric forms of hMX2 are not capable of HIV-1 restriction ,62,63,64Akin to HIV-1 inhibition, HSV-1 infection is not restricted by the monomeric mutant M574D . In conthMX1 exploits its GTPase activity to inhibit viral infection ,76, and The role of GTPase activity in herpesvirus inhibition is less clear. Therefore, while all available data agree on the inability of K131A to inhibit MCMV and HSV-1 infection, there is not a clear picture for the requirement of GTP binding. Schilling and colleagues found that mutant T151A inhibited HSV-1 and MCMV replication  but not infection by murine gamma herpesvirus 68 , pointing to different hMX2 requirements for the inhibition of distinct herpesviruses . HoweverWhile GTPase activity is not necessary for HIV-1 inhibition, the G domain itself plays an important role. Interaction data generated using truncated forms of hMX2 lacking the whole NTD found that these proteins still bind to HIV-1 CA ,37, supp+ elite controller patients  bear CA mutations such as G116A, reducing susceptibility to hMX2 inhibition [The existence of multiple interacting points between hMX2 and CA highlights the complexity of the inhibitory mechanism. Proof of the physiological importance of the hMX2-CA interaction is provided by a recent work reporting how viruses isolated from HLA B27/B57hibition . In facthibition .Intracellular staining shows that hMX2 decorates the nuclear envelope and forms cytoplasmic puncta ,43,58,80It is still unclear how hMX2 localization affects viral inhibition, mostly due to the difficulty of isolating this individual feature from others. Therefore, while deletion of the first 25 amino-terminal residues produces the cytoplasmic accumulation of the protein, it also eliminates other pivotal modulatory activities of the NTD. Nevertheless, several studies have found a correlation between the extent of nuclear envelope accumulation and the potency of inhibition ,74,82. TThe available evidence for herpesvirus inhibition supports a picture akin to HIV-1, showing that the hMX2 short isoform is not antiviral ,40,42,45One of the first CA mutants to be identified as hMX2-resistant was the P90A virus. Pro90 is located on an exposed CA loop named cyclophilin binding loop for being the interaction point of human cyclophilin A (CypA), a well-known HIV-1 cofactor ,84. This+ T cells and linked to reduced nuclear envelope accumulation of hMX2. Further support for the role of nuclear pore proteins on hMX2 antiviral activity can be found in an impressive work by Kane and colleagues, who systematically depleted every single nuclear pore protein and analyzed their effect on hMX2 inhibitory activity. These authors showed that hMX2 requires the participation of some NUPs  for its ability to restrict HIV-1 replication, but this varies with the cell line analyzed. They also found that NUP358 is required for the recruitment of hMX2 to the nuclear pore late in mitosis [In a yeast two-hybrid screening against a human leukocyte cDNA library, several nucleoporins (NUPs) and nuclear pore proteins were scored as interactors of hMX2. Further validation of this screening found that the depletion of nucleoporin 214 (NUP214), transportin 1 (TNPO1), and, especially, both together significantly reduced the antiviral activity of hMX2 in HeLa cells . Importa mitosis . Finally mitosis . What is+ T cells, and dendritic cells by reducing the level of dNTPs available for reverse transcription [hMX2 has been proposed as a necessary player for the antiviral activity of HIV-1 restriction factor SAM domain and HD domain-containing protein 1 (SAMHD1). SAMHD1 inhibits HIV-1 infection in macrophages, resting CD4cription ,88. By dcription . Similarcription . A modelcription . Howevercription .A mass spectrometry screen directed to identify hMX2-associated factors resulted in the discovery of two proteins, named myosin phosphatase target subunit 1 (MYPT1) and protein phosphatase 1 catalytic subunit-β (PPP1CB), both members of a holoenzyme called myosin light chain phosphatase (MLCP), a serine/threonine phosphatase . It was Further investigation revealed several other hMX2 positions phosphorylated. The mutation of most of these residues to alanine (blocking the possibility of phosphorylation) or to aspartic acid did not affect hMX2 antiviral activity . HoweverhMX2 has been shown to inhibit the nuclear import of non-viral cargo. Therefore, hMX2 blocks the nuclear translocation of a chimeric GFP-LacZ protein attached with nuclear localization signals (NLSs) from C-MYC, DDX21, KNS, and hMX2 itself . IntereshMX2 binds to the mitochondria membrane, and this is especially apparent in hepatoma cell lines, such as Hep3B or Huh7, and human primary hepatocytes where MX2 basal levels are high . InteresLastly, hMX2 has been proposed to restrict HIV-1 infection by an alternative mechanism involving the inhibition of the viral Rev protein . AccordiThe number of viruses inhibited by hMX2 is growing fast see . HoweverSimilarly, we still do not know exactly what cellular fraction of hMX2 is responsible for viral inhibition, with both (cytoplasmic and nuclear envelope) having some role ascribed. A comparison between hMX2 and eMX2 could answer this question since both proteins seem to inhibit HIV-1 infection through a similar mechanism while showing rather different cellular distribution. Likewise, while we know the importance of hMX2 phosphorylation for its anti-HIV-1 activity we do not know if other hMX2-inhibited viruses are similarly affected. It is possible to envision a scenario where differently phosphorylated forms of hMX2 inhibit different subsets of viruses.Finally, it would be important to understand the non-antiviral activities of MX2, such as mitochondria metabolism regulation or the inhibition of nuclear import, because this could inform us of the not-yet-appreciated antiviral features of MX2 or, at a minimum, gives us some insight into the role played by this protein on cell metabolism. What is clear is that the antiviral mechanism/s of MX2 is/are complex, with several protein features involved in their regulation, granting further research on this molecular Swiss army knife.


Background: Complete microbial eradication from the root canal and 3-dimensional obturation of the canal space are necessary for an efficient root canal procedure.Enterococcus faecalis.Aim: The current research was conducted to assess the antimicrobial effectiveness of herbal root canal irrigants and Chlorhexidine against E. faecalis (ATCC) bacterial culture overnight before it was inoculated onto Mueller-Hinton agar plates. Agar-well diffusion was used to measure antibacterial inhibition. Respective propolis, Triphala, aloe vera, and chlorhexidine irrigants were added to the appropriate wells in agar plates and incubated for 24 hours at 37°C. Each well's bacterial inhibition zone was measured and recorded. Statistics were used to tabulate and analyze the results.Materials and methods: The brain heart infusion (BHI) broth was used to grow the E. faecalis, subsequently propolis and Triphala, and the lowest by A. vera extract.Results: Chlorhexidine indicated the maximum inhibitory zone against E. faecalis. These irrigants are therefore, suitable for use as root canal irrigating solutions.Conclusion: Propolis, Triphala, and aloe vera were tested herbal remedies that demonstrated an inhibitory zone against  Enterococcus faecalis is the only source of infection in failed root canals and apical periodontitis . The antibacterial inhibition zones around propolis, Triphala, aloe vera, and chlorhexidine medications were identified using the agar disc diffusion method. The whole process was conducted using the asepsis method. Each medication was placed in the appropriate well of the BHI agar plates, which had been prepared. The plates were kept in a 37°C incubator for 24 hours. The bacterial inhibition zone around each well was measured after the plates had been incubated  in contrast to our study. [E. faecalis, according to [E. faecalis [In the current study, chlorhexidine had the highest antimicrobial effectiveness against faecalis . Our stuThe main benefits of using herbal substitutes are their accessibility, affordability, low toxicity, and longer shelf life. Additionally, they provide significant therapeutic advantages and are more affordable than synthetic alternatives . To confLimitation of the study: The present study was an in vitro study with a limited sample size. A major disadvantage of herbal extracts is the need for fresh preparation and modification in taste for acceptability.E. faecalis. Tested herbal substitutes have low toxicity, increased shelf life, and are easily accessible. As a result, these herbal irrigants are also appropriate to use in root canals. Since the majority of studies are ex vivo, there is little information available regarding the efficiency, safety, and higher quality of these products for use in dentistry; hence additional in vivo studies must be conducted to confirm the result of the study.Chlorhexidine is considered as a strong antimicrobial agent. Alternative herbal medications have been tried as a result of sodium hypochlorite and chlorhexidine's side effects. The present study showed that chlorhexidine, followed by propolis, Triphala, and aloe vera, developed an antimicrobial inhibition zone against


Albumins from animals are highly cross-reactive allergens for patients suffering from immunoglobulin E (IgE)-mediated allergy. Approximately 20-30% of cat and dog allergic patients show IgE reactivity and mount IgE-mediated allergic reactions to cat and dog albumin. It is astonishing that allergic patients can develop specific IgE responses against animal albumins because these proteins exhibit a more than 70% sequence identity to human serum albumin (HSA) which is the most abundant protein in the blood of the human body. The sequence identity of cat albumin (Fel d 2) and dog albumin (Can f 3) and HSA are 82% and 80%, respectively. Given the high degree of sequence identity between the latter two allergens and HSA one would expect that immunological tolerance would prohibit IgE sensitization to Fel d 2 and Can f 3. Here we discuss two possibilities for how IgE sensitization to Fel d 2 and Can f 3 may develop. One possibility is the failed development of immune tolerance in albumin-allergic patients whereas the other possibility is highly selective immune tolerance to HSA but not to Fel d 2 and Can f 3. If the first assumption is correct it should be possible to detect HSA-specific T cell responses and HSA-containing immune complexes in sensitized patients. In the latter scenario few differences in the sequences of Fel d 2 and Can f 3 as compared to HSA would be responsible for the development of selective T cell and B cell responses towards Fel d 2 as well as Can f 3. However, the immunological mechanisms of albumin sensitization have not yet been investigated in detail although this will be important for the development of allergen-specific prevention and allergen-specific immunotherapy (AIT) strategies for allergy to albumin. Escherichia coli (E. coli) has then been shown to cross-react with albumins from several different animals . Albumins are water soluble and in contrast to many other blood proteins are not glycosylated. The word albumin has its origins in the word “albumen”, which means protein, and the Latin root word “albus” meaning white, and refers to the white color of egg white when eggs are cooked. Serum albumin is synthesized in and secreted from liver cells as a single-chain protein. Human serum albumin consists of 585 amino acids and according to its sequence has a molecular mass of 66,500 Da  in the blood which can bind various endogenous, exogenous ligands as well as drugs , 15  which assemble in the form of a heart-shaped protein . Each fuAs already indicated, serum albumin plays an important role in the pharmacokinetics of drugs, especially their distribution in the human body. In 1975, G. Sudlow discovered two different types of sites on serum albumin where dansyl-L-asparagine (DNSA) and dansylsarcosirie could be displaced by drugs using fluorescent probe displacement assays . Fatty ahttp://www.allergen.org/viewallergen.php?aid=320; Protein sequence: https://www.ncbi.nlm.nih.gov/protein/CAA59279). If one constructs a phylogenetic tree displaying evolutionary relationships of albumins from various species based on sequence features  is the most frequently recognized albumin allergen . It consfeatures Figure 1features . These sfeatures . The amifeatures , 28–44. Fagales , and PR10 allergens expressed in somatic plant tissues  has been extensively described and explains varying degrees of allergic symptoms in PR10-sensitized patients  and other plants, also known as PR10 allergens comes into mind , 46. IgEpatients , 48. As patients .Likewise, differences in IgE reactivity in terms of specific IgE levels and presumably affinities/avidities of IgE antibodies to albumins have been observed . AccordiThe remaining question is why there is no relevant IgE reactivity to HSA in Fel d 2 and Can f 3-sensitized patients. Again, one possible answer to this may come from previous observations made for the cross-reactive family of the Bet v 1-related PR10 allergen family. In fact, when Cor a 1, the major allergen of hazel pollen, was characterized at the molecular level by PCR and cDNA cloning it was realized that hazel pollen contains highly IgE-reactive and allergenic Cor a 1 isoforms but at the same time, basically non-IgE reactive Cor a 1 isoforms were discovered which differed from the highly allergenic Cor a 1 isoforms only by few important amino acid exchanges . LikewisAlbumin appears to have little resistance to gastrointestinal digestion and/or heating, which would be features of class 1 food allergens to which patients become sensitized by the oral route –62. NeveSuch a diagnostic procedure may help clarify what type of IgE sensitization dominates in the various clinical syndromes that are attributed to IgE cross-reactivity to albumins Table 3 The cat-pork syndrome has been widely reported in recent years, usually in people with respiratory allergies to cat dander or hair who develop acute allergic reactions to pork. It was first reported for patients eating pork after being exposed to cat hair and shown to cause digestive or even systemic allergies , 65–67. It is also possible that cat-allergic patients contain anti-BSA IgE antibodies reacting with milk. J Vicente-Serrano  and KarsLikewise, it was reported that cat-allergic patients had a severe anaphylactic reaction to BSA after artificial insemination with BSA-containing sperms, and after measurement of serum, IgE reactivity to serum albumin from other mammals such as cats, dogs, and pigs was found . SimilarThe bird-egg syndrome was first reported in 1985 when a parrot owner developed respiratory and cutaneous allergic reactions after ingesting egg yolk . After iFor all the aforementioned syndromes, measurement of IgE levels specific for a panel of albumins from the different allergen sources by molecular diagnosis and eventually IgE inhibition experiments will in addition to the measurement of IgE sensitization to source-specific marker allergens provide information about the genuinely sensitizing allergen source for precision-medicine-based approaches for treatment and prevention.Several observations suggest that animals may develop immunological hypersensitivity reactions to HSA. BSA and HSA have been shown to be highly immunogenic in mice in fundamental studies in immunology –91. FurtSubcutaneous sensitization with Aluminum-hydroxide-adsorbed Can f 3 was found to induce strong Can f 3-specific IgE responses as well as Can f 3-specific IgG responses in a murine model of IgE-mediated allergy . HSA hasThe aforementioned examples thus demonstrate that it is possible to induce immunological hypersensitivity and in particular IgE-mediated hypersensitivity against albumin in experimental animal models. Moreover, certain of these animal studies demonstrate that it is possible to prevent the induction of albumin-specific hypersensitivity by the induction of oral tolerance .Due to the similarity of HSA and animal albumins, it is quite possible that patients allergic to animal albumins also contain antibodies and T cells reactive to HSA. Indeed, the appearance of anti-HSA antibodies in patients with systemic lupus erythematosus has been reported . FurtherIgE-auto-reactivity due to cross-reactivity of foreign antigens –117 as wHowever, so far the presence of IgE antibodies specific to HSA could not be demonstrated and we are not aware of attempts to search for HSA-specific T cells in albumin-allergic patients. The question is therefore what the reason could be that so far no IgE antibodies specific for HSA could be detected. If there were HSA-specific IgE antibodies in albumin-allergic patients, these antibodies would occur in extremely low amounts. Given the high abundance of HSA in the blood HSA-specific IgE antibodies would therefore be completely adsorbed by HSA in the form of immune complexes and accordingly will not react in tests measuring IgE reactivity to solid phase bound HSA. The only possibility to detect HSA-reactive IgE would then be to try isolating such putative IgE-HSA immune complexes but this has not yet been done successfully. If indeed such IgE-HSA immune complexes and HSA-specific T cell responses could be found in albumin-allergic patients one may consider failed immunological tolerance as a reason for albumin-specific IgE and T cell responses in albumin–allergic patients Figure 4The second possibility is that patients allergic to exogenous albumins are selectively sensitized to the exogenous albumins, but not to HSA due to highly selective tolerance Figure 4Besides the induction of T cell-based tolerance, AIT based on vaccines containing allergens or recombinant allergen derivatives is another possibility for allergen-specific treatment and prevention of allergy . The indAlbumins from various animals, especially from cats and dogs, are important allergens for allergic patients with respiratory allergy and may contribute to symptoms of food allergy upon intake of albumin-containing food. Despite a high degree of sequence and structural similarity among exogenous albumins and human serum albumin, it is not known whether albumin-allergic patients show HSA-specific auto-reactivity or have developed selective tolerance. Unraveling the mechanisms and epitopes involved in allergy to albumins is important for at least two reasons. First of all, molecular diagnostic tests based on albumins from different sources may help to identify the genuinely sensitizing allergen source and guide precision medicine-based forms of allergen-specific forms of treatment and prevention. Second, knowledge regarding possible auto-reactivity to albumin in sensitized albumin allergic patients and about the potential risks of inducing albumin-specific auto-reactivity may help improve allergen-specific forms of treatment and prevention of patients allergic to animals.ZL and DT contributed to the design of the study, interpreted the findings, and wrote the manuscript. RV, AlK, and MK designed the study and contributed to the interpretation of the findings, writing and revising the manuscript. ZL, DT, IT, KR, AnK, EK, OE, MK, T-HC, MF-T, AlK, and RV provided materials, references, and/or figures/Tables, and read and revised the manuscript. All authors contributed to the article and approved the submitted version.


Thirty patients were included and classified into the CCD( +) and CCD( −) groups . Statistics showed that before iPBM, CCD in the CCD( +) group was 2.74 (exp 1.0081) times higher than that of CCD( −) group (p = 0.1632). After iPBM, the CCD was 0.64 (exp-0.4436) times lower in the CCD( +) group than in the CCD( −) group (p < 0.0001). Cognitive assessment revealed that, before iPBM, the CCD( +) group had a non-significantly 0.1030 lower LCF score than that of CCD( −) group (p = 0.1632). Similarly, the CCD( +) group had a non-significantly 0.0013 higher score than that of CCD( −) after iPBM treatment (p = 0.7041), indicating no significant differences between the CCD( +) or CCD( −) following iPBM and general physical therapy. CCD was less likely to appear in iPBM-treated patients. Additionally, iPBM was not associated with LCF score. Administration of iPBM could be applied in TBI patients to reduce the occurrence of CCD. The study failed to show differences in cognitive function after iPBM, which still serves as an alternative non-pharmacological intervention.The association between intravascular photobiomodulation (iPBM) and crossed cerebellar diaschisis (CCD) and cognitive dysfunction in patients with traumatic brain injury (TBI) remains unknown. We postulate that iPBM might enable greater neurologic improvements. The objective of this study was to evaluate the clinical impact of iPBM on the prognosis of patients with TBI. In this longitudinal study, patients who were diagnosed with TBI were recruited. CCD was identified from brain perfusion images when the uptake difference of both cerebella was > 20%. Thus, two groups were identified: CCD( +) and CCD( −). All patients received general traditional physical therapy and three courses of iPBM . Treatment assemblies were conducted on weekdays for 2 consecutive weeks as a solitary treatment course. Three courses of iPBM were performed over 2–3 months, with 1–3 weeks of rest between each course. The outcomes were measured using the Rancho Los Amigos Levels of Cognitive Functioning (LCF) tool. The chi-square test was used to compare categorical variables. Generalized estimating equations were used to verify the associations of various effects between the two groups.  The symptoms of traumatic brain injury (TBI) can range from mild changes in consciousness to severe coma and death. These are affected by diffuse damage and swelling throughout the brain . TBI resMoreover, some symptoms, including ataxia, postural instability, tremor, and impairments in balance and fine motor skills, are found in TBI. These may be attributed in part to cerebellar damage or so-called hypometabolism  due to tPhotobiomodulation (PBM) is basically a function of energy absorption by utilizing non-ionizing forms of light sources to induce cascade of biological reactions in a specific photoacceptor . PMB canIntravascular photobiomodulation (iPBM) has been advocated as a non‐pharmacological treatment, and new articles sprang up like bamboo shoots after a spring rain since 1990. The use of iPBM shows high efficacy in the treatment of diabetes, coronary artery disease, and other pathological processes over the past few decades –31. To dWe postulate that this intervention may enable better neurologic improvements in patients with TBI. Our study employed a longitudinal method to confirm the effect of iPBM on individuals with TBI. Rancho Los Amigos Levels of Cognitive Functioning (LCF) and SPECT measurements were used to assess the cognitive function and CCD conditions before and after the improvement from iPBM, respectively.The human ethics committee of the medical centre approved this study (TSGHIRB No. 2–101-05–049), which conformed to the principles of the Declaration of Helsinki. This was a prospective study. Patients who were diagnosed with TBI were recruited from the inpatient or outpatient areas of the Tri-Service General Hospital, Taiwan  history of traumatic brain injury in the recent 3 years without or with surgical intervention, including ventriculoperitoneal shunting; (2) regional brain perfusion SPECT conducted in the Department of Nuclear Medicine; and (3) mild to moderate cognitive impairment as measured by the LCF.Exclusion criteria were (1) simultaneous cerebellar abnormalities or cerebral pathology in both sides; (2) blurred brain perfusion SPECT images owing to intolerance or uncooperative behaviour of patient during test ; (3) significantly reduced tracer uptake within the both cerebella; (4) cerebellar diaschisis ipsilateral to the injured side; (5) insufficient or incomplete LCF data measurements; (6) the interval between the SPECT scan and investigation of iPBM was longer than 3 weeks; and (7) a history of brain tumour, or prior brain infection.Brain SPECT images were acquired after intravenous shot of the tracer, ethyl cysteinate dimer (Tc-99 m-ECD). This was purchased from a commercial kit  and prepared by including 25 mCi of freshly eluted Tc-99 m pertechnetate to 5 mL of saline solution. Imaging commenced 30 min after injection of the radiotracer using a dual-headed camera furnished with very high-resolution fan-beam collimators. Data were obtained in a 128 × 128 matrix with a 1.4 × zoom through 360° (180° for each head) with rotation at 3° intervals, for 30 s per angle step. Images were built utilizing a back-projection method  with a MCognitive evaluation was performed using the LCF  tool bef2, total energy 9.00–13.68 J, exposure time 60 min, and energy density 4591.84–6976.60 J/cm2 [Patients with CCD received three courses of iPBM . This was applied with visible red light at a wavelength of 632.8 nm, power output 2.5–3.8 mW (milliwatts), power intensity 1.28–1.94 W/cm60 J/cm2 . This waThe sum of blood irradiated in an assembly was hypothesized to be near 100% of the total blood volume, as the regional-arm-to-brain mean transit time calculated using a radionuclide required < 30 s . Based on = 15 per group). The chi-square test was used for categorical variables. Generalized estimating equations (GEEs) were used to verify the associations of varying effects  in the two groups and to adjust the potential confounders . A p value of 0.05 or less indicated a statistically significant difference. After establishing the concluding GEE models for CCD and LCF score, contrast estimates were then calculated. All data analyses were carried out using the PROC GENMOD function of SAS version 9.4 .The differences in characteristics of those patients were compared between the two groups (n = 15 patients per group). The interval between TBI onset and the time of the iPBM ranged from 0.7 to 1.8 years. The interval between the SPECT scan and the intervention of iPBM ranged from 3 to 7 days. Table Thirty patients with a diagnosis of mild-to-moderate TBI that fit the inclusion criteria completed clinical testing and treatment (p = 0.1632). After iPBM, the CCD( +) had a 0.64 (exp − 0.4436) times lower CCD than the CCD( −) group (Table p < 0.0001). Cognitive assessment revealed that, before iPBM, the CCD( +) group had a non-significantly 0.1030 lower LCF score than that of CCD( −) group (Table p = 0.1632). Similarly, the CCD( +) group had a non-significantly 0.0013 higher score than that of CCD( −) after iPBM treatment (Table p = 0.7041), indicating no significant differences between the CCD( +) or CCD( −) following iPBM and general physical therapy.After GEEs accounting for between-group difference, within-group variation, and the group-by-time interaction effects, we found that before iPBM, the CCD( +) group had a 2.74 (exp 1.0081) times higher CCD than the CCD( −) group  or CCD( −). We found that the phenomenon of CCD could be reduced in iPBM-treated patients. Furthermore, we found that the iPBM was not associated with LCF score. To the best of our knowledge, this is the first study to assess the associations between iPBM treatment and the outcomes of the patients with TBI.Poor long-term outcomes in TBI, including headache, cognitive difficulties, and imbalance, may frequently co-exist with CCD ; therefoThe efficacy of laser therapy may be multifaceted. First, iPBM promotes functional regeneration and alleviates oxidative stress and mitochondrial dysfunction in living bodies . This haWe evaluated cognitive function using the Rancho Los Amigos LCF tool. We observed no significant differences between the patients following iPBM and general physical therapy. The possible explanation is that LCF could not correspond with the dimensional structure of the original tool . CurrentWith respect to the matter of ipsilateral cerebellar diaschisis (ICD), one of exclusion criteria, only very few articles have been documented as opposed to CCD. Lenzi et al. first reported three cases of 15 adults with cerebral ischemia having ICD . ICD alsn = 30). Even so, we add the pre- and post-iPBM material up to obtain 60 sets of data, which is still an opportunity to implement statistics. Further, we used the GEEs, which itself is designed to target small sample size, and yielded meaningful results in CCD times post-treatment. Finally, our study did not assess the effects of different wavelengths, duration, dose, energy density, and power density for each individual treatment. In addition, multiple iPBMs were performed; further studies are needed to clarify the duration until tolerance develops.There are some potential limitations to our study. First, the study design collected data for only 3 months; therefore, we could not assess any long-term effects. Second, the sample size was small (CCD is a negative prognostic factor for neurological recovery. Administration of iPBM could be applied in patients with TBI patients to reduce the occurrence of CCD. The study failed to show differences in cognitive function after iPBM. Therefore, it serves as an alternative non-pharmacological and surgical intervention.


Immunoglobulin E (IgE)-mediated food allergies to wheat that develop after school age typically shows a type of wheat-dependent exercise-induced anaphylaxis (WDEIA). At present, avoidance of wheat products or postprandial rest after ingesting wheat is recommended for patients with WDEIA, depending on the severity of the allergy symptoms. ω5-Gliadin has been identified as the major allergen in WDEIA. In addition, α/β-, γ-, and ω1,2-gliadins, high and low molecular weight-glutenins, and a few water-soluble wheat proteins have been identified as IgE-binding allergens in a small proportion of patients with IgE-mediated wheat allergies. A variety of approaches have been manufactured to develop hypoallergenic wheat products that can be consumed by patients with IgE-mediated wheat allergies. In order to analyze such approaches, and to contribute to the further improvement, this study outlined the current status of these hypoallergenic wheat productions, including wheat lines with a reduced allergenicity that are mostly constructed for the patients sensitized to ω5-gliadin, hypoallergenic wheat by enzymic degradation/ion exchanger deamidation, and hypoallergenic wheat by thioredoxin treatment. The wheat products obtained by these approaches significantly reduced the reactivity of Serum IgE in wheat-allergic patients. However, either these were not effective on some populations of the patients, or low-level IgE-reactivity to some allergens of the products was observed in the patients. These results highlight some of the difficulties faced in creating hypoallergenic wheat products or hypoallergenic wheat lines through either traditional breeding or biotechnology approaches in developing hypoallergenic wheat completely safe for all the patients allergic to wheat. Considering the immune response to wheat, wheat allergies can be divided into immunoglobulin E (IgE)- and non-IgE-mediated reactions . The patThe IgE-mediated food allergies due to wheat that appear during childhood generally develop resistance at a high rate . AccordiAllergen immunotherapy has been used for the IgE-mediated food allergies and can increase the threshold of reactivity to a variety of foods . Wheat oAccording to their chemical properties, wheat proteins are classified as water-soluble albumin, salt-soluble globulins, aqueous alcohol-soluble gliadins, and diluted acid- or alkali-soluble glutenins ,14. Glia1PX2QQ  [To date, a variety of allergens and their IgE-binding epitopes have been identified according to the type of wheat allergy . Table 1 E or G) ,20,21,22 E or G) ,20. The  E or G) . Since t E or G) . α/β-Gli E or G) ,22. The  E or G) .Owing to their close phylogenetic relationship, secalins of rye and hordeins of barley share closely related amino acid sequences with wheat gluten proteins . HMW-gluAn outbreak of wheat allergy (mostly WDEIA) caused by hydrolyzed wheat protein (HWP) occurred in Japan from 2008 to 2010 ,32,33. TRecently, wheat peroxidase-1 and β-glucosidase have been identified as specific IgE-binding allergens that cross-react with grass pollen allergens in the patients with WDEIA who developed a grass pollen allergy ,35.In order to develop wheat products that can be consumed by patients with IgE-mediated wheat allergies, especially WDEIA, a variety of approaches were developed to remove the major wheat allergens described above. These are wheat lines with a reduced allergenicity that are mostly constructed for the patients sensitized to ω5-gliadin, hypoallergenic wheat by enzymic degradation/ion exchanger deamidation, and hypoallergenic wheat by thioredoxin treatment. Wheat lines with a reduced allergenicity were established using either natural occurring wheat deletion lines of allergen genomes or transgenic wheat lines with RNA interference technique. Hypoallergenic wheat were produced by either epitope degradation with specific enzymes after identifying their epitopes using serum IgE of the patients with wheat allergy complicated with AD, or deaminating amino groups of glutamine and/or asparagine within the epitopes by treating with cation exchange resin. A subsequent attempt was made to dissociate disulfide bonds in gluten proteins, such as gliadin and glutenin, to reduce allergenicity using reducing agent thioredoxin. These methods to develop hypoallergenic wheat, and their outcomes, are summarized in Gli-A1 and Gli-D1loci on the short arms of the Group 1 chromosome, whereas ω5-gliadin is encoded on the Gli-B1 locus on chromosome 1B [Gli-B1 locus for reactivity to rabbit ω5-gliadin-specific antiserum and IgE from 10 patients, including those with WDEIA. They found that 1BL/1RS translocated wheat, in which a part of the short arm of the 1B chromosome was replaced with a portion of the short arm of the 1R chromosome of rye, lost reactivity to ω5-gliadin when tested using rabbit ω5-gliadin-specific antiserum [The major allergen in WDEIA is ω5-gliadin, which accounts for only a minor proportion of gluten. Among several ω-gliadins, ω1,2-gliadins are encoded by osome 1B ,66. Denentiserum . In addintiserum ,38. Thesntiserum .Triticum monococcus, an earliest cultivated A genome diploid einkorn, in 14 patients with WDEIA sensitized with ω5-gliadin. A skin prick test using soluble and insoluble extracts failed to induce reactivity in almost all the patients tested. IgE-immunoblotting showed an absence of ω5-gliadin in the proteins of Triticum monococcus, although a variety of reactions were observed with limited cross-reactivity to ω5-gliadin [Triticum monococcus might be a potential candidate for the production of hypoallergenic bakery products in patients sensitized to ω5-gliadin [Lombardo et al. examined the allergenicity of -gliadin . As some-gliadin .Gli A1, Gli B1 and Gli D1) and investigated the reactivity of Serum IgE in several patients with wheat allergies . Although IgE binding to 60 kDa ω5-gliadin was lost in the hybrid line only in one patient with possible WDEIA, the hybrid line was immune-reactive against patients’ IgE with many gluten proteins, including α/β-, γ-gliadins, LMW-glutenin, and non-gluten proteins [Using a traditional breeding method, Waga, et al. established a winter wheat line possessing hybrid genotypes lacking all ω-gliadin coding loci , in which the end of the short arm of chromosome 1B was deleted, lacked the ge model . FurtherYokooji et al. found that the ω5-gliadin content of 1BS-18 Hokushin was 1.21 mg/g gluten, and this is much lower than that of euploid Hokushin (5.17 mg/g gluten) and another Japanese wheat cultivar Norin 61 (5.65 mg/g gluten); ELISA with rabbit polyclonal antibodies specifically recognizing the IgE-binding epitope sequences (KQQSPEQQQFPQQQIPQQQ) of ω5-gliadin was used for the assessment. They speculated that the slight detection of ω5-gliadin in the 1BS-Hokushin was due to cross-reactivity with gliadin components other than ω5-gliadin . Yamada The hypoallergenicity of 1BS-18 Hokushin and another wheat line, 1BS-18 Minaminokaori, was investigated using immunoblotting, and the lack of ω5-gliadin was determined using Serum IgE, which was obtained from patients with WDEIA as well as rabbit polyclonal antibodies against ω5-gliadin epitope peptide. The evaluation for allergenicity showed faint or no reaction bands corresponding to ω5-gliadin . AlthougGlu-B3 and Gli-B1 loci having selective deletions in ω5-gliadin, as well as some LMW glutenins and γ-gliadins using IgE-immunoblotting with sera from patients with WDEIA, and found that the gliadin and glutenin fractions of DH2 had less binding of IgE from the patients compared with that of the wild type wheat line [Lee et al. investigated the allergenicity of wheat mutant line DH20, with a defect in the chromosome B eat line ,47. In aGli-B1 locus of Chromosome 1B [Gli-B1 locus, although they have a TRQ N-terminal amino acid sequence and altered C-terminal amino acid sequence compared with the Gli-B1 ω5-gliadin [Notably, two-dimensional immunoblot analysis revealed the existence of several minor but highly immunogenic ω5-gliadin proteins in a wheat mutant line, DH20, with a deletion of 5.8 Mb, including the osome 1B . These p-gliadin . It is nGli-B1 locus. In the short-to-medium term, these wheat products are expected to be costly because of the high cost of the cultivar development using the transgenic processing. Therefore, it may be more appropriate to supply these products to ω5-gliadin-sensitized patients with WDEIA, who are restricted from using wheat products.Altenbach et al. showed that the ω5-gliadin protein was either undetectable or depleted in two transgenic wheat lines with reduced levels of ω5-gliadin using the RNA interference technique ,51. IgE-Based on the results of IgE-binding epitope analysis of wheat allergens, hypoallergenic wheat flour was subjected to enzymatic modification or deamidation. Tanabe et al. identified IgE epitopes of gluten protein allergens using Serum IgE from patients with AD. They first identified a 30-mer peptide corresponding to a part of the amino acid sequence of LMW glutenin, and then determined that QQQPP is the smallest unit recognized by the patient’s Serum IgE. Substitution experiments with glycine revealed that the amino acids essential for IgE binding are the first Q, and the fourth and the fifth P . PastoreRecently, it has been clarified that the food allergies observed in children with AD are not caused by food allergens ingested orally, but by the cutaneous sensitization caused by a trace amount of food allergens that invade the lesions of AD . Since aSome reports have shown that the deamidation of wheat gliadin decreases allergenicity. Kumagai et al. performed the deamidation of gliadin using a cation exchange resin without affecting peptide-bond and investigated its allergenicity using a rat model as well as patients’ Serum IgE. Compared with undeamidated gliadin, the deamidated gliadin showed lower reactivity against Serum IgE obtained from patients with high levels of wheat-specific IgE, and induced lower levels of gliadin-specific IgE in the rat allergy model of oral administration . Abe et Disulfide bonds usually provide a digestion-resistant feature and increase the allergenicity of food proteins . Using aSince ω-gliadins contain no cysteine residues, they do not participate in the formation of the disulfide bridges that stabilize the gluten protein structure. However, the ω-gliadins interact with other proteins via weak, low-energetic hydrogen bonds. Stawoska et al. suggested that the elimination of ω-fractions from the gliadin complex causes minor modifications to the secondary structures of the remaining gliadin proteins, facilitating the interaction of IgE epitopes with IgE antibodies . NADPH aThe limitations of this study are that we have not presented details of the methods that have been used for developing the hypoallergenic wheat, and that the references written in English have been analyzed while the five references written in non-English languages have been omitted in the analysis among 61 references extracted using PubMed with the keyword “hypoallergenic wheat.”∗02:01:02, a susceptibility gene for WDEIA, could especially avoid a sensitization to ω5-gliadin if they would consume these hypoallergenic wheat products in their daily meals [Several approaches have been used to establish hypoallergenic wheat products that can be consumed by patients with IgE-mediated wheat allergies. These approaches are divided globally into two methods. One is the alteration of allergen epitopes by enzymatic degradation, deamidation, or the addition of reducing agents, and the other is the production of wheat lines that do not contain major allergen epitopes by traditional breeding or biotechnology. In particular, hypoallergenic wheat lines, which lack ω5-gliadin with transgenic or natural breeding techniques, significantly reduced the reactivity of Serum IgE in wheat-allergic patients while retaining the characteristics of flour, such as bread-making properties. However, low-level reactivity to wheat allergens in the wheat-allergic patients has also been observed in these wheat lines. This may be due to cross-reactivity between the epitopes of ω5-gliadin and similar amino acid sequences of other gluten proteins. It is also possible that the wheat-allergic patients have Serum IgE that reacts primarily with α/β-, γ-, and ω1,2-gliadins, or HMW- and LMW-glutenins. Given the complexity of the immune response of patients with WDEIA and the severity of the allergic reaction, it is not feasible for the patients with WDEIA to consume flour from wheat lines with a reduced allergenicity without a thorough analysis of the IgE reactivity of each patient’s serum. Better diagnostic methods should be developed to define sensitization conditions precisely in conjunction with hypoallergenic wheat products. These results highlight some of the difficulties faced in creating new hypoallergenic wheat lines through either traditional breeding or biotechnology approaches in developing hypoallergenic wheat for patients allergic to wheat. Nevertheless, the provision of new wheat lines with a reduced allergenicity in general populations may reduce the number of subjects sensitized to wheat proteins in the future. Subjects possesing HLA-DPB1ly meals . Hypoall


Conventionally, two 4.5 mm cortical screws inserted toward the posterior tibial cortex are usually advocated for the fixation of Fulkerson osteotomy. This finite element analysis aimed to compare the biomechanical behavior of four different screw configurations to fix the Fulkerson osteotomy.Fulkerson osteotomy was modeled using computerized tomography (CT) data of a patient with patellofemoral instability and fixed with four different screw configurations using two 4.5 mm cortical screws in the axial plane. The configurations were as follows: (1) two screws perpendicular to the osteotomy plane, (2) two screws perpendicular to the posterior cortex of the tibia, (3) the upper screw perpendicular to the osteotomy plane, but the lower screw is perpendicular to the posterior cortex of the tibia, and (4) the reverse position of the screw configuration in the third scenario. Gap formation, sliding, displacement, frictional stress, and deformation of the components were calculated and reported.The osteotomy fragment moved superiorly after loading the models with 1654 N patellar tendon traction force. Since the proximal cut is sloped (bevel-cut osteotomy), the osteotomy fragment slid and rested on the upper tibial surface. Afterward, the upper surface of the osteotomy fragment acted as a fulcrum, and the distal part of the fragment began to separate from the tibia while the screws resisted the displacement. The resultant total displacement was 0.319 mm, 0.307 mm, 0.333 mm, and 0.245 mm from the first scenario to the fourth scenario, respectively. The minimum displacement was detected in the fourth scenario . Maximum frictional stress and maximum pressure between components on both surfaces were highest in the first scenario (both screws perpendicular to the osteotomy plane).A divergent screw configuration in which the upper screw is inserted perpendicular to the osteotomy plane and the lower screw is inserted perpendicular to the posterior tibial cortex might be a better option for the fixation of Fulkerson osteotomy.Level of evidence Level V, mechanism-based reasoning. Tibial tubercle (TT) anteromedialization osteotomy, also called Fulkerson osteotomy, has become a standard surgical procedure in patients with patellofemoral (PF) instability associated with increased TT lateralization , 2. ThisProper planning and performance of the osteotomy, secure fixation, and maintaining the stable fixation until the bony union is crucial to prevent implant failure and complications , 5. The John Fulkerson first described anteromedialization tibial tubercle osteotomy in 1983 . In his Our study hypothesized that stability would increase if the screws were placed perpendicular to the osteotomy plane. Stable fixation is essential for the early initiation of rehabilitation and weight-bearing after the osteotomy, as well as the prevention of complications.This study utilized finite element methods that were carried out under static loading conditions and homogeneous isotropic linear elastic model assumptions. Besides, nonlinear contact behavior between related components was considered. Fulkerson osteotomy was generated, and the model was fixed with four different screw configurations.FEA is a numerical method that utilizes models and simulations to examine the mechanical behavior of an object under certain physical conditions in a virtual computer environment. In the finite element method, complex 3D geometric objects are divided into small elements connected with nodes; this procedure is also called spatial discretization. Models can be created using computerized tomography data to simulate real bony geometry. Material properties, contact definitions, and boundary conditions are defined and entered into the software. Finally, force–displacement equations of each small element can easily be computed and combined for the entire structure. Thus, displacements, including sliding and gapping, and strains and stresses arising from these displacements, can be calculated and visualized throughout the model and its components.Currently, the gold standard for assessing the initial stability of fracture or osteotomy fixation remains biomechanical testing using cadaveric models. However, FEA has several advantages over conventional biomechanical experiments. First, this method is cheaper than using fresh cadavers. Second, a complete inspection of the model throughout the entire structure is possible. Conversely, assessing internal strain and damage is exceptionally challenging in cadaver models.Additionally, it is unaffected by geometric variations and bone quality differences between cadavers, which is a significant confounding factor. Another advantage of FEA simulations over biomechanical testing is the ability to evaluate and compare alternative implant designs or configurations of the same implant within the same bone. Moreover, new implant designs might be tested and modified without manufacturing the final prototype. Besides these advantages, FEA inherits certain disadvantages. Simplifying complex geometry and using predefined assumptions regarding material properties and boundary conditions are the significant limitations of the technique. Secondly, the divergence of the models from clinical reality, model verification, and validation are other significant obstacles that might result in misleading interpretations. Since FEA is fundamentally a metamathematical method that finds approximated solutions to biomechanical problems, errors in FEA are inevitable. Thus above-mentioned pros and cons should be considered when evaluating the outputs –22.Computerized tomography (CT) data of a 20-year-old male patient (height 174 cm and weight 76 kg) with recurrent patellar dislocation was used to create the tibial model. The tibial tubercle–trochlear groove (TT–TG) distance was abnormal (23 mm), and Fulkerson osteotomy was indicated for the patient. A TT–TG distance larger than 20 mm is accepted as abnormal.The CT imaging was performed using the CT scanner  installed in the authors’ university hospital. The following were the scan parameters: a total of 232 axial slices were taken at 120 kV, 30 mA, slice distance of 1.0 mm, FoV: 218 mm, from the supracondylar femur to the proximal tibia. The patient gave written informed agreement to the anonymous use of the imaging files. To model and simulate the FEA scenarios, Materialise Mimics–Medical 3D image-based engineering software , SolidWorks parametric solid modeling software , and ANSYS Workbench FEA code  were used.The Fulkerson osteotomy was modeled following prior descriptions . The ostDavis et al.  found thThe accuracy of FEA simulation is considerably affected by the quality of the mesh structure of a model. The skewness metric, which defines how near to ideal a face or cell is in a finite element model, is one of the key quality measurements for a mesh structure in an FEA. The skewness of a distribution may be used to determine its shape and asymmetry, allowing mesh structure verification . A valueThe magnitude of maximum gap formation and sliding distance between the osteotomy fragment and the tibia were calculated Fig. . In addiAfter loading the models with 1654 N patellar tendon traction force, the osteotomy fragment moved superiorly. Since the proximal cut is sloped (bevel-cut osteotomy), the osteotomy fragment slid and rested on the upper tibial surface. Afterward, the upper surface of the osteotomy fragment acted as a fulcrum, and the distal part of the fragment began to separate from the tibia while the screws resisted the displacement.The average sliding through the upper and lower contact surfaces was the least in the fourth scenario . The average gap formation at the upper and lower contact surfaces was the least in the third scenario . The resultant total displacement was the least in the fourth scenario . Maximum frictional stress and maximum pressure between components on both surfaces were highest in the first scenario (FEA-001). The summary of the results is presented in Table Under predefined loading conditions, no permanent deformation or damage was detected on the screws. However, maximum equivalent (von Mises) stress values on the cortical and trabecular bone around the screw threads and the upper surface fulcrum point locally exceeded their yield stress points reported in previous studies , 36, 37.The fourth model (FEA-004) demonstrated the least magnitude of sliding distance in the upper surface of the osteotomy as well as the least magnitude of maximum displacement. Therefore, the fourth model emerged as the most favorable screw configuration, with the highest stiffness among these models. Based on the findings of the current study, a divergent screw fixation in which the upper screw is inserted perpendicular to the osteotomy plane and the lower screw is inserted perpendicular to the posterior tibial cortex might be recommended.The screw configuration proposed in this study has some advantages besides providing better stability. Two previous radiologic studies investigated the safe zone for TTO fixation to prevent iatrogenic popliteal vessel injury, a devastating complication of this procedure , 9. The Secondly, this screw configuration might reduce the number of implant removal operations. The tibial tubercle is in contact with various surfaces during kneeling. Due to its prominence and relatively thin overlying soft tissue, the skin over the tibial tubercle area is vulnerable to irritation. Moreover, prominent hardware causes significant discomfort. Therefore, hardware removal is the most frequent secondary surgical intervention performed following Fulkerson osteotomy . A previThe majority of previous biomechanical studies have assessed the fixation techniques of TTO used in the extended exposure of revision knee arthroplasty –19, 42. l-lactide (PLLA) screws with stainless-steel screws in the flat osteotomy. Although the stainless-steel screws demonstrated approximately two-fold higher stiffness, the authors reported that the PLLA screws could resist the tractive forces of active knee extension. Furthermore, Ünal et al. [Cosgarea et al.  comparedl et al.  have repThree previous FEA studies investigated the fixation of TTO used in the extended exposure of knee arthroplasty without medialization –17. The Patellar height can be normalized by distalizing the TT during Fulkerson osteotomy in patients with accompanying patella alta. In the last FEA study, the biomechanical stability of the various 3.5 mm, 4.5 mm cortical screws and 3.5 mm 1/3 tubular plate-screw augmentation options were compared in Fulkerson osteotomy with distalization procedure . Since tThe current study has various limitations as well as strengths. The inherent constraints of FEA must be considered while evaluating the results. Several preset assumptions were used, such as boundary conditions and material properties. Secondly, since the data in this FEA study are absolute values, a statistical comparison was not made. Despite the limitations of this study, it also has some strengths. CT data of a patient with patellofemoral instability and an increased TT–TG distance were employed to create a precise model to simulate the clinical reality. Since the bone is not uniform, the cortical and trabecular bones were separately defined with a bonded contact model. Although a cadaveric experiment did not validate the results of this FEA, it provides important information about the biomechanical characteristics of Fulkerson osteotomy and its fixation.A divergent screw configuration in which the upper screw is inserted perpendicular to the osteotomy plane and the lower screw inserted perpendicular to the posterior tibial cortex (FEA-004) might be a better option for the fixation of Fulkerson osteotomy. Surgeons who prefer two 4.5 mm cortical screws for Fulkerson osteotomy fixation can achieve a more stable fixation by applying this simple modification in screw configuration. In addition, this modification may reduce the risk of neurovascular injuries and thus allow safer bicortical screw fixation. Finally, it can reduce the need for implant removal by shifting the screw heads away from the direct contact area of the knee. However, these propositions need to be supported by further clinical studies.


The effects caused by differences in data acquisition can be substantial and may impact data interpretation in multi-site/scanner studies using magnetic resonance spectroscopy (MRS). Given the increasing use of multi-site studies, a better understanding of how to account for different scanners is needed. Using data from a concussion population, we compare ComBat harmonization with different statistical methods in controlling for site, vendor, and scanner as covariates to determine how to best control for multi-site data.The data for the current study included 545 MRS datasets to measure tNAA, tCr, tCho, Glx, and mI to study the pediatric concussion acquired across five sites, six scanners, and two different MRI vendors. For each metabolite, the site and vendor were accounted for in seven different models of general linear models (GLM) or mixed-effects models while testing for group differences between the concussion and orthopedic injury. Models 1 and 2 controlled for vendor and site. Models 3 and 4 controlled for scanner. Models 5 and 6 controlled for site applied to data harmonized by vendor using ComBat. Model 7 controlled for scanner applied to data harmonized by scanner using ComBat. All the models controlled for age and sex as covariates.Models 1 and 2, controlling for site and vendor, showed no significant group effect in any metabolites, but the vendor and site were significant factors in the GLM. Model 3, which included a scanner, showed a significant group effect for tNAA and tCho, and the scanner was a significant factor. Model 4, controlling for the scanner, did not show a group effect in the mixed model. The data harmonized by the vendor using ComBat (Models 5 and 6) had no significant group effect in both the GLM and mixed models. Lastly, the data harmonized by the scanner using ComBat (Model 7) showed no significant group effect. The individual site data suggest there were no group differences.Using data from a large clinical concussion population, different analysis techniques to control for site, vendor, and scanner in MRS data yielded different results. The findings support the use of ComBat harmonization for clinical MRS data, as it removes the site and vendor effects. As with many imaging modalities, multiple sites and scanners are used to increase sample sizes and to best sample and represent the population in magnetic resonance spectroscopy (MRS) studies. However, scanner effects are substantial; both between and within vendor effects can affect MRS data . AdditioIt is common to control for site-related variance within statistical models. Another method is to harmonize data, for example, using ComBat . ComBat To validate and compare approaches to account for multi-site data, one approach is to collect data on the same individuals across all scanners used in the main study . While ideal, this experimental design needs to include many control participants scanned at each site  to validConcussion is a clinical condition that is becoming increasingly prevalent, with many studies of concussion using MRS to determine biochemical alterations . Group dUsing data from a pediatric cohort including patients with concussion or orthopedic injury (OI) across five sites, we compared the use of GLM models and linear mixed-effects models, controlling for scanner, site, and vendor, to ComBat harmonization. ComBat was first validated on MRS data by For clarity, here site refers to a research center in a single city, vendor is the scanner manufacturer, and scanner is an individual MRI machine .The data for the current study included 545 MRS datasets (361 concussion 184 OI) acquired across the five sites and six scanners (one site had two scanners). A total of 287 participants were scanned with GE scanners and 258 with Siemens scanners. The parent study was designed to better understand pediatric concussion [Advancing Concussion Assessment in Pediatrics (A-CAP)] and included two groups: participants with concussion and a comparison group with OI. Recruitment occurred at five emergency departments in Canada , with an overall goal of 700 concussion participants and 300 OI participants within 2 years. After the initial recruitment, the eligible participants returned 1–2 weeks following injury for an assessment that typically included an MRI scan with an MRS acquisition.Briefly, all the participants were from 8 to <17 years of age. The concussion participants were defined as children who had sustained a blunt head trauma and presented with at least one of the following characteristics: an observed loss of consciousness, a Glasgow Coma Scale (GCS) score of 13 or 14, or at least one acute sign or symptom of concussion. Signs of more severe traumatic brain injury resulted in exclusion from the sample. The OI participants were defined as children who sustained either an upper or lower extremity fracture, sprain, or strain due to blunt force resulting in an Abbreviated Injury Scale  score of2. Sites using a GE scanner acquired a 3D T1-weighted fast spoiled gradient echo brain volume (FSPGR BRAVO) image with a TR/TE/TI = 8,250/3.16/600 ms with a field of view of 24 cm2. Both acquisitions used 192 slices, a flip angle of 10°, and had a voxel size of 0.8 mm × 0.8 mm × 0.8 mm.All imaging was performed at 3T. A T1-weighted anatomical acquisition was acquired for voxel placement and tissue segmentation. Sites using a Siemens scanner acquired a 3D T1-weighted magnetization-prepared rapid acquisition gradient echo (MPRAGE) with TR/TE/TI = 1,880/2.9/948 ms and a field of view of 25.6 cmin vivo MRS studies is included in A short echo time point-resolved spectroscopy (PRESS) sequence was used at all sites. PRESS was chosen as it was available at all sites; it is also consistent with recent recommendations from the ENIGMA MRS working group in traumatic brain injury . The folAs the GE data had individual averages available, the pre-processing pipeline included the following: combination of receiver channels, removal of bad averages, retrospective shot-by-shot frequency and phase correction, left shifting, and zero-order phase correction, following the consensus of best practices . These pmyo-inositol, lactate, N-acetyl-aspartate (NAA), N-acetyl-aspartyl-glutamate (NAAG), phosphocholine, phosphocreatine (PCr), phosphoenolamine, scyllo-inositol, and taurine. The default macromolecular and lipid basis sets were also included in the LCModel analysis.The data were then quantified relative to water with LCModel version 6.3-1J , which iFinally, outputs from LCModel were corrected for tissue-specific relaxation and water visibility according to recommendations and guidelines . For eacSpectral quality was first assessed with visual inspection by one analyzer (PLL), and a second analyzer (ADH) assisted in borderline decisions for quality. Quantitative measures of quality included the linewidth  of the water peak and the signal-to-noise ratio (SNR) of the NAA peak, both determined from FID-A. Spectral fitting quality was assessed using Cramer-Rao lower bounds generated in LCModel. The thresholds for quality were an SNR of at least 45 and a Cramer-Rao lower bound of less than 20% for each metabolite.n = 29/19), and the disproportionate sample size between the two groups (concussion/OI n = 37/11).There is no gold standard available to evaluate the performance of each approach to account for site/scanner effects. However, the performance can be partially evaluated by the consistency between the results of the full dataset (after accounting for site/scanner) and the results of each site independently. The effect size (Cohen’s d) of the group  was calculated for four of the sites to serve as a reference for expected group differences in the entire sample when accounting for site. Additionally, the effects of age and sex were explored at the four sites to serve as a reference for their effects on metabolites at each site. The Montreal site was excluded from single-site analyses due to the small sample size, which was also split between the two scanners used at this site . Age and sex were controlled for in all analyses either as covariates in the general linear model (GLM) or as fixed effects (Linear Mixed Models). Between model fits were compared by using the Akaike information criterion (AIC) for the GLM’s and the mixed models.Model 1: GLM model including covariates for vendor (GE or Siemens) and site (five sites) applied to the metabolite concentrations.Metabolite concentration ∼ (Group) + (Age) + (Sex) + (Site) + (Vendor).Model 2: Linear mixed-effects model including group as a fixed effect, while site and vendor are included as random effects on metabolite concentrations.Site)( + RandomVendor)(.Quantified Metabolite concentration ∼ (Group) + (Age) + (Sex) + RandomModel 3: GLM model including a covariate for scanner  applied to the metabolite concentrations.Metabolite concentration ∼ (Group) + (Age) + (Sex) + (Scanner).Model 4: Linear mixed-effects model including group as a fixed effect, while scanner is included as a random effect on metabolite concentrations.Scanner)(.Metabolite concentration ∼ (Group) + (Age) + (Sex) + RandomModel 5: GLM model including a covariate for site applied to harmonized metabolite concentrations by vendor using ComBat.Metabolite Concentrations Harmonized by Vendor ∼ (Group) + (Age) + (Sex) + (Site).Model 6: Linear mixed-effects model including group as a fixed effect, while site is included as a random effect on harmonized metabolite concentrations by vendor using ComBat.Site)(.Harmonized Metabolite Concentrations by Vendor ∼ (Group) + (Age) + (Sex) + RandomModel 7: GLM model applied to harmonized metabolite concentrations by scanner using ComBat.Harmonized Metabolite Concentrations by Scanner ∼ (Group) + (Age) + (Sex).https://github.com/Jfortin1/ComBatHarmonization/tree/master/R) in R (version 4.0.4), as performed by ComBat harmonization was performed on MRS data using the neuroComBat function .The concussion group was composed of 62% male participants, and the average age was 12.31 ± 2.46 years. The OI group was 55% male and had an average age of 12.57 ± 2.19 years. The groups did not significantly differ in age and sex.p = 0.009). The mean SNR of GE/Siemens data was 82.8/185, and the FWHM was 10.6/8.34 Hz. A full breakdown of the FWHM and SNR of each site is displayed in The SNR (measured using the NAA peak) had a similar range across the injury groups, but it was significantly higher in the concussion group compared to the OI group , and one site had a trend level significance (p = 0.053). Age was also significant in the Glx analyses for one site (p = 0.013), with trend level significance in one other site (p = 0.058). Sex was not a significant factor in any metabolite at any of the four sites (p > 0.05).When examining the age effects, we found that age was a significant covariate in tNAA analyses for two sites  in any metabolite. The vendor was a significant factor for each metabolite, and the site was significant for tNAA, tCho, and Glx. Age was significant for tNAA and Glx. Sex was not significant in any metabolite models. Additional model details are shown below in p < 0.05). The random effects of the site and vendor did not significantly impact the models (p > 0.05). The full model results are shown in Model 2: The linear mixed-effects model showed that group was not significant for any metabolite and that age had significant effects on tNAA levels, while age and sex had significant effects for Glx levels . The random effect of the scanner did not significantly impact any metabolites (p > 0.05). The full model results are shown in Model 4: The linear mixed-effects model showed that the group was not significant for any metabolite, and tNAA had significant age effects, while Glx had significant age and sex effects . The random effect of the site did not significantly impact any harmonized metabolite data (p > 0.05). The full model results are shown in Model 6: The linear mixed-effects model showed that the group was not significant for any metabolite, and tNAA had significant age effects, while Glx had significant age and sex effects (Model 7: The data harmonized by the scanner are shown in p < 0.05), and the group also did not have a significant effect.The follow-up analysis of a linear mixed-effects model of ComBat-harmonized data by the scanner, including scanner as a covariate, showed no significant effect of the scanner  that included scanner as a covariate (Model 3) showed a significant group effect for tNAA and tCho. tNAA and tCho were significantly lower in the concussion group compared to the OI group. Given the absence of a group effect in all other models and the analyses at each individual site, we conclude that group does not have a significant effect in this dataset and that the significant group effect seen when including scanner as a covariate (Model 3) was spurious. Additionally, the GLM Model 3 had the highest AIC for each metabolite in comparison to GLM models 1, 5, and 7, indicating a worse model fit. The linear mixed-effects models all performed similarly, although models 2 and 6 had similar AIC values, and model 4 had the largest AIC value. The best model determined from AIC appears to be GLM model 7 or the mixed-effects model 6, though similar results were also achieved in other models (Model 1 and Model 2). This work demonstrates that caution is needed when controlling for scanner/site/vendor, as this can have substantial implications on the results.Despite the increasing standardization of imaging and MRS protocols, acquisition schemes can differ by vendor, for example, the pulse shapes and minimum achievable echo time , 2022. FComBat is a technique that harmonizes data for a chosen parameter  by estimating an empirical statistical distribution of multiple defined parameters . It has the advantages of maintaining measures with meaningful values (quantified metabolite levels) and maintaining biological variability. Previous work in a healthy adult population of MRS data from 20 different sites and three different MRI vendors found that site and vendor effects were removed following ComBat harmonization . The curIn addition to removing site/scanner effects, it is important to maintain biological effects when harmonizing data. For that purpose, age and sex effects were examined in all the analyses. Some metabolites are known to be affected by development and are thus related to age . tNAA inThe current work has limitations. The first is that ComBat only allows for the harmonization of one factor at a time. In some cases, it is desirable to harmonize by more than one factor. For example, in our data, the site and vendor are two factors that were considered. To simultaneously address both, we used a combination variable, “scanner,” and controlled for it in the statistical analyses (GLM and mixed-effect models) and harmonized for it with ComBat. Secondly, ComBat uses the full dataset in the harmonization process, and new data cannot be added without performing harmonization on the new full dataset. This is because ComBat takes the empirical distribution of the full dataset and applies this to each sample. It is therefore not possible to add single datasets or to directly compare the numerical results of ComBat-harmonized data with other studies or datasets. Beyond these general limitations of ComBat, in this study, there were no group differences. While these results broadly suggest that caution is warranted in accounting for site/scanner effects, we cannot definitively conclude from this data that when true group differences exist, different approaches to account for multi-site/scanner effects could mask these effects. Regardless, the importance of thoroughly investigating the approach to account for multi-site/scanner effects remains an important finding, as erroneous interpretations may result. One recommendation for future studies is to investigate the consistency of the results when different approaches to account for site are used and also the consistency with the individual site data. In the future, machine learning may provide an alternative approach to harmonize or control for multi-site/scanner effects in MRS studies . Lastly,In a large clinical population, we found that different analysis techniques used to control for the site and scanner in MRS data could yield different results. Therefore, we recommend ensuring that there is consistency between single scanner data and different approaches to account for the scanner in multi-scanner studies. We have also demonstrated that ComBat harmonization can control for site (or vendor or scanner) effects in clinical MRS data.A dataset with deidentified participant data and a data dictionary will be made available upon reasonable request from any qualified investigator, subject to a signed data access agreement.This study was approved by the research ethics board at each participating site, and informed consent and assent was obtained from the parents/guardians and the youth participants respectively.PL: formal analysis, data curation, writing the first draft, and data visualization. PL, AH, and TB: conceptualization and methodology. AH: project administration and supervision. All authors contributed to data collection, reviewing, and editing the final submitted manuscript.


A single transseptal puncture can allow for passage of both the delivery sheath and the intracardiac echocardiogram (ICE) probe during left atrial appendage closure (LAAC). With this approach, the ICE probe is carefully directed through a dilated septal tract. However, the passage of the ICE probe through this tract can be difficult. We have previously reported a technique to facilitate transseptal passage of the ICE catheter using a snare system.2DS2-VASc score = 4 and HAS-BLED score = 4. The patient was referred for LAAC. Computed tomography angiography was used for device sizing and preprocedural planning (We describe an 82-year-old male with multiple medical issues, including paroxysmal atrial fibrillation, heart failure with reduced ejection fraction, chronic kidney disease, history of gastrointestinal bleeding, and gait instability. His CHAplanning . IntraveAfter initial attempts at passing the ICE probe through the septal tract were unsuccessful, we theorized that placing a second 0.035” wire might facilitate ICE passage by propping open the tissue. To do this, we readvanced the double-curve sheath into the left atrium and removed the dilator. We then introduced a Super Stiff J-tip Amplatz guidewire 0.035” × 180 cm alongside the Bayliss wire and withdrew the sheath back into the inferior vena cava, leaving both wires in place. The ICE catheter was then directed at the intersection of the 2 wires and able to cross through the septum . Once thLAAC is increasingly performed for stroke risk reduction in patients with atrial fibrillation.Consent was obtained from the patient for publication of this report and any accompanying images.The authors have no funding to report.The authors report no conflict of interest.


Dear Editor,1 We report a patient who was misdiagnosed as transverse myelitis suggestive of multiple sclerosis based on acute onset bilateral foot drop. However, detailed history, careful examination, and electroneuromyography (ENMG) were consistent with HNPP.Hereditary neuropathy with liability to pressure palsy (HNPP) is a rare, autosomal dominant disorder that typically presents with episodic, multifocal neuropathy, and recurrent transient pressure palsies.A 22-year-old male developed a sudden onset of weakness in his legs. Imaging of the brain and spine, serum, and cerebrospinal fluid analysis were all normal. Normoactive deep tendon reflexes with acute onset were interpreted as transverse myelitis. He was given methylprednisolone, which had no obvious effect. He was then referred to our clinic and we learned that the patient had cross-legged sitting while playing a computer game for hours. He had bilateral ankle and toe dorsiflexion weakness; however, inversion was normal bilaterally. He had hypoesthesia on the dorsum of both legs. There was no pathological reflex.Electroneuromyography showed that sensory nerve conduction (SNC) velocities were slowed in the right median and ulnar nerves but not sural nerve. There was a conduction block in both peroneal nerves at fibular head. Motor conduction velocities were slowed at the elbow segment in both ulnar nerves showing cubital tunnel syndrome . Distal 1 Bilateral peroneal nerve palsy is seen rarely. Prolonged squatting such as Strawberry picker’s palsy, holding and pressing the lateral aspect of the flexed knees in a supine position such as obstetric or orthopedic surgical process, use of the pneumatic compression devices or casts, excessive and rapid weight loss can be an etiological factor for bilateral peroneal nerve palsy.2 Hereditary neuropathy with liability to pressure palsy can mimic some inflammatory neuropathies; a study that included 73 patients with HNPP showed 2 patients were considered as Guillain–Barré Syndrome (GBS) initially. The first patient complained of acute distal paresthesia and paresia in the lower extremities. The second patient, misdiagnosed as GBS, complained of subacute onset quadriparesis for 10 days, and he was given intravenous immunoglobulin (IVIg). However, the patients had not undergone lumbar puncture (LP).3 A feature of SNC abnormalities in GBS is reduced amplitude higher in the median, ulnar, or radial nerve compared to the sural nerve, also called sural sparing. We observed sural sparing in ENMG, but LP was not consistent with GBS in our case. Acute and bilateral foot drop can be rarely seen in degenerative spinal diseases such as a posterolateral disc protrusion at the L3-4-5 levels, which can be treated surgically and should be in the differential diagnosis.4Hereditary neuropathy with liability to pressure palsy is rarely seen and characterized by recurrent painless peripheral mononeuropathies at entrapment sites secondary to minor trauma or compression. The peroneal nerve is the most common entrapped, nevertheless, multiple compression neuropathy can be seen simultaneously in HNPP. Electrophysiologically, a nonuniform, demyelinating, polyneuropathy pattern with a pronounced distal slowing in some nerves at entrapment sites can be seen.5 and bilateral foot drop was seen simultaneously in 1 of them.2 Misdiagnosis of HNPP may lead to inappropriate treatment with methylprednisolone, IVIg, or plasma exchange and unnecessary procedure like LP.To the best of our knowledge, only 2 case reports of bilateral foot drop associated with HNPP were presented in the literature6The patients with HNPP mostly have a heterozygous 1.5-Mb deletion in chromosome 17p11.2, the region that encompasses the gene for PMP22. The episodes of pressure palsies are rarely permanent and the main management of HNPP is the prevention of compression. Tendon transfer surgery or decompressive surgery may be helpful in persistent symptoms like foot-drop or wrist-drop, carpal or cubital tunnel syndrome.6Consequently, in especially younger patients, HNPP should be considered in the differential diagnosis when entrapment neuropathy findings were on more than 1 site in ENMG studies, or recurrent entrapment neuropathies such as foot-drop or wrist-drop, carpal or cubital tunnel syndrome were seen. Early diagnosis and the avoidance of precipitating factors like trauma, skinny clothes, rapid weight loss, prolonged crossed-leg sitting, or leaning on elbows could prevent further progress of the diseaese.


IIbβ3 signaling, are not yet fully understood.Platelets play a crucial role in cardiovascular diseases (CVDs) and are activated by endogenous agonists like collagen. These agonists initiate signal transduction through specific platelet receptors, resulting in platelet aggregation. Glabridin, a prenylated isoflavonoid found in licorice root, is known for its significance in metabolic abnormalities. Glabridin has been observed to inhibit collagen-induced platelet aggregation, but the precise mechanisms, specifically concerning NF-κB activation and integrin αIn this study, platelet suspensions were prepared from healthy human blood donors, and the aggregation ability was observed using a lumi-aggregometer. The inhibitory mechanisms of glabridin in human platelets were evaluated through immunoblotting and confocal microscopy. The anti-thrombotic effects of glabridin were assessed by histological analysis of lung sections in acute pulmonary thromboembolism and by examining fluorescein-induced platelet plug formation in mesenteric microvessels in mice.IIbβ3 inside-out signals such as Lyn, Fyn, Syk, and integrin β3 activation and NF-κB-mediated signal events, with similar potency to classical inhibitors BAY11-7082 and Ro106-9920. Glabridin and BAY11-7082 inhibited IKK, IκBα, and p65 phosphorylation and reversed IκBα degradation, while Ro106-9920 only reduced p65 phosphorylation and reversed IκBα degradation. BAY11-7082 reduced Lyn, Fyn, Syk, integrin β3, phospholipase Cγ2 and protein kinase C activation. Glabridin reduced platelet plug formation in mesenteric microvessels and occluded vessels in thromboembolic lungs of mice.Glabridin inhibited integrin αIIbβ3 inside-out signals and NF-κB, which contributes to the antiplatelet aggregation effect of glabridin. Glabridin could be a valuable prophylactic or clinical treatment option for CVDs.Our study revealed a new pathway for activating integrin αThe online version contains supplementary material available at 10.1186/s13020-023-00779-9. ADP, collagen (type I), dimethyl sulfoxide (DMSO), bovine serum albumin (BSA), heparin, ethylenediaminetetraacetate (EDTA), phenylmethylsulfonyl fluoride (PMSF), sodium orthovanadate, sodium pyrophosphate, aprotinin, leupeptin, NaF, and paraformaldehyde (PFA) were purchased from Sigma-Aldrich . Phospho-Syk (Tyr2+ (1 mM). The platelets were counted using a Coulter counter . Washed platelets (3.6 × 108 cells/mL) were preincubated with a solvent control (0.1% DMSO) or glabridin (5–30 µM) for 3 min before being stimulated with collagen (1 µg/mL). Aggregation ability was observed using a lumi-aggregometer  . Aft. AftIIbβion Fig.  4, 21]..IIbβ3, weraction . Triflaveraction . These reraction . Glabridraction) . PlateleIIbβ3 activation through inside-out mechanisms (Fig. 3 phosphorylation stimulated by immobilized fibrinogen in platelets was validated in vivo, and its mutation led to bleeding disorder and strongly affected clot retraction in vitro [3 phosphorylation, which clearly demonstrates that collagen stimulates integrin β3 inside-out signals and subsequently influences integrin β3 phosphorylation. In this study, glabridin markedly diminished Fyn, Lyn, and Syk and integrin β3 phosphorylation stimulated by collagen, indicating that glabridin inhibits platelet aggregation through integrin β3 inside-out signals.Following vascular injury, platelet adhesion and aggregation are triggered by the exposure of subendothelial collagen at the injury site, leading to vascular thrombosis. Collagen is present in the subendothelial space and within the tunica media of blood vessels, making it the most crucial protein that interacts with platelets and induces activation responses. Among collagen receptors, GP VI is believed to play a key role and is a necessary factor for platelet aggregate formation on the collagen surface under blood flow. GP VI is a membrane protein in the immunoglobulin superfamily that forms a complex with the Fc receptor γ-chain containing immunoreceptor tyrosine-based activation motifs and is phosphorylated by SFKs, such as Fyn and Lyn . Subsequsms Fig. . Additioin vitro . In addi3 inside-out signals than Ro106-9920, and these signals are critical in glabridin-mediated antiplatelet activity.NF-κB’s role in nucleated cells is well-established, as it has been extensively studied. When triggered by stimuli such as cytokines, ultraviolet radiation, or free radicals, NF-κB is activated and can cause inflammation, as well as impair cell survival, differentiation, and proliferation . In humaAnimal models are crucial in understanding the therapeutic significance of test drugs in various diseases. To further evaluate the in vivo efficacy of glabridin against vascular thrombosis, platelet plug formation in mesenteric microvessles  was perfIIbβ3 inside-out signaling in human platelets, as depicted in Fig. This study identified glabridin as a potential antithrombotic agent that blocks integrin αAdditional file 1: Figure S1. Effects of glabridin on cytotoxicity in human platelets. Washed human platelets were pretreated with either the solvent controlor glabridinfor 20 min, and a 10 μL of the supernatant was dropped on a Fuji Dri-Chem slide LDH-PIII. Data are presented as the mean ± standard error of the mean. Figure S2. Inhibitory profiles of glabridin for IKK, p65, Lyn and integrin β3 activation stimulated by collagen in human platelets. Washed platelets were preincubated with a solvent controlor glabridin, followed by the addition of collagento stimulateIKK,p65,Lyn, andintegrin β3 phosphorylation.