Since the discovery of HCV in 1989, several diseases have been related to chronic infection by this virus. Often, patients with hepatitis C virus (HCV) complain of cognitive impairment even before the development of hepatic cirrhosis, which they described as “brain fog.” Several studies have proposed a link between chronic HCV infection and the development of cognitive alterations, but the inclusion of confounding factors in their samples significantly limits the analysis of the results. In this article, we will give an overview about cognitive dysfunction in patients with HCV. The occurrence of cognitive alterations in patients with chronic liver disease is extensively documented in cases of hepatic encephalopathy and minimal hepatic encephalopathy resulting from the development of cirrhosis and its subsequent evolution to hepatic insufficiency. However, with the onset of hepatitis C virus (HCV) infection, complaints of cognitive changes in patients without cirrhosis or significant hepatic impairment have been reported , 2.Complaints of extrahepatic involvement in HCV infections are more frequent than those related to hepatic involvement since these occur late with the development of liver cirrhosis and its subsequent evolution to its decompensated form . It is bPatients infected with HCV often report neuropsychiatric complaints even before the development of significant liver changes. Among the frequently described neuropsychiatric complaints are the presence of mild cognitive impairment, depression, and fatigue . The preThe pattern of cognitive impairment described above involves the cortical regions of the frontal lobe and the nuclei of the base in a pattern similar to that observed in HIV infection . HoweverThe occurrence of central nervous system (CNS) involvement is seen in other viral infections, and human immunodeficiency virus (HIV) infection is one of the best studied to date. The family Flaviviridae to which HCV belongs has different types of viruses with recognized neurotropism, such as West Nile virus, Saint Louis encephalitis virus, Murray Valley virus, and Japanese encephalitis virus. Besides, yellow fever and dengue virus may occasionally result in encephalitis –11.The fact that other members of the Flaviviridae family have recognized neurotropism, such as West Nile virus, is a frequent argument for explaining the nature of the hepatitis C virus in causing cognitive dysfunction. Since the discovery in 1920 of the viral cause of yellow fever, Flaviviridae family viruses have been documented as causes of arboviruses and liver disease in humans. Arboviral infections cause a broad spectrum of diseases, and after, acute infections can also progress to much more complex secondary conditions, resulting in long-term physical and cognitive impairment or early death .The Flaviviridae family is currently classified into four genera: Flavivirus, Hepacivirus, Pestivirus, and Pegivirus. Although they belong to the same family and share structural features and strategies of replication in common, there is a great phylogenetic distance between members of the genus Hepacivirus to which the HCV belongs and arbovirus belonging to the genus Flavivirus , 14. TheThe “Trojan Horse” effect: this hypothesis considers the possibility of HCV entering the brain through the infection of circulating monocytes in the blood. Monocytes are precursors of the microglia in the CNS, thus allowing HCV to reach the brain parenchyma . The presence of HCV-infected microglia could result in the release of inflammatory interleukins such as tumor necrosis factor-alpha, interleukin-1, interleukin-6, and the release of neurotoxins such as nitric oxide and viral proteins, which would result in changes in cerebral function and cognitive alterations. This hypothetical scenario, which is similar to that postulated for HIV type 1 (HIV-1) infection, is corroborated by studies that demonstrated a close relationship between HCV sequences found in the cerebrospinal fluid and viral sequences found in the lymphatic system and peripheral blood mononuclear cells , 15, 16The direct action of the virus through viral replication in neurons: the presence of HCV in the CNS has been described in several studies that used PCR-based techniques to detect the presence of the viral genome in the cerebral parenchyma and cerebrospinal fluid. In addition, some authors have reported the presence of negative-strand HCV RNA in the CNS, which suggests that there is viral replication in the brain parenchyma , 17, 18Effect of the inflammatory process: chronic HCV infection produces cytolytic effects on hepatocytes, culminating in the activation of the immune system. Therefore, the systemic inflammation produced could contribute to the observed brain dysfunction. This hypothesis is based on a growing body of evidence that demonstrates that the activation of the immune system in peripheral tissues can affect CNS functioning, causing affective, cognitive, and behavioral disorders. The presence of peripheral proinflammatory cytokines, such as interleukin-1 and interleukin-6, are the most likely mediators of these effects, penetrating the blood-brain barrier through active transport mechanisms, promoting the activation of the vagus nerve, and stimulating the neurotransmitter system. Chronic HCV-infected patients produce proinflammatory cytokines such as interleukin-6, interleukin-4, and tumor necrosis factor-alpha, which may result in cognitive impairment in vitro studies have shown that cerebral microvascular endothelial cells are susceptible to HCV infection. These cells are an integral part of the blood-brain barrier, and at least two independent derivatives of the cerebral microvascular endothelial cell line (hcmec/D3 and hbmec) express receptors on its external plasmatic membrane that allow HCV invasion. In addition to these data, immunohistochemical staining of the brain tissue revealed the presence of four receptors necessary for the entry of HCV into microvascular cells. SR-BI receptor expression is restricted to cerebral microvascular endothelium, suggesting that brain tropism occurs only through these cells [Blood-brain barrier endothelial cell infection: se cells .Although the exact mechanism that would result in the cognitive changes observed in patients with hepatitis C is not known, some proposals have been made to explain this occurrence:Cellular apoptosis and reduction of the endothelial barrier activity were observed in cultures of endothelial cells infected with HCV. Thus, a possible mechanism proposed for the neuropathogenesis of HCV infection would be the direct viral invasion of endothelial cells, resulting in the apoptosis and breakdown of the blood-brain barrier that could allow inflammatory cytokines, viral particles, and other neurotoxic substances to enter the CNS, which would result in brain dysfunction and the neuropsychiatric changes reported by these patients. Astrocytes are in close contact with the basal lamina of endothelial cells, which secrete factors that help regulate their homeostasis. Probably, HCV endothelial cerebral infection may, therefore, impact astrocytic homeostasis, or even that HCV may also infect astrocytes by contiguity , 17, 18.However, the presence of HCV RNA in brain tissue samples has to be considered with reservations, since it may be the result of contamination after the occurrence of the breakdown of the blood-brain barrier . In addiIn the study conducted by Fishman et al., HCV RNA levels were quantified in multiple brain and liver samples from patients infected with the virus. It demonstrated that HCV levels in the brain tissue were 1,000 to 10,000 times lower than those found in the hepatic tissue . This daThe most attractive hypothesis seems to be the infection of endothelial cells of the blood-brain barrier. Once infected, these cells would enter into apoptosis, resulting in the rupture of the blood-brain barrier, with the consequent entry of viruses, immune cells, and cytokines, resulting in neuroinflammation , 17–20.Approximately 50% of patients with hepatitis C have complaints of fatigue and cognitive deficits even before the development of significant hepatic impairment , 7, 21.n = 30), (2) HBV-infected patients (n = 29), and (3) a group of healthy controls (n = 12). The authors found a statistically significant increase in the choline/creatine ratio in the white matter and basal ganglia of patients with HCV when compared to the other groups [The first evidence of the occurrence of brain changes was discovered by Forton et al. who analyzed the cerebral metabolic relationships through the use of magnetic resonance spectroscopy in three distinct groups: (1) patients infected with HCV without the presence of significant fibrosis or cirrhosis  resulted in a group of HCV carriers with cognitive performance similar to age and educational level-paired control group . HoweverThe data presented in the literature indicate varying degrees of control over confounding factors, such as liver cirrhosis and depression. Such factors, combined with the use of different types of neuropsychological tests and the assessment of different domains of cognitive functions, provide great difficulty in comparing the results of preexisting studies.As noted in Despite all the exposed limitations, most studies have demonstrated the presence of cognitive changes, involving several functions such as attention and working memory, in a pattern that suggests the involvement of the frontal cortex and the basal ganglia, or the connections between these structures.The literature consistently demonstrates the presence of cognitive deficits in patients with chronic HCV infection. However, the heterogeneous nature of published works with different degrees of control of confounding factors and designed as cross-sectional studies makes it impossible to categorically establish HCV infection as the sole responsible factor for the reported cognitive changes.per se.A large body of studies have established the presence of HCV penetration through the blood-brain barrier, HCV replication within the brain, and changes in neurocognitive tests when compared to controls, including works that demonstrated cognitive impairment independent of the degree of depression. However, the inclusion of confounding factors in several studies, the lack of standardization in the neuropsychological tests, and the absence of cohort studies preclude the assertion that HCV can cause brain dysfunction Future longitudinal studies with the use of neuropsychological and neurophysiological cognitive assessments before and after the use of direct-acting antivirals may provide further information on the role of HCV infection as a cause of cognitive impairment.


The severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), the cause of the current pandemic coronavirus disease 2019 (COVID-19), primarily targets the respiratory system. Some patients also experience neurological signs and symptoms ranging from anosmia, ageusia, headache, nausea, and vomiting to confusion, encephalitis, and stroke. Approximately 36% of those with severe COVID-19 experience neurological complications. The virus may enter the central nervous system through the olfactory nerve in the nasal cavity and damage neurons in the brainstem nuclei involved in the regulation of respiration. Patients with cerebellar ataxia (CA) are particularly vulnerable to severe outcome if they contract COVID-19 because of the complexity of their disease, the presence of comorbidities, and their use of immunosuppressive therapies. Most CA patients burdened by progressive neurologic deficits have substantially impaired mobility and other essential functions, for which they rely heavily on ambulatory services, including rehabilitation and psychosocial care. Cessation of these interventions because of isolation restrictions places the CA patient population at risk of further deterioration. This international panel of ataxia experts provides recommendations for neurologists caring for patients with CA, emphasizing a pro-active approach designed to maintain their autonomy and well-being: continue long-term medications, promote rehabilitation efforts, utilize the technology of virtual visits for regular contact with healthcare providers, and pay attention to emotional and psychosocial health. Neurologists should play an active role in decision-making in those CA cases requiring escalation to intensive care and resuscitation. Multi-disciplinary collaboration between care teams is always important, and never more so than in the context of the current pandemic. The novel zoonotic corona virus (severe acute respiratory syndrome coronavirus 2: SARS-CoV2) has caused a global pandemic, coronavirus disease-2019 (COVID-19), which presents primarily with severe pulmonary disease, acute respiratory collapse, and multisystem failure , the samCerebellar ataxias (CAs) are a group of heterogeneous disorders from both the phenotypic and genetic standpoints. CAs include chronic neurodegenerative disorders such as the autosomal dominant spinocerebellar ataxias (SCAs), which affect cerebellar and extra-cerebellar structures, including brainstem and motor neurons, with widespread dysfunction of the motor system and other neurological domains. Patients with the various CAs are particularly vulnerable to COVID-19 for several reasons: their neurological syndrome is complex, comorbid medical illnesses are common, immune-mediated ataxias are managed with immunosuppressive medications such as rituximab, mycophenolate, and corticosteroids, which require frequent monitoring, CAs may affect elderly people, and all of these predispositions to severe response to the viral infection are compounded by cerebellum-specific neuropsychological impairments. General practitioners (GPs), who most frequently care for these patients and their families, are reporting that they are overwhelmed by the pandemic, with their usual meticulous engagement in managing their long-term course and supervening acute issues being superseded by the immediate need to care for the surging numbers of COVID-19 patients. Patients with CA in many centers are even finding that they are having difficulty connecting with their suddenly overburdened GPs. Adding to the stress on the CA patient population world-wide is the reality that in-person or at-home support services, including psychological counseling or therapy visits, have stopped, and necessary ambulatory care services such as speech, physical, and occupational therapy interventions have come to an abrupt halt. The consequence is that patients are reporting dramatically decreased levels of rehabilitative and maintenance care, which is having a demonstrable negative impact on their overall care and well-being.All societies around the world, and most particularly the vulnerable populations, are severely challenged by the COVID-19 pandemic. There are, however, three considerations specific to patients and families dealing with CAs.First, dysphagia, ataxic respiration, maintenance of airway protection, and aspiration pneumonia are an ever-present concern and risk in CAs . Should Second, there is intense pressure on healthcare systems due to limited numbers of beds in intensive care units (ICUs), which are facing an enormous challenge in terms of abrupt reorganization of their procedures and decisions to treat patients . PatientThird, the neurocognitive and behavioral-affective syndrome in CA patients manifests with impairments in executive function and visuo-spatial cognition and in personality changes, including blunting of affect or impaired behavior . PatientIn our institutions, we have instituted the following seven practices and share these recommendations with neurologists caring for the CA patient population:Emphasize that the recommendations to the general population to avoid contracting the infection need to be followed seriously and rigorously by CA patients, their families, and caregivers. This includes staying at home as long as the local/national authorities determine quarantine is still required, maintaining physical distancing if leaving the house or interacting with others outside the immediate household, adhering to the advertised protocols for hand-washing, avoiding touching the face, wearing masks when in contact with others outside the home, and meticulous cleansing and disinfecting of surfaces and of objects brought into the house. Take a pro-active approach to educating patients regarding travel restrictions.Continue all necessary medications, whether for the symptoms and manifestation of the CA or for other medical conditions, for instance, 4-aminopyridine or acetazolamide in episodic ataxias. Patients with immune-mediated ataxias should not discontinue their immunosuppressive drugs. The dysphoria, anhedonia, and sometimes suboptimal decision-making encountered in CA patients may contribute to unjustified interruption of medications or undue influence by social media sites offering unsolicited and erroneous medical advice.Promote rehabilitation efforts through speech and language therapy and physical and occupational therapy in CA patients. Discontinuation of rehabilitation is likely to exacerbate symptoms and worsen ataxia, as is already evident in our phone or video virtual visits with patients. Contact should be maintained with providers of these rehabilitation services to devise programs that can be carried out at home and monitored remotely. The effect of this cessation of in-person rehabilitation care provides an opportunity for quantitative research in the future to assess the impact of this unexpected change in the care model. Because neurological disorders are not uncommon in COVID-19, it may be relevant to remind patients, caregivers, and paramedics that the ataxic syndrome may worsen due to the lack of rehabilitation or the interruption of medications. This exacerbation should be distinguished from a new-onset COVID-19 infection, which is primarily characterized by fever, dry cough, tiredness, pains, nasal congestion, sore throat, or diarrhea.Use the virtual visit platforms of telemedicine. We are fortunate to have this technology, which has emerged as the primary way to interact with and care for patients through telephone contact or real-time interactive video platforms in this environment in which in-person encounters for routine care are not possible. Whereas, telemedicine technology is not perfect or equipped to perform a comprehensive neurological examination, in our experience it is nevertheless adequate for assessing the overall mental state and speech and for examination of hyperkinetic movement disorders, ataxia, hand dexterity, and balance, while maintaining the social connection with patients and their families and giving them the confidence that they are cared for and are not being abandoned.Emphasize the need for assessment and monitoring of patients' emotional and social health, which may be adversely affected in this time of great stress and anxiety and superimposed upon the real social isolation that many CA patients already feel because of the nature of their underlying disorder. Be aware that emotional and social impairments of cerebellar patients may render virtual interaction more difficult and taxing, so that extra encouragement might be needed to use virtual means. These patients may also have diminished understanding of the social duty to follow the strict hygiene measures necessary for the common welfare . The cogTake an active role in management decisions regarding CA patients stricken with COVID-19 whose illness may require ICU-level care in the context of reduced access to ventilator care. Current management strategies need to be fine-tuned in these instances . InterniBe mindful in this unprecedented time that it is fully appropriate to be attuned to the needs of our medical and paramedical colleagues who are themselves in need of attention . InsomniNone of us has ever personally encountered such a dire situation as is posed by this pandemic. This set of recommendations offered by the international panel of ataxia experts is based on our collective clinical experience and review of the rapidly expanding clinical and basic science literature. We expect that the results of clinical trials and larger studies of the pandemic in all its manifestations will enable us to provide more substantive and evidence-based guidelines for neurologists, including ataxiologists, in the future.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


This Special Issue focuses on eutrophication and related ecological health risks—one of the biggest challenges to sustainable water management. It is increasingly recognized that eutrophication has multidimensional consequences for water quality, both ecosystem and human health, as well as economic activities. These consequences depend on site-specific conditions, specifically, the ecological stability of the system, land use types, climate change, and the presence of other contaminants, including infectious disease agents. This Special Issue contains ten research papers that focus on, among other factors, phosphorus, cyanobacteria, off-flavor substances, macroinvertebrates, chemical stress, and land-use effects, thereby increasing our understanding of the multidimensional effects of eutrophication.  Freshwater is a crucial resource for the survival of life on earth ,2. HowevEutrophication is one of the most prevalent challenges faced by freshwater systems globally ,4,5 and Within this context, harmful algal blooms represent one of the major ecological health risks associated with eutrophication . This isIn summary, the Special Issue “Eutrophication and the Ecological Health Risk” aims to share results and findings from current research on eutrophication and related ecological health risks, with a special focus on freshwater sustainability.Notably, the studies included in this Special Issue reflect only a small and specific portion of this research field. Although only a few articles in this collection focus on the overall scope of the eutrophication and related ecological health risks, I would like to highlight the importance of broadening the context to include multidimensional problems when presenting results on this interesting and challenging subject.Herein, I summarize the contributed papers in the context of eutrophication and related risks to the health of ecological systems to paint an overall picture of this Special Issue . Three sThe call for submissions to this Special Issue “Eutrophication and the Ecological Health Risk (EEHR)” stretched from December 2018 to March 2020. A total of 15 submissions were received, of which 10 were accepted for publication.Microcystis aeruginosa in Lake Taihu, China. The authors used physical and chemical indexing and molecular particulate P analysis with 31P nuclear magnetic resonance to investigate alkaline phosphatase activity in particulate matter and water. Their results indicate PPOM to be the most important P-pool in water columns during cyanobacterial blooms. Furthermore, particulate orthophosphate was determined to be the main P-species released during the early stage of PPOM degradation. The authors highlight the contribution of P released during the degradation of PPOM for the control of lake eutrophication.Kong et al.  evaluateWan et al.  used theAnabaena variabilis cultured in the laboratory. Their results indicate that temperature, both independently and in combination with bacterial abundance, has a significant effect on the degradation of exDNA. In the study, the highest degradation rate was observed in samples exposed to high microbial activity, with exDNA degrading completely within a single day. However, light intensity and pH showed little effect on the degradation rate. The authors suggest that the degradation of exDNA in freshwater ecosystems is driven by the combination of both biotic and abiotic factors and can occur rapidly under specific conditions.Zulkefli et al.  evaluateKim et al.  carried Lumbriculus variegatus, to copper sulfate, and demonstrated the effectiveness of using body segment data from these line-shaped animals in the detection of biological responses. Line body shape detection with parameters expressing body segments broadens the scope of behavioral characterization of elongated animals, adding an extra dimension that reveals the complexity of line-shaped bodies compared with point detection in round-shaped species. Notably, the patterns of time-series line movements of the test oligochaete were determined using a recurrent self-organizing map. Ji et al.  investigDicrotendipes fumidus) that inhabits large-scale weirs. Their results indicate that the most common operational taxonomic unit (OTU) among individuals included phytoplankton, such as Tetrahymena sp., Pseudopediastrum sp., Tetradesmus dimorphus, Biddulphia tridens, Desmodesmus armatus, and other Desmodesmus spp. Calculations of the selectivity index (E’) show that chironomid larvae have a significant preference for certain phytoplankton taxa. Furthermore, results from this study suggest that combinations of different parameters, including physicochemical water quality, prey organism  particle size, and chemical effects (chemokinesis), influence the feeding behavior of Chironomidae larvae. The authors emphasize the potential of DNA meta-barcoding in the assessment of biological indicators and the impact on food-web structures in large-scale weirs using dietary insights.Jo et al.  used a DScenedesmus quadricauda, isolated from brackish water, against dissolved salt stress due to N and P enrichment. Their results showed the highest salinity concentration to inhibit the growth rate of the test alga, regardless of specific nutrient levels. However, with an increase in nutrient enrichment, the alga showed increased tolerance to dissolved salts, due to intracellular proline synthesis. The study highlights the potential of nutrient enrichment in reducing the adverse effects of dissolved salt stress on the test alga by promoting cell growth and proline synthesis. Furthermore, results from the study suggest that the tolerance of algae to dissolved salt stress varies with habitat conditions, as N, P, and salinity levels affect both algal survival and development. The authors highlight the importance of considering the potential effect of various environmental factors on salt stress adaptability, particularly cellular proline accumulation.Park et al.  evaluatePark and Lee  investigLee et al.  evaluateLee et al.  analyzedCultural eutrophication is one of the primary challenges to sustainable water management and needs urgent attention due to cumulative anthropogenic activities. It is increasingly recognized that eutrophication has multidimensional consequences linked to water quality, ecosystem and human health, as well as economic activities. Furthermore, the enrichment of nutrients interacts with many site-specific conditions, specifically, the ecological stability of the system, land-use types, climate change, and the presence of other contaminants, including infectious disease agents. It is essential that future studies acknowledge and consider the complexity of these multiple interactions.


Bone regeneration has become a research hotspot and therapeutic target in the field of bone and joint medicine. Stem cell-based therapy aims to promote endogenous regeneration and improves therapeutic effects and side-effects of traditional reconstruction of significant bone defects and disorders. Human amniotic mesenchymal stem cells (hAMSCs) are seed cells with superior paracrine functions on immune-regulation, anti-inflammation, and vascularized tissue regeneration. The present review summarized the source and characteristics of hAMSCs and analyzed their roles in tissue regeneration. Next, the therapeutic effects and mechanisms of hAMSCs in promoting bone regeneration of joint diseases and bone defects. Finally, the clinical application of hAMSCs from current clinical trials was analyzed. Although more studies are needed to confirm that hAMSC-based therapy to treat bone diseases, the clinical application prospect of the approach is worth investigating. Large bone defects and disorders, either congenital or acquired, severely affect the patients' appearance and function . MoreoveDifferent types of scaffold, bioactive factors, and seed cells are the three major elements of tissue engineering. Thus, finding an ideal scaffold to replace the autologous bone translation in the treatment of bone disorder is under intensive research. Nowadays, the scaffold matrix used for bone tissue engineering includes inorganic material, polymers, and their composites . In addiin situ tissue regeneration by applying bioactive factors locally . In this study, we reviewed the source, characteristics, and roles of hAMSCs in bone regeneration, not only in the reconstruction of bone defects but also in the treatment of arthritis. Thus, hAMSCs might be used as an innovative treatment option to promote endogenous bone regeneration.MSCs are specialized cells with multi-differentiation potentials, which can be activated to differentiate into tissue cells under specific inducing conditions , 34. Pre6 hAMSCs  . AlthougRA is a chronic, autoimmune, inflammatory joint disease characterized by hyperplasia of the synovial membrane and infiltration of immune and inflammatory cells. The synovial cell fibrosis, excessive production of inflammatory cytokines, and osteoclast appearance led to joint destruction and disability . The immin vitro . The transplanted mice had improved bone structural quality, high mineral density, and better mineralization, while the genes related to osteogenesis were upregulated and those associated with inflammation, TGF-β, and osteoclast differentiation were downregulated (in vivo, they did not seem to transform into osteoblasts. In specimens from early bone defect healing, hAMSCs polarized macrophages to M2 that could secrete pro-angiogenic and osteogenic cytokines, such as BMP-2 and VEGF (Based on the egulated . The β-tegulated . In our and VEGF . Moreoveand VEGF . Combineand VEGF , 83.Stem cell therapies exert their effects on a wide range of diseases and injuries, including immune disorders , variousin vivo are also needed to further elucidate, which are important to determine the indications, timing, dosage, and accurate administration of hAMSC-based therapy. For the treatment of bone regeneration and other bone disorders, more efforts should be made to optimize the therapeutic effects of hAMSC-based therapy by combining with other biomaterials and bioactive factors. Despite these challenges, it is no doubt that MSC-based therapy has a promising clinical application prospect. Since previous studies have demonstrated the hAMSCs with excellent MSC properties, hAMSC-based therapy is worthy to be further studied in depth and finally put into clinical practice.Although hAMSCs have become an alternative source of stem cells in regenerative medicine and tissue engineering due to their advantages such as easy gain, sufficient quantity, and superior properties, the application from laboratory research to clinical practice in the future needs further exploration. We still need to carry out further studies on hAMSCs acquisition, storage, and transportation to form standardized standards to maintain and improve the therapeutic potential of hAMSCs, so as to ensure the clinical application effects. It has been well-known that autologous MSCs represent the primary sources considered safe for transplantation and minimization of immunological risk. Preclinical studies should confirm the safety and immunological risk of allogenic hAMSCs for transplantation by comparing with autologous MSCs, and then the mechanisms of hAMSCs in promoting skeletal system diseases JL and ZZ helped to draft the manuscript. FJ and YX contributed to the conception and supervision of the study. JW contributed to the consultation and revision of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


St. Louis encephalitis virus (SLEV) is a flavivirus that circulates in an enzootic cycle between birds and mosquitoes and can also infect humans to cause febrile disease and sometimes encephalitis. Although SLEV is endemic to the United States, no activity was detected in California during the years 2004 through 2014, despite continuous surveillance in mosquitoes and sentinel chickens. In 2015, SLEV-positive mosquito pools were detected in Maricopa County, Arizona, concurrent with an outbreak of human SLEV disease. SLEV-positive mosquito pools were also detected in southeastern California and Nevada in summer 2015. From 2016 to 2018, SLEV was detected in mosquito pools throughout southern and central California, Oregon, Idaho, and Texas. To understand genetic relatedness and geographic dispersal of SLEV in the western United States since 2015, we sequenced four historical genomes  and 26 contemporary SLEV genomes from mosquito pools from locations across the western US. Bayesian phylogeographic approaches were then applied to map the recent spread of SLEV. Three routes of SLEV dispersal in the western United States were identified: Arizona to southern California, Arizona to Central California, and Arizona to all locations east of the Sierra Nevada mountains. Given the topography of the Western United States, these routes may have been limited by mountain ranges that influence the movement of avian reservoirs and mosquito vectors, which probably represents the primary mechanism of SLEV dispersal. Our analysis detected repeated SLEV introductions from Arizona into southern California and limited evidence of year-to-year persistence of genomes of the same ancestry. By contrast, genetic tracing suggests that all SLEV activity since 2015 in central California is the result of a single persistent SLEV introduction. The identification of natural barriers that influence SLEV dispersal enhances our understanding of arbovirus ecology in the western United States and may also support regional public health agencies in implementing more targeted vector mitigation efforts to protect their communities more effectively. Following the detection of West Nile virus in the United States, evidence of the historically endemic and closely related virus, St. Louis encephalitis virus (SLEV), dropped nationwide. However, in 2015, a novel genotype of SLEV, previously restricted to Argentina, was identified as the etiological agent of an outbreak of neurological disease in Arizona, United States. Since that time, the genotype has expanded throughout the Western United States, including into California, Nevada, Texas, Idaho, and Oregon. In this study, samples containing SLEV, provided by public health and mosquito abatement agencies, were sequenced and used in phylogenetic analyses to infer patterns of SLEV movement. Three independent routes of SLEV dispersal were identified: Arizona to Southern California, Arizona to Central California, and Arizona to all locations east of the Sierra Nevada mountains. The Sierra Nevada mountains and the Transverse Ranges appear to separate the three routes of SLEV movement, suggesting that geographic features may act as barriers to virus dispersal. Identification of patterns of SLEV dispersal can support regional public health agencies in improving vector mitigation efforts to protect their communities more effectively. Flaviviridae, Flavivirus) maintained in an enzootic cycle involving Culex spp. mosquitoes and passeriform and columbiform birds. While SLEV infections are non-fatal in birds, spillover into humans  whe wheCx. tThe relationship between mountain ranges and SLEV dispersal is further complicated by involvement of the avian hosts, passeriform and columbiform birds. While birds are more mobile than mosquitoes, there is evidence that the Sierra Nevada, Cascade, and Transverse Mountain Ranges are also barriers for gene flow within some passerine bird species –60, wherIn addition, the Mojave and Colorado deserts in the southwestern US may have also contributed to the pattern of SLEV expansion. Mosquito populations relay on the maintenance of aqueous larval habitats originating from natural  and anthropogenic  water sources ,62,63. TGiven the diverse ecologies of the western US, variation in bird and mosquito species distributions may influence viral persistence and dissemination patterns. In central CA and AZ, a single introduction of SLEV was maintained locally year-to-year, while multiple short-lived introductions were observed in southeastern CA. The ecologies of southern AZ and southeastern CA are more similar, as both are arid deserts dotted with cities and smaller towns. Whether SLEV persists in a particular area may be attributable in part to the patchiness of the environment. As for Eastern equine encephalitis virus, another bird-transmitted arbovirus , our finFinally, while the natural dispersal of SLEV-competent birds and mosquitoes seem like the most obvious drivers of SLEV expansion, anthropogenic transport should not be neglected. While humans are considered dead-end hosts for SLEV and cannot perpetuate the SLEV transmission cycle, human behavior could have facilitated the transport of SLEV-infected mosquitoes. Transport and survival of mosquitoes has been reported in personal automobiles , as wellIn this study, we failed to detect any historically endemic SLEV genotypes  in the western US after 2014, suggesting that all SLEV activity in the western US is the result of the recent introduction of genotype III. However, it is unclear if historically endemic SLEV genotypes continue to circulate in the remaining portions of the US. Our results also revealed three distinct routes of SLEV dissemination that support the hypothesis that geographic and ecological features, likely the Sierra Nevada, Cascade, and the Transverse Ranges, influenced the movement of SLEV in the western US. It is possible that similar geographic barriers may also influence the movement of other avian arboviruses in the US, like WNV and Western equine encephalitis virus, the latter of which has not been detected in CA since 2006, but which re-emerged in Mexico in 2019 . Underst


There has been a growing interest in using diagnosis-related groups (DRGs) payment to reimburse inpatient care worldwide. But its effects on healthcare and health outcomes are controversial, and the evidence from low- and middle- income countries (LMICs) is especially scarce. The objective of this study is to evaluate the effects of DRGs payment on healthcare and health outcomes in China.A systematic review was conducted. We searched literature databases of PubMed, Cochrane Library, EMBASE, Web of Science, Chinese National Knowledge Infrastructure and SinoMed for empirical studies examining the effects of DRGs payment on healthcare in mainland China. We performed a narrative synthesis of outcomes regarding expenditure, efficiency, quality and equity of healthcare, and assessed the quality of evidence.Twenty-three publications representing thirteen DRGs payment studies were included, including six controlled before after studies, two interrupted time series studies and five uncontrolled before-after studies. All studies compared DRGs payment to fee-for-service, with or without an overall budget, in settings of tertiary (7), secondary (7) and primary care (1). The involved participants varied from specific groups to all inpatients. DRGs payment mildly reduced the length of stay. Impairment of equity of healthcare was consistently reported, especially for patients exempted from DRGs payment, including: patient selection, cost-shifting and inferior quality of healthcare. However, findings on total expenditure, out of pocket payment (OOP) and quality of healthcare were inconsistent. The quality of the evidence was generally low or very low due to the study design and potential risk of bias of included studies.DRGs payment may mildly improve the efficiency but impair the equity and quality of healthcare, especially for patients exempted from this payment scheme, and may cause up-coding of medical records. However, DRGs payment may or may not contain the total expenditure or OOP, depending on the components design of the payment. Policymakers should very carefully consider each component of DRGs payment design against policy goals. Well-designed randomised trials or comparative studies are warranted to consolidate the evidence of the effects of DRGs payment on healthcare and health outcomes in LMICs to inform policymaking. In medicine, the provider payment method is an important measure to allocate healthcare resources, to influence behaviours of health providers, and to achieve goals of the health system . OriginaIn the most recent health reform, China has made great achievement toward universal health coverage (UHC) through expanding national health insurance schemes to up to 95% of the population, which reimburse about 50–70% of healthcare expenditure of the insured . As publThis review focused on inpatient care, which usually occurred in the setting of tertiary or secondary care. However, unlike many other countries, primary care facilities  are also important providers of inpatient care in China , thus weThe DRGs payment system has two fundamental components. The first is the grouping logics which classify tens of thousands of inpatient services into a limited number of groups (often hundreds or around a thousand) based on the similarity of diagnoses and treatments patients received and relevant resources used. The second is the fixed price of each group defined by its average cost, which forms the base rate of reimbursement to healthcare providers for services they provide to each inpatient, with or without adjustment to regional economic status or hospital characteristics , 16. DRGDRGs payment is a type of prospective case payment method, which is often implemented by the health insurance bodies, either public or private. Since the reimbursement price of a case (including the whole services provided to a patient) is defined previously by the average cost of the group it is classified into, mechanically it shifts the certain financial risk of healthcare from patients or insurers to health providers. Therefore, it offers health providers incentives to contain the cost of healthcare for each inpatient by reducing unnecessary services, shortening the length of stay (LOS) in hospitals and increasing the number of treated patients in a certain period, thus could increase the efficiency of healthcare and obtain more profit . HoweverThere is a gap between current evidence of the effects of DRGs payment on healthcare and what is needed to inform health policy making in LMICs. As far as we know, most of the evidence regarding DRGs payment came from HICs. While it is important and valuable, it may be difficult to adapt it directly to LMICs. Comparing to HICs, LMICs often have more challenges and difficulties to implement DRGs payment. They usually have fewer resources, weaker health workforce and inadequate medical supplying , 21. AddHowever, previous relevant systematic reviews (SR) either only summarised the progress of DRGs payment in LMICs but did not examine its effects on healthcare , or did A SR with narrative synthesis of evidence was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) .We included randomized controlled trials (RCTs), non-randomised clinical trials (NRCTs), controlled before-after (CBA) studies, interrupted time series studies (ITS) and uncontrolled before-after studies (BA) using the definitions of study designs of EPOC , 27. TheWe searched electronic databases of PubMed, Cochrane Library, EMBASE, Web of Science, Chinese National Knowledge Infrastructure (CNKI) and SinoMed from their initiatives to May 2018. The search strategy was firstly designed in PubMed using MeSH and free-texts (appendix search strategy), and adapted for other databases. Chinese terms equivalent to English terms were used in search of Chinese literature databases. References of included studies and relevant reviews were scanned for potential eligible studies. Study selection was conducted by two reviewers  independently according to the study inclusion and exclusion criteria, first by scanning titles and abstracts and later by reading full texts. Disagreements were resolved by discussion.Data extraction was performed by one reviewer (KZ) using pre-defined data extraction form and checked by an assistant (XYL) independently. Disagreements were resolved by discussion. Data extracted included first author, publication year, study location, setting, study design, study period, type of participants, type of intervention, type of control, and outcomes. Methodological quality of included studies was assessed using modified Newcastle-Ottawa Scale (NOS) . The cerWe aimed to conduct meta-analysis but it was not applicable due to the diversity of study design, intervention and outcomes reported across included studies. Thus, we summarised the characteristics of included studies and performed narrative synthesis of evidence regarding the effects of DRGs payment on expenditure, efficiency, quality and equality of healthcare in mainland China. When more than one publication reported the same DRGs experiment, the one with the best methodological merits and most complete outcomes was chosen for the data synthesis. Sensitivity analysis was performed by only including primary studies with high methodological quality (low risk of bias) .In total, 1442 citations were identified from the systematic literature search. After removing duplicates, the titles and abstracts of 1231 citations were scanned against inclusion criteria, among which 1171 were excluded. The full text of 60 potentially eligible citations were obtained and read and 37 citations were excluded. Finally, 23 publications representing 13 studies were included, among which 4 studies were published in English and 9 were in Chinese , with only fixed rate for insurance payment but no clear policy incentives (such as fixed rate) to contain the overall EPA or OOP per admission , 41, or The reported effects of DRGs payment on the OOP were also mixed Table . Among tSeven among the eleven studies reported that the LOS reduced after piloting DRGs payment, including three CBA and four BA , 43–47. Five studies reported the impacts of DRGs payment on the quality of healthcare. On the positive side, one CBA in Beijing reported that the 2 weeks readmission rate reduced in DRGs payment piloting hospitals while increased in control hospitals (FFS) . A CBA fFour CBA reported worrisome outcomes related to the equity of healthcare, including patient selection, cost shifting and worse outcomes in special patient groups –13, 43. One ITS and 1 BA found healthcare provider’s behaviour of up-coding of diagnoses or operations which tend to inflate the claims from the payers , 44 Tab.The results of the two studies with overall low risk of bias reported a reduction of EPA, OOP and LOS , but mixed results of quality of care and worsened equity of care, in which patient selection, cost-shifting, and longer LOS was found for patients who were exempted from DRGs payment scheme.This review had five important findings. Firstly, there were large variations of DRGs payment policy design across studies in mainland China. When a study claimed experimented on DRGs payment, the patients involved may vary from several groups to all inpatients. There was also large variation in the method to determine the payment rate, whether a fixed rate of the overall EPA or OOP existed (compared to only a ceiling for the insurance reimbursement), whether hospitals can choose the payment method for an individual patient, which may create very different incentives to the behaviours of health providers.Secondly, it seemed that DRGs payment was more likely to contain healthcare expenditure when it was consistently applied to all inpatients, with no differentiation by patient characteristics, disease status or insurance status, excepted for those proved to be more appropriate of other payment methods (such as per diem payment for long-term care or psychiatry diseases); when the base rate was calculated using historical data of the same level and type of hospitals, and involved negotiation between providers and insurance payers; with fixed rate of the overall expenditure (and OOP) per admission rather than for insurance payment only. Otherwise, DRGs payment may create unwanted incentives of providers to shift cost to OOP, uninsured, older or more complicated patients, which will harm the quality and equity of healthcare –13, 43.Third, most studies indicated that DRGs payment could reduce the LOS, which is in accordance with findings from previous studies . By reduFourth, we found that DRGs payment can improve the quality of healthcare by reducing unnecessary medications or procedures, such as the reduction of prescription of antimicrobials and caesarean rate , 31. HowFifth, as mentioned previously, the evidence of cost-shifting or patient selection was found, especially when the DRGs payment was only applied to a small number of groups (proportion) of patients,. There was cost-shifting to FFS paid, uninsured, older and more complicated cases –13, 43. Finally, we found up-coding behaviour of healthcare providers, a tempt and misconduct to locate the patient to a higher paid group than they should be, to obtain more profit , 44. ThiThere are few publications about the effects of DRGs payment on healthcare and patient outcomes in LMICs. A pervious SR included 12 studies from China, Thailand and Vietnam found that prospective payment had reduced health expenditure, LOS and readmission rates and improved service quality outcomes by reducing prescribing of unnecessary drugs and diagnostic procedures . HoweverThis review accumulated and critically evaluated current best available evidence of the effects of DRGs payment on healthcare in China, in which not only its desired effects but also unwanted effects were summarized. Important components of the DRGs payment policy design and their potential incentives were also discussed, which has consolidated and expanded the evidence base of the effects of DRGs payment on healthcare in LMICs . Since CHowever, there were several limitations of this review. Firstly, though the largest number of eligible studies up-to-date were identified and included, some unpublished studies may be missing in this review. Secondly, the data extraction and quality assessment was conducted by one author, though double-checked, fell short of methodological rigours. Thirdly, no randomised trial has been found, and the quality of evidence for the majority of outcomes was generally low or very low. Fourthly, though important to understand the potential incentives and effects of DRGs payment, the details of components of DRGs payment policy and related context were under-reported in included studies, which may limit the interpretation and application of research findings. At last, only short time effects (1–2 years) of DRGs payment were identified in this review. Its long-term effects, especially on patient health outcomes, warrant further investigation.There is preliminary evidence that DRGs payment can mildly improve the efficiency of healthcare by reducing the LOS, but impair the equity and quality of healthcare, especially for those exempted from the DRGs payment scheme. However, DRGs payment may or may not containing the health expenditure, either total or OOP, depending on payment design. And its effects on quality of healthcare were mixed. What’s more, the strength of the evidence was limited by the low or very low overall quality for majority of the outcomes.Health policy makers should be very careful in designing DRGs payment policy components, including using established sound DRGs grouping logics and appropriate payment rate calculation with reasonable adjustment, considering the settings  and range of implementation , and mechanisms to monitor and assure the quality and equity of healthcare.Well-designed RCTs or other comparative studies measuring not only process outcomes but also patient health outcomes are warranted to consolidate the evidence base of DRGs payment for improving health system performance in China and other LMICs. To help interpreting findings and better inform health policy making, future studies explicitly describing the components of DRGs payment policy and contextual factors that may affect its effectiveness would be welcomed.Additional file 1: Table S1. Summary of the effect of diagnosis-related groups payment on expenditure per admission (yuan). Table S2. Summary of the effect of diagnosis-related groups payment on out-of-pocket payment (yuan). Table S3. Summary of the effect of diagnosis-related groups payment on length of stay (day). Table S4. Summary of the effect of diagnosis-related groups payment on quality of care. Table S5. Summary of the effect of diagnosis-related groups payment on equity of care.


Plasmodium and Toxoplasma, the causative agents of malaria and toxoplasmosis, respectively. The PLPs are expressed in the different lifecycle stages of the pathogens and can target and lyse a variety of cell membranes of the invertebrate and mammalian hosts. The PLPs thereby either function in host cell destruction during exit or in overcoming epithelial barriers during tissue passage. In this review, we summarize the various PLPs known for apicomplexan parasites and highlight their roles in Plasmodium and Toxoplasma lifecycle progression.Perforins are secreted proteins of eukaryotes, which possess a membrane attack complex/perforin (MACPF) domain enabling them to form pores in the membranes of target cells. In higher eukaryotes, they are assigned to immune defense mechanisms required to kill invading microbes or infected cells. Perforin-like proteins (PLPs) are also found in apicomplexan parasites. Here they play diverse roles during lifecycle progression of the intracellularly replicating protozoans. The apicomplexan PLPs are best studied in  Members of the pore-forming Membrane Attack Complex/Perforin (MACPF) superfamily are highly conserved in both prokaryotes and eukaryotes, and are mainly used for immune defense or virulence. During the co-evolution of pathogens and hosts, both have developed pore-forming proteins facilitating target membrane lysis and translocation of molecules.Plasmodium or representatives of the genera Toxoplasma, Babesia, and Eimeria.Eukaryotic parasites of the phylum Apicomplexa express MACPF domain-containing proteins termed perforin-like proteins (PLPs). The Apicomplexa comprises a diverse group of intracellularly replicating protozoans that share the apical complex, composed of secretory organelles, such as the micronemes and rhoptries—and structural elements. Calcium-regulated protein discharge from the micronemes is fundamental to motility, cell invasion and egress of apicomplexan parasites  as its definitive host, but can use other vertebrates as intermediate hosts. Lifecycle progression of apicomplexan parasites is highly dependent on host cell traversal as well as invasion of and egress from host cells.Many apicomplexan parasites exhibit complex lifecycles, during which they reproduce both asexually and sexually, and which include one or more hosts. For example, the malaria parasite Plasmodium and T. gondii, we will concentrate on these species as representatives.We here review the role of apicomplexan PLPs (ApiPLPs) during lifecycle progression, with special focus on the processes of cell traversal and host cell egress. As most work about ApiPLPs has been done on The MACPF superfamily is named after the central protein domain shared by the membrane attack complex (MAC) proteins of the human complement system  and the cytolytic perforin (PF) of cytotoxic T lymphocytes and natural killer cells. However, members of the superfamily can be found in all three domains of life, i.e., eubacteria, archaebacteria, and eukaryotes , consists of a central four-stranded β-sheet that is flanked by two α-helical clusters . Non-target membranes might further be protected from lysis through the presence of inhibitor proteins as it has been shown in humans as a mechanism to avoid self-cell destruction by the complement system , and the host cell membrane (HCM). Host cell exit follows a strictly regulated programme, during which rupture of the PVM precedes HCM breakdown . Both steps may involve lytic PLPs . The invT. gondii, only TgPLP1 hitherto showed a clear involvement in host cell exit   is present in sporozoite micronemes and secreted, when these traverse the sinusoidal endothelium , PPLP4 and PPLP5 were shown to be essential for the traversal of the mosquito midgut epithelium by ookinetes, while in P. falciparum, only PPLP4 has been attributed a role in this process so far (Kadota et al., Anopheles mosquitoes. Interestingly, while in P. falciparum, PPLP4 is initially expressed in female gametocytes and later localizes to the ookinete micronemes, in P. berghei, PPLP4 was reported to be present on the entire surface of the ookinete (Wirth et al., Another epithelial crossing occurs during exit of the mosquito midgut by the motile Plasmodium ookinetes involve several different PLPs. The interplay of these proteins and potential co-dependencies will be the focus of further studies.Despite an increasing number of publications that shed light on the structure of apicomplexan PLPs and their functions during parasitic lifecycle progression, many questions about their mode of action and regulation remain. For instance, further studies are needed to determine how membrane specificity is achieved. What are the receptors for initial membrane binding and how are non-target membranes protected from lysis? How many monomers are involved in complex formation, and, given the fact that some apicomplexan PLPs are predicted to encode multiple MACPF domains, are less of these monomers necessary to form a pore? Furthermore, the role of the unconserved N-terminal regions of apicomplexan PLPs, which vary in length and sequence, remains to be elucidated. Interestingly, some processes, such as the traversal of epithelial cells of the mosquito midgut by JS, GP, and SB wrote the manuscript. All authors contributed to the manuscript and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Peripersonal space (PPS) is defined as the space surrounding the body where we can reach or be reached by external entities, including objects or other individuals. PPS is an essential component of bodily self-consciousness that allows us to perform actions in the world  and protect our body while interacting with the surrounding environment. Multisensory processing plays a critical role in PPS representation, facilitating not only to situate ourselves in space but also assisting in the localization of external entities at a close distance from our bodies. Such abilities appear especially crucial when an external entity  is approaching us, thereby allowing the assessment of the salience of a potential incoming threat. Accordingly, PPS represents a key aspect of social cognitive processes operational when we interact with other people . The underpinnings of PPS have been investigated largely in human models and in animals and include the operation of dedicated multimodal neurons  within brain regions involved in sensorimotor processing , interoception (insula), and visual recognition . Although the defensive role of the PPS has been observed in psychopathology  the relation between PPS and altered states of bodily consciousness remains largely unexplored. Specifically, PPS representation in trauma-related disorders, where altered states of consciousness can involve dissociation from the body and its surroundings, have not been investigated. Accordingly, we review here: (1) the behavioral and neurobiological literature surrounding trauma-related disorders and its relevance to PPS; and (2) outline future research directions aimed at examining altered states of bodily self-consciousness in trauma related-disorders. Peripersonal space (PPS) refers to the space surrounding the body where we can reach or be reached by external entities, including objects or other individuals . It is aIn this review, we discuss PPS and its relation to bodily self-consciousness in psychopathology using a multidisciplinary perspective that includes cognitive science, neuroscience, psychiatry, and clinical psychology. We present first a definition of PPS and illustrate its characteristics and functions. We then identify the cortical and subcortical structures underlying PPS representation in animal models and in humans. Furthermore, we explore the scant literature describing the relation between psychopathology and PPS, with a focus on trauma-related disorders, where out-of-body experiences can be an important component of the underlying psychopathology. Finally, we describe the importance of studying PPS in trauma-related disorders in an effort to not only enhance our understanding of the critical role of bodily self-consciousness in these disorders but also to deepen our insight regarding the characteristics of PPS that are influenced by psychological traits and states.Bodily self-consciousness has been described as the conscious experience of owning a body (self-identification), occupying a specific location in space (self-location), and having a specific perspective from where to perceive the world that coincides with one’s body  is defined as the space surrounding the body where we can not only reach and manipulate objects by movement but we can also be reached by external elements, including other individuals. By contrast, extra-personal space constitutes an area further from the body, where objects cannot be reached, and the environment is explored primarily through visual means . InteresThe concept of PPS stems from electrophysiological research on monkey models . Here, rMovement of the body in space while monitoring its surroundings is critical to the notion of PPS . As PPS To identify and investigate PPS, researchers have focused on the mechanisms underlying multisensory integration. Multimodal neurons involved in the representation of PPS activate when tactile, visual, and auditory stimuli are presented close to the body but not when far away from the body, thus allowing for the identification of PPS boundaries around the body. Critically, researchers have recognized approaching stimuli as most relevant to identify PPS boundaries, likely because they might represent a potential incoming threat . Here, aResearch in humans and animal models have shown that PPS can vary depending on what part of the body is examined. Indeed, a specific representation of PPS has been identified for the hand, the arm, the face, and the trunk . This unIn summary, the PPS representation is characterized by: (a) being specifically dedicated to a limited space surrounding the body; (b) being hyper-sensitive to stimuli that are moving toward the body; (c) being anchored to body parts . Collectively, these findings assist in shaping our understanding of PPS as an essential feature for bodily self-consciousness, where either distinct and/or unified flexible representations of our own body in space guide our actions through the external environment.A key feature of PPS is its plastic and dynamic representation. Whereas plastic changes refer to the flexibility elicited through training or learning, dynamic changes occur in response to modifications in the environment or in response to the internal state changes of an individual, including emotional state changes . ExtensiThis gradual expansion of the boundaries between near and far space is of critical importance in psychological disorders involving altered perception of self-other distinction and has indeed been observed in schizophrenia and autism spectrum disorders . Here, Nin front of subjects and was stroked in synchrony with the real body, Body illusion experiments have also shown dynamic changes in PPS as revealed through illusions experienced by subjects. For example, when a virtual body was placed The use of a mirror has also been shown to produce dynamic changes in PPS in humans. For example, Similar results were obtained among healthy participants in a study investigating event-related potential (ERP) correlates of crossmodal interactions between tactile (delivered via a tactile stimulator) and mirror-reflected visual stimuli (LED light) . Here, mAnother impressive finding by Interestingly, recent studies have utilized biologically plausible network modeling to simulate and investigate the neural networks underlying the PPS representation . Here, HNotably, equally dynamic social cognitive processes and interactions with other people may affect the extent of PPS. In a study investigating PPS and social interactions, face-centered PPS appeared to shrink in the presence of another person as compared to a mannequin placed at a distance of 1m from the participant . Specifi1.As Holmes and Spence  pointed More recently, a series of studies  examinedCentral to work surrounding PPS is the notion that this space represents not only a zone where an individual can have an effect on objects, but also the space where we can be reached by external entities  and potentially be harmed. As PPS surrounds one’s body, it represents a vital space for any contact with the external environment. This perspective has been adopted by researchers investigating PPS as a defense zone. For example, The hand-blink reflex has also served as a key experimental procedure to study the concept of PPS as a defense zone. This reflex consists of involuntary blinking of the eye that is generated by stimulation of the median nerve in the wrist and is mediated by the reticular formation in the brainstem . In a grAdditional work suggests that the defensive function of PPS depends on attention selection , where aIn summary, two main functions of the PPS have been identified: (1) a goal-oriented representation of space where bodily self-consciousness subserves motor intentions and action planning; and (2) a defense zone where bodily self-consciousness is oriented to protect the body from incoming potential threats.The initial definition of PPS derived from neurophysiological studies performed in primates in the 1980s examining bimodal neurons in the periarcuate (premotor) cortex ,b. MultiThe ventral-caudal premotor cortex , adjacent to the ventral-rostral premotor cortex (area F5) and to the primary motor cortex, contains multisensory neurons that respond to both visual and tactile stimuli, and a somatotopic map of arms, hands, and face . InteresAnother notable characteristic observed through neurophysiological studies of PPS in monkeys is the observation that neurons in the premotor cortex activated by the presence of an object in the space surrounding the body continue firing in the absence of the visual stimulus if the monkey believes the stimulus is still there, thus suggesting that PPS is maintained internally on the basis of previous experience .Studies examining the neural correlates of PPS in humans reproduce largely findings in monkeys. Emerging work using electroencephalography to record electrical brain activity in humans  showed eA wealth of functional neuroimaging studies have further established a PPS neural network that encompasses the ventral intraparietal sulcus, the lateral occipital cortex, and the ventral premotor cortex see . The venConversely, the ventral premotor cortex is involved in hand movements, recognition of other individuals’ hand movements, motor aspect of speech, associative sensorimotor learning and sensorimotor integration . For exaCrucially, the neural correlates underlying PPS representation appear to overlap with brain areas associated with other aspects of bodily self-consciousness. For example, fronto-parietal regions that process multisensory information are linked to both PPS and body ownership . In addiAs illustrated in As described above, the hand-blink reflex has been used to measure the defensive response within the PPS. This brainstem-driven reflex is modulated by the sensorimotor cortices responsible for representation of PPS . Here, SUsing a line bisection task in far and near space , Lourenco and colleagues  found thA recent study found that adults with autism spectrum disorder had a PPS that was smaller and with sharper boundaries  than those observed in healthy controls . Here, tA recent study investigated PPS in schizophrenic adults  using a Experiencing trauma has the potential to strongly impact the individual’s life, with associated biological, social, and psychological repercussions. In trauma-related disorders  hyper-arousal, re-experiencing, avoidance, negative mood and cognition, as well as dissociative symptoms may occur, with affected individuals enduring significant impairment in their lives . This arCritically, altered neural activity and connectivity associated with PTSD symptomatology shows significant overlap with cortical and subcortical regions that have been found to be involved in the PPS representation e.g., .Accordingly, we propose that trauma-related symptoms may affect the representation of PPS, especially when considering its defensive purpose. As previous research demonstrates, psychological traits can influence PPS boundaries: whereas, for example, trait anxiety and claustrophobia have been correlated with larger PPS boundaries , schizotBy contrast, the dissociative subtype of PTSD, characterized by depersonalization and derealization  is likelSimilarly, a review of studies on peripersonal space in schizophrenia and in autism spectrum disorder  have shown altered neural activity and functional connectivity in PTSD and its dissociative subtype either during trauma processing and at rest . In partThe insula serves as a fundamental structure for interoceptive awareness. Interoception plays a crucial role in bodily self-consciousness and represents an essential function for differentiating internal and external sensory inputs. Interestingly, PTSD is often characterized by hyperarousal symptoms, where interoception  may overload the conscious experience of the bodily perception. By contrast, the dissociative subtype of PTSD is characterized by detachment from the body, including bodily signals, with a resulting impairment of interoceptive awareness . In numeA more recent study examining the functional connectivity of the insula in PTSD at rest showed decreased functional connectivity of the insula with sensorimotor cortices  in PTSD as compared to healthy controls, with even weaker connectivity observed in the dissociative subtype as compared to the PTSD group. These findings have been discussed in relation to the limited capacity of individuals with PTSD and its dissociative subtype to integrate afferent information from internal states and from the environment into a unified conscious experience , an abilFinally, the vestibular system serves as fundamental neural network involved in interoceptive awareness and multisensory information processing. This latter is essential to orient the body in space and has been considered crucial to the PPS representation. Vestibular neurons have been indicated to be involved in trimodal visuo-tactile vestibular integration to allow the processing of self-location and self-identification, two main aspects of bodily self-consciousness . InteresTaken together, the neuroimaging studies reviewed here support the hypothesis of an atypical representation of the PPS in PTSD, where neural structures related to bodily self-consciousness, self-location, motor planning, and multisensory integration show altered neural activity and/or functional connectivity in PTSD and its dissociative subtype when compared to controls. This neural pattern can be interpreted as a general reorganization of neural networks in PTSD that favors innate alarm responses to potential threats and preparation for defense responses, thus affecting the integration of multisensory afferent and efferent inputs, with the resulting representation of the bodily self and its surroundings being biased toward potential incoming threats .On balance, our review of PPS and its relation to trauma-related disorders points clearly to the need for further study within this field and, overall, aims to inspire future directions of research on PPS and bodily self-consciousness in the aftermath of trauma.Although this work provides an extensive overview of PPS characteristics and its relationship with psychological traits and symptoms, it is not intended as a systematic review but rather as a perspective contribution to the understanding of PPS and trauma-related disorder. Investigation of the different aspects of PPS representation  in psychopathology can deepen our scientific and clinical understanding of bodily self-consciousness, particularly in relation to the altered states of consciousness that underlie dissociative symptoms characterizing certain psychological disorders, including trauma-related disorders. Depersonalization and derealization symptoms remain among the most difficult psychological symptoms to recognize, diagnose, and treat, despite seriously impacting the quality of life of individuals . A greatGiven that trauma-related disorders are also associated with impairment of bodily self-consciousness in relation to a threat response , investiFinally, studying the neural correlates of PPS in diverse contexts  among healthy individuals and individuals with trauma-related disorders appears crucial to a deeper understanding of functional connectivity and integration between subcortical structures in the brainstem that are dedicated to innate alarm response, balance, and consciousness, sensorimotor cortices devoted to multisensory integration, and prefrontal and posterior cortices involved in higher-order cognition, such as social cognition and self-referential processing.DR contributed to conception, literature review, and wrote the original draft of the manuscript. MM and RL contributed to funding acquisition. All authors contributed to manuscript revision, read, and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In the current work, we discovered and analyzed the epidemiological paradox between coronavirus disease 2019 (COVID-19) and malaria in the initial phase of the ongoing pandemic. From the analysis of distribution data, the endemic presence of malaria seems to protect some populations from COVID-19 outbreak, particularly in the least developed countries. In this sense, molecular and genetic variations associated with malaria  might play a protective role against coronavirus infection. Moreover, the mechanism of action of some antimalarial drugs, e.g., the antiviral function, suggests their potential role in the chemoprophylaxis of coronavirus epidemics, despite possible adverse effects . All these data provide important insights to understand the spreading mechanisms of COVID-19, and to direct scientific research toward the study of some currently available medications. The recent spread of coronavirus disease 2019 (COVID-19) constitutes an important and unsolved public health problem with potentially serious economic and social consequences . . 6]. SimAlthough we cannot exclude an underestimation of the real cases of SARS-CoV-2 epidemic in poorest countries of Africa due to the lack of appropriate diagnostic techniques, no official report has documented an increase in the death rate for pneumonia of unknown causes. Accordingly, alternative hypotheses can be derived from epidemiological data to explain the disproportional spread of the disease. An absolutely curious element regards the comparison between the distribution maps of Beta-CoVs diseases  and malaria through which it is possible to reveal an inverse relationship in the overall number of cases infected with coronaviruses and Plasmodium parasite A–D [9]. As of 28 March 2020, 10:00 (CET), i.e., after approximately three months of pandemic, merely 247 total cases of COVID-19 (with six deaths) have been detected in the six African countries with the highest number of malaria cases, which are defined by the World Malaria Report 2019 , the number of COVID-19 cases and deaths has been 324,343 and 18,740, respectively. Meanwhile, 85,228 cases of COVID-19 and 1243 deaths have been reported in the United States of America (~327 million of people)  might play a role in limiting the spread of COVID-19. Accordingly, some variants of the ACE2 receptor, which is used by the coronavirus to infect cells, may protect these populations ,11,12. TSecondly, a different discussion can be made regarding the treatment used for malaria, which widely involves the use of chloroquine and its derivatives . These drugs are currently used in Western countries, mainly for some autoimmune disorders, and monitored over the years, particularly to verify their ocular toxicity (‘chloroquine retinopathy’).Of note, literature data on the efficacy of these drugs against Beta-CoVs syndromes have been scientifically evidenced by the first SARS epidemic ,14.More recently, some authors have reported the usefulness of hydroxychloroquine at a dosage of 400 mg per day for ten days in the treatment of symptomatic SARS-CoV-2 pneumonia . The mecOf note, chloroquine is commonly used in several countries in the treatment and prevention of malaria despite drug resistance or government recommendations , due to its low price and wide availability .With similar characteristics to chloroquine, amodiaquine and mefloquine are also widely used in Africa as antimalarials with antiviral action against SARS-CoV and MERS-CoV . SurprisIt is of relevance to note that travelers planning a trip to some countries where malaria is endemic must take these drugs for prophylaxis, thus reducing the possibility of viral transmission. From all these considerations, it is possible to presume that the use of chloroquine, its derivatives, and other antimalarials may represent an unintentional chemoprophylaxis in African countries against Beta-CoVs epidemics, which potentially slows down the spread of COVID-19. Therefore, the involuntary achievement of an indirect protection from SARS-CoV-2 infection (similar to "herd immunity") for individuals who are not immune, in malaria countries, is likely to occur for different reasons. This slowdown of the epidemic in these countries may allow local populations to have extra time to implement all the rules for the prevention of contagion in an effective and timely manner.Interestingly, although the low median age of Africans is expected to be associated with a reduced case fatality rate, the high presence of young adults in Africa does not eliminate the risk of contagion within the population or the possibility of detecting a certain number of cases.Starting from the analysis of epidemiological data on malaria and on the effectiveness of antimalarials in the treatment of Beta-CoVs diseases, it is possible to state that scientific research is expected to verify the potential of antimalarials in reducing the spread of COVID-19 even in non-African countries. For instance, the effect of the administration of chloroquine derivatives in areas where malaria is endemic seems to preserve these geographic areas  from COVID-19 outbreak, despite some rare side effects . In this sense, a drug repurposing-based approach for COVID-19 would have numerous advantages, including prompt availability , more experience with regard to contraindications and side effects, and elimination of costs associated with de novo drugs discovery. A famous example of successful repurposed drug is Viagra (Pfizer) for erectile dysfunction .Testing these assumptions could have important implications for epidemic management strategies. Accordingly, at least 10 clinical trials are currently underway to verify the efficacy of chloroquine and its derivates for COVID-19  . In particular, it is important to understand whether the prophylactic administration of antimalarial medications in populations at risk may contribute to a significant containment of SARS-CoV-2 epidemic with important economic and social outcomes. Even the mere prophylactic administration of chloroquine or its derivatives to ‘exposed’ health workers would help to ensure greater serenity in emergency management. The advantages would undoubtedly include the immediate availability of a very low-cost drug, whose side effects , potential therapeutic doses, and contraindications, in some subcategories of the population , have long been known. In conclusion, all these data provide important insights to better understand the early spreading mechanisms of COVID-19, and to direct scientific research toward the study of the existing antimalarials drugs . Further studies should be carried out promptly to verify the hypothesis presented here without overlooking the innumerable advantages given by the implementation of a suitable strategy in the shortest possible time frame. Delaying such studies could lead to unbearable loss in terms of human lives and economic resources.


Balkan endemic nephropathy (BEN) is a form of interstitial nephritis seen only in certain geographical areas in the Balkan peninsula. Herein we describe the gross and histological changes in a diseased 42-year-old male Caucasian patient with BEN. All the changes fit the classically described alterations, with copper hue discoloration of the skin of the torso and orange discoloration of the soles and palms. Grossly, the kidneys were atrophic, with the left one weighing 31 grams and the right one 32 grams. Their surface was predominantly smooth with areas of fine granulations and cystic transformations. Histology revealed hyalinization of the glomeruli, predominantly in the external part of the cortex, severe vascular changes, interstitial fibrosis, and scant inflammatory cell infiltrate. The renal pelvis and ureters revealed multiple urothelial papillomas and atypical urothelial hyperplasia. BEN is only one geographical variant of interstitial nephritis caused by exposure to aristolochic acid. Other forms of this condition include Chinese herb nephropathy/aristolochic acid nephropathy, as well as several similar endemic conditions with a yet unestablished link to aristolochic acid. Balkan endemic nephropathy (BEN), which was first described by Tanchev in 1956, is a form of interstitial nephritis, with severe gross reduction of renal parenchyma, acquired copper hue of the skin, and increased prevalence of urothelial papilloma of the ureters and urothelial malignancies . The ageAt the time of death, the patient was 41 years old. At the age of 34 years, he had presented with anemia, hypertension, and uremia. Clinical examination and laboratory tests revealed severely decreased renal function and the patient was referred to hemodialysis. Due to the non-specific findings, the diagnosis of the patient was defined as chronic nephritis with end-stage kidney disease.In the following years, the patient suffered recurrent thrombotic events of the arterio-venous fistula (AVF) formed for hemodialysis, a progression of the hypertensive state, severe episodes of anemia, and respiratory infections. During a hospital stay for the removal of the thrombotic AVF, for which the previous procedure of hemodialysis could not be performed properly, the patient presented with worsening uremia, severe anemia (hemoglobin levels of 58 mg/ml), and expired.Due to the clinical diagnosis of chronic nephritis with end-stage kidney disease and the short hospital stay, the patient was referred for autopsy. Before the autopsy, a copper hue discoloration of skin and orange discoloration of the palms and soles was noted Figure .The kidneys were of a grossly diminished size and weight Figure . The lefRenal histology revealed a decreased cortical thickness, diffuse glomerular sclerosis in the superficial part of the cortex, thyroidization of the renal medulla, severe vascular changes with hyalinization, arteriosclerosis, and vascular obliteration, with diffuse interstitial sclerosis and scattered lymphocytic inflammatory cell infiltration Figures , 4.The ureters histologically revealed not only multiple papillomas but also diffuse atypical urothelial hyperplasia Figure .The rest of the gross and histological findings were uneventful other than scattered areas of fibrinous inflammation of the serous membranes due to the severe uremia.Despite local descriptions dating back to as early as 1953, the first official report of 665 patients was published in 1956 [The etiology of the condition had been widely disputed with genetic, toxic, and infectious agents being the most widely discussed. Recent data has suggested that BEN develops due to long-lasting exposure to aristolochic acid, due to the virtually identical clinical and morphological manifestation of aristolochic acid nephropathy (AAN), also referred to as Chinese herb nephropathy (CHN) -8. It waSeveral other forms of endemic nephropathies have also been described recently, with some harboring clinical similarities to BEN-CHN-AAN, such as ochratoxin nephropathy in Tunisia, chronic kidney disease of unknown etiology in Sri Lanka, and Mesoamerican nephropathy, which may present as other geographical variants of the same disease Table  4-7,9-1-19-14.The increasing unregulated use of food supplements can in the future lead to an increased incidence of these conditions in non-endemic areas and can have severe life-threatening complications for the patients’ lives not only due to the development of chronic renal failure but also to the development of urothelial malignancies.The depicted changes in our case underline the gross and histomorphological changes associated with BEN-CHN-AAN, with the classical complex of renal pathology.BEN is a form of interstitial nephritis associated with urothelial malignancies. The condition is likely due to the longstanding exposure to aristolochic acid and is a variant of BEN-CHN-AAN. The described gross and histological changes are specific for this complex condition.


Grafting is a technique used for millennia for vegetative propagation, especially in perennial fruit crops. This method, used on woody and herbaceous plants, can improve several agronomic characteristics, such as yield or vigor, as well as tolerance to biotic and abiotic stresses. However, some scion/rootstock combinations suffer from poor graft compatibility, i.e., they are unable to form and/or sustain a successful graft union. Identifying symptoms of graft incompatibility is difficult because they are not always present in the first years after grafting and in most cases the causes of incompatibility are still poorly understood. Studies of changes in transcript abundance during graft union formation indicate that grafting responses are similar to responses to wounding and include the differential expression of genes related to hormone signaling, oxidative stress, formation of new vascular vessels, cell development, and secondary metabolites, in particular polyphenols. This review summarizes current knowledge of the changes in transcript abundance, redox status and metabolites accumulation during graft union formation and in cases of graft incompatibility. The goal of this review is to discuss the possibility of identifying marker transcripts, enzyme activities and/or metabolites of grafting success and graft compatibility which could be used to score grafting success for genetic research and in breeding programs. We highlight gaps in current knowledge and potential research directions in this field. Grafting is a traditional horticultural technique that manipulates plant wound healing mechanisms to join together two genotypes to form a composite plant. Grafting is used for different reasons: for example, to control vegetative multiplication, reduce the time to obtain the fruits, change cultivars quickly, increase or decrease the size, or provide tolerance to biotic or abiotic stresses , which requires rapid wound closure to prevent water loss and pathogen entry. Polymerized phenolic compounds such as suberin and lignin accumulate to act as a physical and antimicrobial barrier at the site of wounds. Wounding triggers an oxidative stress burst, changes to metabolism, wound-related hormone signaling and the initiation of defense responses such as the induction of pathogenesis-related proteins. During graft union formation, there is a proliferation of parenchymal cells, to form the callus which will serve as a bridge between the two tissues. Then, there is the differentiation of the cambial cells into vascular vessels, which begins with the formation of phloem vessels in some herbaceous plants [from 3 days after grafting (DAG)] and then xylem vessels  and auto-grafting (when the same plant is grafted with itself) are only used in scientific study  between two hetero-grafts and the scion homo-graft was first done in grapevine  could be a marker of graft compatibility, being expressed at a lower level, and in lower protein concentration and activity in incompatible callus grafts  . This has led to the study of the role of PHENYLALANINE AMMONIA LYASE (PAL), the first and committed step in the phenyl propanoid pathway, in graft union formation and graft incompatibility. In N. benthamiana/Arabidopsis at 2 h after grafting, and 1, 3, 5, and 7 DAG and compared to gene expression in intact stems  rapidly results in the formation of a strong carbon gradient from the carbon-rich scion to the carbon-starved rootstock, which disappears once the phloem has reconnected. This asymmetry triggers the differential expression of the sugar-responsive genes above and below the graft union , such as singlet oxygen, superoxide, hydrogen peroxide, and hydroxyl radicals, which can cause severe damage to cell structure and functions. Plant have complex antioxidant system to control ROS via non-enzymatic  and enzymatic antioxidants . The high expression of genes , only one study has quantified PAL activity at the graft interface, which was 2-fold higher than to the surrounding woody tissues 28 DAG in homo-grafts of grapevine  of clones of Vaccinium spp. and pear trees), but this did not affect scion metabolite concentrations (Hudina et al., The most famous example of a secondary metabolite involved in graft incompatibility is prunasin, which has been long known to be responsible for graft incompatibility in pear/quince grafts (Gur et al., Eucalyptus gunnii 20 DAG (De Cooman et al., Several phenolic compounds, such as gallic acid, gentisic acid, ellagic acid, p-coumaric acid, catechin, and quercetin-3-glucoside, were found in high concentration in less compatible combinations compared to more compatible combinations in micro-grafts of In both cherries and apricots rootstock polyphenol concentration differs between different genotypes and it seems like the rootstock alters scion polyphenol concentrations just above the graft union (Usenik and Stampar, Uapaca kirkiana 3 years after grafting; both total soluble and cell wall bound phenol concentrations were higher at the graft interface than the surrounding woody tissues for some, but not all, of the homo- and hetero-grafts studied (Mng'omba et al., Total soluble and cell wall bound phenol concentrations were studied at the graft interface of homo- and hetero-grafts of U. kirkiana grafts (Mng'omba et al., In addition to the quantification of metabolites in bulk samples, the accumulation of polyphenols at the graft interface has been studied using imaging methods; the visualization of necrosis areas and callus development provides knowledge of the tissue specific location of different metabolites. For example, flavonoid accumulation has been studied in callus grafts (Pina and Errea, As described above, there have been a number of studies into the accumulation of phenolic compounds associated with graft union formation and these studies have highlighted the complexity of the metabolite responses of different species. It is difficult to make generalities about the metabolite response to grafting because different samples have been taken, such as, entire stems vs. just the phloem, cambium and/or bark. Many of the results in the literature are difficult to interpret because control samples are missing. Similarly the metabolite profile of woody tissues appears to change over time suggesting that a marker of graft incompatibility may only be valid at a certain developmental stage.It is known that graft incompatibility is under genetic control (Salesses and Al Kaï, GL drafted and SC revised the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.