Endometriosis is a chronic disease, in which endometrial-like tissue is found outside the uterine cavity. Lesions are typically located in the true pelvis but can be found, in addition to extragenital endometriosis, in the respiratory system, the diaphragm, the pleura or the pericardium. As the extrauterine endometrial lesions undergo the menstrual cycle, they cause many symptoms, including pain, and besides infertility, they all mostly affect the quality of the patient’s life. Pharmacological management of endometriosis significantly increases in importance either as a first-line treatment or as a complementary therapy after surgery. Yet, current research on antagonists of the gonadotropin-releasing hormone (GnRH) has revealed their potential benefits in endometriosis treatment. Their mechanism of action is to down-regulate the hypothalamic–pituitary–gonadal axis and therefore induce a hypoestrogenic state. The resulting reduction of estrogen levels prevents disease progression and diminishes the recurrence rate after surgical removal of endometriosis. The present review summarizes recent reports of the role oral GnRH antagonists have as a significant treatment option for pain reduction in endometriosis patients. Endometriosis is a chronic condition in which endometrial-type mucosa  is found outside the uterine cavity and undergoes exfoliation during menstruation. For now, despite the high number of patients with endometriosis, the pathogenesis of this disease is not completely understood. Several hypotheses have attempted to explain the development of this condition. The most popular theory is based on retrograde menstruation. It claims that the menstrual endometrial tissue migrates to the abdominal cavity, where it can implant and proliferate ,2,3. TheThe localization of endometriotic lesions can vary, and it can manifest itself with numerous symptoms, such as dysmenorrhea, hypermenorrhea, gradually increasing acute premenstrual pain, pelvic pain, dyspareunia, painful ovulation, pain while defecating and/or when urinating, nausea and abdominal bloating; therefore, the diagnosis is often difficult to make. However, one of the most common symptoms of endometriosis is pain—both associated with the menstrual cycle and independent from the menstrual cycle.Overall, pelvic pain and dysmenorrhea represent the type of pain typically associated with endometriosis. Dyspareunia is a condition that may affect 30% to 50% of patients and, together with infertility, it has a tremendous impact on sexual life and reproductive plans. The urge to urinate and dysuria are both related to the location of the urinary bladder, while dyschezia, diarrhea and constipation can easily be mistaken for Irritable Bowel Syndrome (IBS). Endometriosis-related symptoms affect productivity at work, everyday activities and social relationships. Thus, clearly, endometriosis negatively affects the physical and mental well-being of women, their quality of life and consequently has psychological effects that can even lead to depression .Diagnosis of endometriosis poses challenges for doctors, and the lack of appropriate diagnostic tools enabling correct diagnosis in medical practice has always been the most problematic. Magnetic resonance imaging (MRI) and ultrasound scans helped diagnose endometriosis but the process was still complicated. In many cases, laparoscopy was the only form of examination that allowed the diagnosis of the disease ,17. HoweNSAIDs are the most commonly used drugs which reduce and control pain, but they do not eliminate the cause of the disease. Hormonal therapies rely on the suppression of the endometriotic tissues, but they have undesirable side effects secondary to hormonal suppression, and such therapies need to be closely monitored. The newest medications, which are currently evaluated in endometriosis therapy, preliminarily with satisfactory results, are antagonists of the gonadotropin-releasing hormone (GnRH) .https://clinicaltrials.gov/ and https://www.cochranelibrary.com/central/about-central (accessed on 17 December 2022) were checked in detail. The detailed search method is described in the The studies and research cited in the presented review were selected from PUBMED, Google Scholar and Science Direct databases. Additionally, the websites including In order to measure patients’ pain, different scales were used: the Biberoglu and Behrman Score (B&B), the Visual Analog Scale (VAS), the Numerical Rating Scale (NRS), The Composite Pelvic Signs and Symptoms Score (CPSSS), Endometriosis Health Profile-30 (EHP-30), The Endometriosis Health Profile-5 (EHP-5) and Patient Global Impression of Change (PGIC). The use of those scales depends on the geographic region—in Europe, VAS is used more frequently but the FDA recommends the B&B Score and its components . The VASGnRH is the superior hormone which controls mammalian reproductive physiology. Three types of GnRH have been described: GnRH type I (GnRH-I), GnRH type II (GnRH-II) and GnRH type III (GnRH-III), which are different in amino acids collection . GnRH isThe introduction of GnRH-I analogs of molecular structure modifications, including agonists and antagonists, was synthesized. The action of GnRH agonists depends on the reversible blockade of pituitary gonadotropin secretion. The proper action of this treatment requires 7 days or more of constant exposure; therefore, its use is more difficult compared to GnRH antagonists which immediately suppress gonadotropin secretion. Seemingly, GnRH antagonists are as successful as GnRH agonists and also include such advantages as shorter treatment time, lower risk of ovarian hyperstimulation syndrome, less consumption of FSH and improved patient acceptance ,43,44. TGnRH antagonists work by competitive action on GnRH receptors, which are present in endometrial cells. Compared to endometrial cells of women without endometriosis, eutopic endometrial cells of women with endometriosis are marked by an increased proliferation rate and lower susceptibility to apoptosis. Therefore, the question of how they can impact endometriosis was raised. GnRH antagonists can inhibit the growth and proliferation of endometrial cells by modulating angiogenic and apoptotic mechanisms. It is based on an increase in the expression of the pro-apoptotic cell proliferation, including proteins Bax and FasL, and a decrease in the expression of the anti-apoptotic protein Bcl-2 . MoreoveGnRH agonists, due to their hypoestrogenic qualities, prove effective in the treatment of endometriosis-associated pelvic pain. However, apart from the therapeutic effects on endometrial lesions, such intervention causes many side effects, commonly including vasomotor symptoms, vaginal dryness and headaches. One of the most severe side effects of long-term treatment with GnRH agonists is osteopenia  .To alleviate this undesirable effect, add-back therapy (ABT) is successfully used . This isThe main purpose of ABT is to achieve the perfect estradiol range, which would both protect bone mineral density and simultaneously eliminate endometrial lesions . Some stElagolix is a novel, non-peptide, oral, short-acting competitive GnRH antagonist approved by the United States Federal Drug Administration (USFDA) in 2018  for the For the first time, the Elagolix efficiency was evaluated in a multicenter, double-blind, phase 2 Daisy PETAL trial. The group of 137 women aged 18 to 49 with endometriosis was divided into the research group taking Elagolix 150 mg daily and into the control group with placebo intake. The results were as follows: in the research group, a greater number of patients reported at least a 30% reduction in pain scores from baseline to week 8 for dysmenorrhea, for NMPP measured using CPSSS and for dyspareunia.Moreover, during the phase 2 Daisy PETAL trial, women taking Elagolix had significantly lower PGIC scores compared to placebo recipients. At week 8, 60.3% of women, receiving Elagolix reported being “much improved” or “very much improved” compared with 30.2% of placebo recipients. Quality-of-life measures were also assessed in this research. During the 8-week period, Elagolix recipients demonstrated greater reduction from baseline compared with placebo for four of five EHP-5 dimensions: pain, self-image, control and powerlessness, social support. Eventually, both groups of patients who received Elagolix, in open-label therapy, reported similar improvements in all the EHP-5 dimensions for women from Elagolix groups in the double-blind period. Adverse events (AEs) occurred in 9.9% of Elagolix recipients, and the most frequent were nausea, headache and hot flashes. There were no significant shifts observed in lipid profile or BMD .The effectiveness and safety of two different doses of Elagolix for treating endometriosis-associated pain (EAP) were studied in the randomized, double-blind, multicenter, phase 2 Lilac PETAL trial. The number of 155 women with endometriosis were randomized to the three groups: placebo groups, the group receiving Elagolix in the dose of 150 mg or the group receiving Elagolix in the dose of 250 mg daily for 12 weeks. After this period, placebo recipients were rerandomized to Elagolix groups and Elagolix patients continued their trial for 12 additional weeks. There were observed reductions in the monthly mean in NRS in all three treatment groups at weeks 4, 8 and 12. The decreases were greater among Elagolix patients compared to placebo recipients at week 12, but it was not statistically significant. There were also significant decreases in dysmenorrhea measured by a modified B&B scale for 150 mg and 250 mg Elagolix recipients compared to the placebo group during 12 weeks. The reductions in monthly mean dysmenorrhea and NMPP scores continued through weeks 13 to 24. Mean reductions were significantly greater for Elagolix 150 mg compared with the placebo at weeks 8 and 12 and for Elagolix 250 mg compared with the placebo at weeks 4 and 8. Dyspareunia scores lowered between 13 to 24 weeks similar to Elagolix treatment groups during weeks 1 to 12. The EHP-5 was used to assess the quality of life during Elagolix trials, and in all three treatment groups, the improvement in all EHP-5 dimensions was observed. The most significant improvements were reported in the Elagolix 150 mg group .The next study, the randomized, double-blind, multicenter, phase 2 Tulip PETAL trial, also evaluated the impact of two different doses of Elagolix: 150 and 250 mg per day on pelvic pain. The 174 patients with a laparoscopic diagnosis of endometriosis were divided into four groups administering different substances over the period of 12 weeks: two groups taking Elagolix, the third group receiving LA and the placebo group. Patients who earlier received Leuprorelin or the placebo were rerandomized to Elagolix at week 12. There was a reduction in the mean percentage of days with analgesic use among all patients participating in the trial, but unfortunately, the results were not statistically significant. During week 12, all four trial groups reported decreases from baseline in NRS in the case off EAP. Dysmenorrhea was also reduced in 150 and 250 mg Elagolix groups and LA recipients compared with patients receiving the placebo. Unfortunately, changes in NMPP and dyspareunia in the Elagolix treatment groups were not statistically significant, although in the LA group, they were. There were also improvements in all dimensions of the EHP-5 in each patient group. The Elagolix and the LA recipients had larger decreases compared with the placebo. The comparison between 150 mg and 250 mg doses of Elagolix versus LA was statistically relevant and stated a higher LA influence on the pain component of EHP-5 .In the Elaris Endometriosis I (EM-I) and the Elaris Endometriosis II (EM-II), two similar, double-blind, randomized, six-month phase 3 trials were compared: two doses of Elagolix—150 mg once daily (lower dose group) and 200 mg twice daily (higher dose group) with placebo. The trial was conducted among 875 premenopausal women in EM-I and 788 in EM-II. After 6 months of treatment, about 42.1–43.4% women taking the lower dose and 75.3% taking the higher dose had a significant reduction in dysmenorrhea, versus 23.1% of placebo recipients. NMPP was observed by about 45.7% of patients receiving lower doses and by 62.1% receiving higher doses versus 34.9% of placebo recipients. Moreover, women who received 200 mg of Elagolix resulted with a lower use of analgesics at 3 months and 6 months, and they needed rescue opioids less often than those receiving the placebo. Significantly more women taking either dose of Elagolix reported “much” or “very much” improvement on the PGIC scale at 6 months when compared with those taking the placebo. What is more, due to the EHP-30, women from Elagolix groups during treatment experienced better quality of life compared with the placebo recipients, based on the mean change from baseline to 3 months and 6 months .During EM-I and EM-II, at least one adverse event (AE) was reported, and the most frequently demonstrated were hot flashes, headaches and nausea. Patients who took lower or higher doses of Elagolix more frequently reported hot flashes compared with placebo recipients, but their maximum severity was mild or moderate. Elagolix treatment was associated with increases in lipid profile: total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol and triglycerides. What is more, Elagolix, as a GnRH analog, may also reduce BDM through its hypoestrogenic mechanism ,57. DuriThe Elaris Endometriosis III (EM-III) and the Elaris Endometriosis IV (EM-IV) were extended Elaris Trials. Studies were also double-blind, placebo-controlled phase 3 trials. The aim of Em-III and Em-IV was to evaluate the results after an additional 6 months of treatment. Women who were in Em-I and Em-II on an active treatment used the same Elagolix doses in the extension research, whereas women who were placebo recipients in Em-I and Em-II were rerandomized to each Elagolix group . After oRelugolix is another orally active, nonpeptide GnRH-receptor antagonist which was already approved in Japan in 2019 for symptoms associated with uterine fibroid treatment after the study by Osuga et al. comparing Relugolix with leuprorelin injections for uterine leiomyomas . The FDAThere are several phase 3 trials evaluating the efficacy of Relugolix in various indications completed. They include SPIRIT 1 and SPIRIT 2 ,66. PremIn SPIRIT 2, 623 patients were enrolled, 115 did not complete the treatment and 1 was not treated. After 24 weeks, there were 174 patients in group 1, 165 in group 2 and 168 in the placebo group. For dysmenorrhea, 75% of patients responded in the Rel-CT group, while 30% responded for the placebo. In the case of NMPP, the responses for Rel-CT amounted to 66% vs. 43% for the placebo. In group 2, the response criteria were met by 73% for dysmenorrhea and 53% for NMPP. Patients receiving Rel-CT at week 24 presented better daily functioning, assessed by the EHP-30 score; moreover, a higher number of patients were opioid-free in both SPIRIT 1 and SPIRIT 2 trials. Undesirable effects included mainly headaches, hot flashes and nasopharyngitis. Changes in BMD were overall comparable with the placebo.Conducted trials demonstrate that one-a-day, oral Rel-CT therapy significantly improves patients’ quality of life, lowers pain levels and is generally well tolerated, causing a minimal loss in BMD. The SPIRIT extension trial, planned for 80 weeks, will provide us with additional effectiveness and safety data ,66.Linzagolix is a new orally active GnRH antagonist, not yet approved by the FDA and is currently under clinical examination. It is associated with the reduction of pain and the degree of growth of endometriotic lesions . The firLinzagolix was used in a follow-up, prospective, randomized, double-blind study in subjects who completed the 6-month treatment period in study 18-OBE2109-002-Edelweiss 2 . Patient2 at the screening visit and who suffered from moderate to severe endometriosis-related pain during the screening period. The results of the study are pending. In March 2022, the sponsor of the ObsEva study announced the results for Linzagolix 200 mg with ABT and Linzagolix 75 mg without ABT in the phase 3 EDELWEISS 3 trial in patients with moderate to severe endometriosis-associated pain [Currently, further investigation is being conducted into the efficacy and safety of both Linzagolix ad-ministered orally once daily for 3 months and Linzagolix in the dose of 75 mg alone or of 200 mg in combination with ABT (ABT: estradiol (E2) 1 mg/norethisterone acetate (NETA) 0.5 mg) versus a placebo in the management of moderate to severe EAP . The twoted pain . There w3 at the start of the study and 204 ± 126 cm3 at 24 weeks). Such symptoms as pelvic pain, dyspareunia and dyschezia also decreased. At week 24, the mean global pelvic pain scores were 0.6 ± 0.7, whereas in the beginning, the scores were 8.4 ± 1.1. The mean dyspareunia scores were 0.1 ± 0.2 at 24 weeks, whereas at the baseline, the results were 1.2 ± 1.2. The mean dyschezia scores were 1.6 ± 2.2 compared to 2.7 ± 2.8 in the beginning. The above study clearly indicated that Linzagolix significantly reduced patients’ complaints, which may suggest its effectiveness in the treatment of adenomyosis. Moreover, the obtained results may also suggest that the drug will be effective in the course of treatment for endometriosis. Importantly, both adenomyosis and endometriosis were treated as two separate entities. In adenomyosis, the endometrium  is implanted deep into the myometrium. In endometriosis proper, the mucosal cells (endometrium) are found outside the uterus. Thus, the promising results of clinical trials in the case of adenomyosis, the specific form of endometriosis, require further analysis, as they may prove to be a breakthrough in the treatment of subsequent gynecological diseases.At the end of 2021, the results of the study on Linzagolix in the treatment of uterine adenomyosis were presented . The res3) and no myoma greater than 12 cm in diameter. The subjects were recruited from May 2017 to October 2020. Ultimately, 511 women were enrolled in the PRIMROSE 1 study and 501 women were enrolled in the PRIMROSE 2 study. There was a reduction in menstrual bleeding in all groups treated with Linzagolix and Linzagolix alone with and without ABT compared to the placebo . After 24 weeks, the group receiving 200 mg of Linzagolix demonstrated a decrease in the mean uterine volume by 31% in the PRIMROSE 1 treatment and 43% in the PRIMROSE 2 treatment. Furthermore, a reduction in the mean uterine volume (15%) was also observed in the treatment alone in the 100 mg and 200 mg doses with the addition . Therefore, clearly, Linzagolix (100 mg or 200 mg) with or without adjuvant therapy offers opportunities to significantly improve the quality of life of women with symptomatic uterine fibroids [Jacques Donnez et al. in 2022 conducted a study in which Linzagolix with and without hormonal ABT was implemented to treat symptomatic uterine fibroids. The treatment with PRIMROSE 1 and PRIMROSE 2 lasted 52 weeks. These were two identical studies, randomized, parallel, double-blind, placebo-controlled, phase 3 trials. They included women aged 18 and older with US-confirmed fibroids, who also suffered from heavy menstrual bleeding assessed by the alkaline hematin method bringing 80 mL or more of menstrual blood per cycle for at least two cycles. Participants in the study were required to have at least one myoma with a diameter not smaller than 2 cm  reduction in dysmenorrhea and about 50% improvement in NMPP compared to women who received placebo. What is more, when still under examination in phase 2 studies, Elagolix, unlike progestins , did notGnRH analogs: agonists and antagonists are a second-line therapy in the course of endometriosis therapy . They woElagolix, unlike other GnRH antagonists, is prescribed as monotherapy without hormone replacement therapy. Furthermore, Relugolix as a once-a-day self-administered oral medication possesses an excellent adherence profile. In addition, the principles of the Relugolix therapy are more comprehensible for patients and, thus, they are in compliance with the medical recommendations, which is an improvement over Elagolix. Moreover, Elagolix has a more complex treatment regimen in comparison to Relugolix and may require a dose adjustment depending on the patient’s condition. Due to the positive results in studies and the minimal changes in BMD, which are one of the most serious side effects of GnRH antagonists, Linzagolix in the dose of 200 mg with ABT may have the potential to replace Elagolix or Relugolix. It is suggested that those doses of Linzagolix might be used for long-term treatment, unlike other GnRH antagonists. Moreover, the greatest advantage of Elagolix therapy is the fact that it is the longest-known drug and is safely used in the treatment of endometriosis.The treatment with GnRH antagonists was also connected with many side effects. During Elagolix trials, changes in the lipid profile, such as increased LDL cholesterol and total cholesterol levels, were observed . Some trMoreover, the side effects of GnRH antagonists include the reduction of BMD and the risk of osteopenia and osteoporosis as a result of hypoestrogenemia. Therefore, Relugolix treatment is currently limited to 6 months , and ElaWhat is more, only about 1% of the women who attended EM-I, EM-II, EM-III and EM-IV trials, and took 150 mg, and less than 3% of those taking 250 mg of Elagolix, needed to discontinue the study because of the incidence of hot flashes . During We should not forget about the limitations of conducted studies. In the Daisy Petal trial, the main limitation was the fact that the participants were recruited from patients who previously took part in the Elagolix trial . The TulAnother issue associated with GnRH antagonist therapy is their cost. For example, Elagolix, produced by AbbVie Inc. in the North Chicago, IL, USA, is priced at about USD 10,000 per year (USD 2500 per 3 months), which can be unaffordable for patients or cause a budget burden for tax-funded healthcare systems, especially in low-income countries . Sze WanCurrently, there is a clinical study conducted to evaluate the safety and efficacy of Elagolix in combination with concomitant hormonal ABT among premenopausal participants with moderate to severe endometriosis-associated pain. The trial is expected to terminate in 2023 . In the What is more, there is a currently undergoing study assessing the contraceptive efficacy of Relugolix combination therapy  by the At-Risk Pearl Index (PI) in women with uterine fibroids or endometriosis and who are at risk for pregnancy ,85. ThisIn conclusion, pain in endometriosis is one of the most challenging problems; however, the patients still cannot be offered a satisfactory treatment. GnRH antagonists appear to be a promising group of drugs but they also demonstrate numerous side effects, mostly associated with hypoestrogenic states, such as decreased BMD, hot flashes and mood or sleep disturbances. However, their pharmacokinetic profile tends to be less damaging in comparison to GnRH agonists. Based on the knowledge concerning the possible side effects, patients individually should decide whether to choose or not to choose this kind of pharmacological therapy among others. The main advantages of GnRH antagonists observed so far include the reduction of dysmenorrhea and NMPP, but further studies are necessary to compare the efficacy and safety of different analogs of GnRH antagonists.


Hippocampus is one of the neurogenic zones where adult neurogenesis takes place. This process is quite complex and has a multicomponent regulation. A family of G protein-coupled trace amine-associated receptors (TAARs) was discovered only in 2001, and most of them (TAAR2-TAAR9) were primarily considered olfactory. Recent studies have shown, however, that they are also expressed in the mouse brain, particularly in limbic formations, and can play a role in the regulation of emotional behaviors. The observations in knockout mice indicate that at least two members of the family, TAAR2 and TAAR5, have an impact on the regulation of adult neurogenesis. In the present study, we analyzed the expression of TAARs in the murine and human hippocampus using public RNAseq datasets. Our results indicate a low but detectable level of certain TAARs expression in the hippocampal cells in selected high-quality transcriptomic datasets from both mouse and human samples. At the same time, we observed the difference between humans, where TAAR6 expression was the highest, and murine samples, where TAAR1, TAAR2, TAAR3, TAAR4 and TAAR5 are more pronouncedly expressed. These observations provide further support to the data gained in knockout mice, indicating a role of TAARs in the regulation of adult neurogenesis in the hippocampus. Adult neurogenesis was first described in 1960s . NeurogeDG has C-shape and, at the cellular level, has several distinct layers: the molecular, granule cell layers, subgranular zone and hilus (polymorphic layer) B. The moThe hippocampus also has C-shape and is divided into three different areas based upon histology features: CA1, CA2 and CA3. All of them have five cell layers A. The stDuring adult neurogenesis, the neuronal stem cells became fully maturated neurons. In DG, it leads to the formation of only one type of neurons—granule cells . The proThe regulation of adult neurogenesis is also very complex. The most central among them are transcription factors with their receptors, a large number of which are G protein-coupled receptors (GPCRs), their signaling cascades, products of lipid metabolism  and metaBiogenic monoamine neurotransmitters, such as norepinephrine, dopamine and serotonin (5-HT), are known to be involved in the adult neurogenesis regulation via activation of their respective GPCRs ,9. The lThe studies performed in knockout mice indicated that TAAR2 and TAAR5 can modulate dopamine and serotonin systems and are involved in the regulation of emotions ,17. ReceRNA sequencing data were searched in the National Center of Biotechnology Information (NCBI) Gene Expression Omnibus (GEO)  for the https://singlecell.broadinstitute.org/single_cell, accessed on 15 February 2022) was searched for the term “hippocampus”. When all records without data on TAARs expression were excluded, the only remaining record, SCP1 “Study: Single nucleus RNA-seq of cell diversity in the adult mouse hippocampus (sNuc-Seq)”, was included in the review ” is represented by TPM-normalized values. It was analyzed as it stands by the Single Cell Portal interactive interface.https://www.gtexportal.org/home/ (accessed on 17 March 2022).GTEx transcriptomic data were obtained from dbGaP accession number phs000424.v8.p2 on 17 March 2022. Data were visualized by GTEx Portal interactive interface available at Since the data from GEO data included in the overview were presented in raw counts, the expression values were normalized using the trimmed mean of M-values (TMM) method of the edgeR package  to avoidp > 0.05).The range of transcriptomic datasets representing the diversity of expression patterns in the hippocampus was narrowed down to the most deeply sequenced samples analyzed in mouse studies. No datasets consisting of human data met the criteria for inclusion in the review. As reviewed datasets consist of control groups and matched experimental groups, differential expression analysis was performed in all datasets to estimate the possible difference in TAARs expression between untreated animals and animals treated under the experimental conditions or maintained under atypical experimental circumstances. The differential expression analysis revealed no influence on the size of the animals’ social network, maternal exposure to urban particulate matter, sleep deprivation or long-term potentiation of the hippocampal slices in vitro after sampling the TAARs expression pattern (Mus musculus domesticus) whose age is uncertain.Since no significant differences in TAARs expression could be detected between control and experimental animals, the groups were merged for further analysis so that, in total, TAARs expression was estimated in 79 hippocampal whole tissue samples. The group studied consisted of 50 males and 29 females. In total, 50 animals were 2–4 months old C57BL/6 mice, and the other 29 animals were wild house mice , GABAergic neurons and non-neuronal cells such as glia and ependyma . The samThus, TAARs expression in the mouse hippocampus seems to be sporadic and low-positive, and its distribution between hippocampal structures and different cell types is heterogeneous. It may be estimated only in deep-sequenced samples. The obtained results do not answer the question whether TAARs expression in the murine hippocampus is constitutive or inducible and context-dependent. At the same time, acquired expression patterns are reproducible and demonstrated in different studies performed independently in several laboratories.GTEx Analysis V8 (dbGaP Accession phs000424.v8.p2) dataset demonstrates that TAARs expression pattern in the human hippocampi is not fully congruent to the mouse data. Only TAAR6 expression reaches TPM cut-off 0.1 in the small number of samples in this dataset. At the same time, TAAR6 mRNA is absent in the murine samples. All other TAARs, including TAAR1, TAAR2, TAAR5, TAAR8 and TAAR9, were accidentally expressed in a few samples at the below cut-off levels .TAARs belong to the class of GPCRs. Humans have 6, and mice have 15 functional TAARs genes. The majority of them (TAAR2–TAAR9) were originally supposed to play a role in sensing innate odors. However, they were also identified in the gastrointestinal tract, heart, kidneys, platelets, the spinal cord and brain . TAAR1 hWe analyzed the open-source data including RNA and scRNA sequencing. The study has some considerable limitations. Sequencing depth in public transcriptomic data is often suboptimal for the evaluation of TAARs expression. TAARs are characterized by an extremely low level of expression; therefore, we used the reading depth with a minimum number of reads in SRA files > 50 million as a criterion for including data in the analysis. Commonly, expression levels in the samples mentioned as TAARs-positive do not reach the cut-off level recommended in the Expression Atlas database .Paying attention to all limitations, we detected an expression of TAAR1, TAAR2, TAAR3, TAAR4 and TAAR5 in RNA sequencing of whole hippocampal tissue from mice. This expression level is extremely low, and it can be characterized as sporadic; in most of the specimens, it remained negative. One of the datasets was obtained from the whole tissue of the hippocampus, but the DG was previously removed from it, and in this case, we did not detect expression of TAAR1, TAAR2 and TAAR5.Data from single-cell RNA sequencing as well as sequencing of CA1 cells isolated from the mouse hippocampus show that TAAR3 is expressed in these cells, as well as TAAR4. Otherwise, single-cell RNA sequencing data confirmed that TAARs expression in various cells of the hippocampal formation is low and mostly sporadic, wherein TAARs can be detected both in neuronal  and glial  cells. A low level of expression of all functional TAARs was also observed in the human hippocampus. These data are consistent with a previous study, where we found a predominantly limbic pattern of distribution of TAAR5 in the human brain in a similar transcriptomic analysis . A similTAARs are tuned to broad and overlapping sets of ligands (mostly represented by products of amino acid decarboxylation). The most known among them are β-phenylethylamine (PEA), tyramine, tryptamine, octopamine, 3-iodothyronamine (T1AM) and biogenic amines such as dopamine or serotonin ,32. The It was shown that TAAR1 ligand PEA  modulate+ depolarization [TAARs can be activated by some polyamines. Cadaverine and diamine putrescine binding to TAAR6 and TAAR8 were also studied in silico ,43. Addirization  and wererization . Acute drization . Putrescrization . Sperminrization . Interesrization  and strorization , conditirization . The conrization .It is proposed that TAAR6 might represent one of the endogenous hallucinogen receptors for N, N-dimethyltryptamine (DMT) . DMT is i activation [Monoamine neurotransmitters, such as norepinephrine, dopamine and serotonin (5-HT), are involved in the adult neurogenesis regulation via activation of their respective GPCRs ,9. Previtivation ,17,60. Ttivation .s activation after the binding on TAAR1/5-HT1b heterodimer instead of Gi/o signaling activation after its recognition by homodimeric 5-HT1b [TAAR1 also has the potential to interact with the 5-HT1b serotonin receptor, which is considered to be involved in newborn cell survival in the adult dentate gyrus ,62,63. Tc 5-HT1b . AltogetNorepinephrine regulates latent neural stem cell activity and adult hippocampal neurogenesis through α2- and β-adrenergic receptors. For instance, stimulation of α2-adrenergic receptors inhibits hippocampal precursor activity and decreases hippocampal neurogenesis, and stimulation of β-adrenergic receptors activates the quiescent precursor pool and enhances their proliferation in the adult hippocampus ,65. TherThe amount of data indicating the existence of a relationship between the system of trace amines, their receptors and neurogenesis is constantly increasing. It should be noted that while the majority of current data points out the role of TAARs in adult neurogenesis, an intriguing possibility of involvement of TAARs in the neurogenesis during development remains essentially unexplored and requires careful investigation. Here, we demonstrated that certain TAARs are expressed in various types of cells in mouse and human hippocampal formation at a low but detectable level. Furthermore, we found the difference in the representation of different types of TAARs between mouse and human samples. At the moment, it is difficult to explain this difference because the number of TAARs in mice is greater than in humans and their neuronal functions, which are not yet fully understood, may not be identical. Nevertheless, the present observations provide additional support to the data gained in knockout mice that indicate an important role of TAARs in the regulation of adult neurogenesis. Further mechanistic studies are warranted to explore if such regulation can occur directly via TAAR-related signaling events or indirectly through an additional involvement of other monoaminergic mediators and GPCRs.


During the breeding progress, screening excellent wheat varieties and lines takes lots of labor and time. Moreover, different climatic conditions will bring more complex and unpredictable situations. Therefore, the selection efficiency needs to be improved by applying the proper selection index. This study evaluates the capability of CTD as an index for evaluating wheat germplasm in field conditions and proposes a strategy for the proper and efficient application of CTD as an index in breeding programs. In this study, 186 bread wheat varieties were grown in the field and evaluated for three continuous years with varied climatic conditions: normal, spring freezing, and early drought climatic conditions. The CTD and photosynthetic parameters were investigated at three key growth stages, canopy structural traits at the early grain filling stage, and yield traits at maturity. The variations in CTD among varieties were the highest in normal conditions and lowest in spring freezing conditions. CTD at the three growing stages was significantly and positively correlated for each growing season, and CTD at the middle grain filling stage was most significantly correlated across the three growing seasons, suggesting that CTD at the middle grain filling stage might be more important for evaluation. CTD was greatly affected by photosynthetic and canopy structural traits, which varied in different climatic conditions. Plant height, peduncle length, and the distance of the flag leaf to the spike were negatively correlated with CTD at the middle grain filling stage in both normal and drought conditions but positively correlated with CTD at the three stages in spring freezing conditions. Flag leaf length was positively correlated with CTD at the three stages in normal conditions but negatively correlated with CTD at the heading and middle grain filling stages in spring freezing conditions. Further analysis showed that CTD could be an index for evaluating the photosynthetic and yield traits of wheat germplasm in different environments, with varied characteristics in different climatic conditions. In normal conditions, the varieties with higher CTDs at the early filling stage had higher photosynthetic capacities and higher yields; in drought conditions, the varieties with high CTDs had better photosynthetic capacities, but those with moderate CTD had higher yield, while in spring freezing conditions, there were no differences in yield and biomass among the CTD groups. In sum, CTD could be used as an index to screen wheat varieties in specific climatic conditions, especially in normal and drought conditions, for photosynthetic parameters and some yield traits. In recent years, climate change has resulted in significant variations in seasonal climatic conditions within growing seasons with the emergence of abnormal weather events, including drought, heat, spring freezing, and others, which have had a great impact on the growth and production of many crops ,2,3,4,5.Rht-B1b and Rht-D1b are positive for CT, according to QTL analyses in multiple environments [Canopy temperature (CT) has been widely employed to evaluate and select wheat in drought and hot conditions as a valuable predictor of abiotic stresses ,9,10. CTronments . CT is aronments . CT has ronments ,15. CT ironments ,17.Derived from CT, canopy temperature depression (CTD) has been suggested to reflect the difference between the plant canopy temperature (Tc) and the ambient air temperature (Ta) . CTD hasHowever, different climatic conditions will bring complex and unpredictable situations to wheat breeding, and the reliability of CTD as a selection index has been questioned . ChangesThe test materials included 186 bread wheat varieties or advanced lines, mainly from winter wheat regional trials in the Huang–Huai Winter Wheat Region of China. Among them, 75 varieties passed the national trials, 42 varieties passed the provincial trial for release in the corresponding regions, and 7 wheat varieties introduced from overseas were included, as shown in 2 in area, with 6 rows of 2.0 m in length, row spacing of 25 cm, and plant spacing of 3.3 cm. Based on local practices in wheat production, 750 kg/Ha compound fertilizers (N:P:K = 18:18:5) were applied before sowing during the preparation of the land, which was the same for each year. Wheat growth mainly depended on soil water storage and precipitation during the growth period. Chemical herbicides were used for field weeding in mid-November. Fungicides were used in late April to control stripe rust and powdery mildew, and other field management procedures were the same as local production.The field experiment was conducted in the experimental field of the Institute of Water Saving Agriculture in Arid Regions of China, Northwest A&F University, Yangling, Shaanxi  during three growing seasons . Wheat was sown in early October and harvested in early June of each growing season. The experiment was conducted in an incomplete randomized block design with 2 replicates. The plots were 3.0 m® View-Infrarot Anzeiges software along with other equipment. Then, the CTD (°C) was calculated following the equation CTD = Ta − Tc.At the stages of heading (GS55), early filling (GS71), and middle filling (GS75) of wheat, CTs (Tc) were measured using a handheld portable infrared thermal imager . Meanwhile, a Huayi PM6508 calorimeter was used to measure the air temperature (Ta) every 20 min. The growth stages were recorded for each variety, and the difference in the heading time of these varieties was about 3–5 days. When about 50% of tillers in a variety plot reached the growth stage, CT measurements were carried out thrice with a handheld portable infrared thermal imager from 12:00 to 15:00 on a sunny day. The near-infrared images were taken twice, one plot at a time, on the middle 3 rows of a 1-m-long plot by standing on the same side of the plot, tilted horizontally at an angle of approximately 30°. Five areas, including wheat leaves, stems, and spikes, were chosen from the images, and the canopy temperature was captured using the IRBISAt the middle grain filling stage (GS75), a ruler was used to measure the spike layer width, spike length, distance from the spike to the flag leaf, peduncle length, plant height, and the length and width of the flag leaf using the standard methods .2 concentration (Ci). A 2 × 3 cm2 leaf chamber was used in the fixed conditions of photosynthetic active radiation (1200 mmol m−2 s−1), airflow rate (0.5 dm3 min−1), leaf chamber temperature (25 °C), and CO2 (390–410 mmol mol−1) so as to avoid the negative effects of weather conditions during the day. Instantaneous water-use efficiency (WUEi) was calculated as the ratio of assimilation to transpiration (A/E). The Ci/Ca ratio was calculated to reflect the ability of stomata to limit CO2.At the heading, early filling, and middle filling stages of the wheat, at the time of taking near-infrared images, the photosynthetic parameters of flag leaves were investigated, which took about 3 days for these varieties according to their heading date. The photosynthetic parameters of flag leaves were measured with a Li-6400XT gas exchange system  from 8:30 to 13:00 on sunny days, including the net photosynthetic rate (A), stomatal conductance (Gs), transpiration rate €, and intercellular CO2 in the center rows of each plot was harvested from the ground, dried in the greenhouse for 1 week, weighed to obtain biomass , then threshed and dried to about 13% water content so as to obtain grain yield, and the harvest index was calculated [At the maturity stage (GS91), 1 mlculated .Data analysis—including descriptive statistics, correlation analysis with Pearson’s correlation, cluster analysis with the Ward method, and one-way ANOVA analysis to test for the significance of differences in the traits among different groups using Duncan’s new multiple-range tests—was conducted using Statistics for Windows, Version 17.0. .There were some variations in the air temperatures over the three wheat growing seasons, which were 9.01 °C, 9.53 °C, and 8.44 °C. It was important to note that the lowest temperature suddenly dropped to −0.5 °C on the night of 7 April 2018, which caused severe freezing damage to most wheat varieties at the booting–heading stage. The main stem ears and several tillers of many varieties suffered severe freezing damage; therefore, 2017–2018 was considered a spring freezing climatic condition. The rainfall amounts for the three growing seasons were 288.1 mm, 324.8 mm, and 189.3 mm, which, for the 2016–2017 and 2017–2018 growing seasons, were greater than the average of the last 10 years (219.7 mm) for the region, while for 2018–2019, it was less, with only 55.9 mm rainfall in the early growing season (October to March) compared with 184.2 mm and 201.5 mm for the 2016–2017 and 2017–2018 growing season, respectively, resulting in severe drought at the earlier growth stage. Thus, the 2018–2019 growing season was characterized as an early drought prior to reproductive growth, as shown in There were wide variations in CTD among the wheat varieties across the three growing seasons. In the normal (2016–2017) growing season, CTD variations were more obvious among genotypes, with similar trends observed among varieties at the three key growth stages, while in the spring freezing (2017–2018) growing season, the overall variations in CTD at the heading and early filling stages were lower; in the drought (2018–2019) growing season, the greatest number of CTD variations were found at the heading stage, and the smallest were at the early filling stage, as shown in CTDs at the three stages were significantly and positively correlated in the same growing season, with the highest correlations (0.75) observed in the normal (2016–2017) growing season, followed by the drought (2018–2019) growing season and the lowest (0.382) in freezing (2017–2018) growing season, as shown in The canopy structure traits, including the width of the spike layer, spike length, the length and width of flag leaves, flag leaf area, and plant height, were investigated. In A correlation analysis between the CTDs at the three growth stages and the canopy structure traits revealed various correlations across the three growing seasons, as shown in In the spring freezing growing season, the CTDs at the three growth stages were all positively correlated with plant height , the peduncle length , and the distance from the spike to the leaf , and the CTDs at both the heading and middle filling stages were negatively correlated with the flag leaf length .In the drought growing season, the CTDs at the three growth stages were all positively and significantly correlated with the flag leaf length  and flag leaf area ; the CTD at both the heading and early filling stages was positively and significantly correlated with flag leaf width ; and the CTD at the early filling stage was positively correlated with plant height (0.289) and the distance from the spikes to the leaves (0.159); however, the CTD at the middle filling stage was negatively correlated with the plant height (−0.341) and the distance from the spikes to the leaves (0.173).Clearly, there were more canopy structural traits correlated with the CTDs at the three stages in the drought and freezing growing seasons, which suggested that canopy structure traits were the main traits affecting CTD, especially in the stressed growing seasons.The investigation of the photosynthetic parameters indicated there was a wide range of variations among the wheat varieties in the three growing seasons, as shown in The correlations between CTDs and photosynthetic parameters at the corresponding stages were further investigated, and various correlations were observed in different growing seasons, as shown in In the freezing growing season, the CTD was negatively correlated with A (−0.152), E (−0.281), and Gs (−0.251) but positively correlated with A/E (0.189) at the heading stage; the CTD was negatively correlated with E (−0.281) but positively correlated with A/E (0.177) at the early grain filling stage; and the CTD was negatively correlated with Ci (−0.149) and Gs (−0.185) at the middle grain filling stage.In the drought growing season, the CTD was positively correlated with A (0.585), E (0.533), Ci (0.558), Gs (0.631), and Ci/Ca (0.559) at the heading stage; the CTD was negatively correlated with A (−0.306) but positively correlated with Ci (0.195) and Ci/Ca (0.197) at the early filling stage; and the CTD was positively correlated with A (0.234), E (0.231), and Gs (0.192) but negatively correlated with A/E (−0.164) at the middle filling stage. This suggested that CTD was greatly affected by the photosynthetic performance of the plant and could be used to reflect the status of photosynthetic capability, especially in normal and drought growing seasons.2 decreased by 17.80% and 3.60% and 49.89% and 38.36%, while the 1000-kernel weight increased by 24.11% and 23.56% in the freezing and drought growing seasons, respectively. Finally, the grain yield and biomass decreased by 20.62% and 15.51% and 30.84% and 31.45% in the freezing and drought growing seasons, respectively, as shown in Compared with the normal growing season, the grains per spike and spike number per mAs shown in In the spring freezing growing season, CTDs at both the heading and early filling stages were only negatively correlated with the harvest index .2 (−0.165), while the CTD at the early filling stage was positively correlated with biomass (0.150).In the drought growing season, CTDs at both the heading and middle filling stages were negatively correlated with grains per spike  but positively correlated with the harvest index ; the CTD at the middle filling stage was negatively correlated with spike number per mTo further understand the effects of CTD and canopy structural traits on yield traits, three kinds of cluster analysis were conducted using CTDs at the three growth stages, the canopy structural traits, and their combination for each growing season using the Ward method due to the greater influences of canopy structural traits on CTD. For easy comparison, the wheat varieties were clustered into three groups in each climatic condition. The clusters are presented in 2, 1000-kernel weight, and the harvest index were observed between Cluster 1 and Cluster 3, but not between Cluster 2 and Cluster 3.Multiple comparisons of the yield traits were further conducted, as shown in 2 and the 1000-kernel weight among the three clusters.In the spring freezing growing season, there were significant differences in CTDs at the heading and middle grain filling stages among the three clusters. However, differences were only found in the spike number per m2 between varieties in Cluster 2 and the other two clusters.In the drought growing season, varieties in Cluster 2 with moderate CTDs at heading and early grain filling stages and higher plant height obtained the highest grain yield, while significant differences were observed in the biomass and spike number per m2; in spring freezing, there were no differences in yield and biomass among the CTD groups.In normal conditions, wheat varieties with higher CTDs achieve higher grain yields and 1000-kernel weights; in drought conditions, the wheat varieties with moderate CTDs achieve higher grain yields, biomasses, and spike numbers per mCTD is highly variable at different growth stages and in various growing conditions. The coefficient of variation in CTDs averages 39% in pre-heading drought conditions and 25% in the normal growing season . The CTDThe CTD reflects the canopy function and was greatly affected by the traits contributing to the canopy structure. Previous studies observed that CT was strong and negatively correlated with plant height in common wheat in drought conditions (R = −0.64) ,27, and 2 transport. CTD and some photosynthesis parameters were strongly correlated at the heading stage, but less at the early and middle grain filling stages, as shown in Previous studies found that CTD could indirectly reflect the photosynthetic properties of plants, especially E at the whole crop level, and CTD was related to Gs and A in wheat . In the 2. In spring freezing, there was no difference in yield and biomass. These results were partially consistent with the yield benefit of a cooler canopy at the grain filling stage in drought and high temperature conditions [CT’s ability to screen wheat genotypes under water stress is based on its close relationship with grain yield and genotype differences among varieties ,33. Prevnditions ,17, and nditions ,37,38. Tnditions .In general, CTD could be an index for evaluating wheat germplasm for canopy structural traits, photosynthetic capability, and yield traits in the field under different climatic conditions, especially for normal and drought conditions, and the application of CTD in freezing conditions should be further investigated.Based on this study, it was found that CTD could be an index for evaluating the photosynthetic and yield traits of wheat germplasm in different environments, with varied characteristics in different climatic conditions. In normal conditions, the varieties with higher CTDs at the three growth stages had higher photosynthetic capacities and the highest yields; in drought conditions, the varieties with high CTDs had better photosynthetic capacity, but those with moderate CTD had the highest yield; and in spring freezing conditions, though CTD was hard on yield traits, it still could reflect canopy structural traits and the photosynthetic capacity to some extent.


Many plants confront several environmental stresses including heat, water stress, drought, salinity and high-metal concentrations that are crucial in defining plant productivity at different stages of their life cycle. Nitric oxide (NO) and Silicon (Si) are very effective molecules related in most of them and in varied biochemical events that have proven to be protective during cellular injury caused by some stress conditions like water stress. In the current work, we studied the effect of Si and NO alone and NO + Si interactive application on the response of plants exposed to water deficiency and well-watered plants for the Milord apricot variety. Water stress caused a reduce in chlorophyll content, dry and fresh weight, leaf area, stomatal conductivity, leaf relative water content and nutrient elements, while it caused an increase in leaf temperature, leaf proline, leaf malondialdehyde (MDA) content and membrane permeability. Si, NO and Si + NO combination treatments under water stress conditions significantly decreased the adverse effects of water stress on leaf temperature, leaf area, dry and fresh weight, stomata conductivity, relative water content, membrane permeability, L-proline and MDA content. The shoot dry weight, chlorophyll content, stomata conductivity and leaf relative water content in Si + NO treated apricot saplings increased by 59%, 55%, 12% and 8%, respectively. Combined treatment (Si + NO) was detected to be more effective than single applications (Si or NO) on some physiological, biochemical, morphological and nutritional properties of apricot under water stress conditions. Global climate change is one of the hottest issues of the last decade, and it has been emphasized as the most important environmental problem affecting the expansion or contraction of habitats, survival, development and reproduction of many plant species worldwide . DroughtRecently, the treatments of NO fertilization as an alternative method in plant development in drought stress is becoming increasingly important . Plant rApricot, which is among the deciduous species, is an important species widely grown in Mediterranean countries, although it is cultivated in many parts of the world. In these countries, it has become an indispensable product for producers as it provides a good source of economic income. Although apricot is known as a drought tolerant plant species due to some of its characteristics, water shortage is the biggest problem in the Mediterranean climate zone. Therefore, irrigation is needed for commercial apricot production . In receTo the best of our knowledge, there are no previous studies on alleviating drought stress in plants by applying NO, Si and their combination together (Si + NO) ,7, excep3 in the ratio 14:10:18 and with sodium silicate (Si) and nitric oxide (NO) donor sodium nitroprusside (SNP) solution were used. Sapling was irrigated equally for approximately eight weeks (mid-March to mid-May). After eight weeks, water stress for saplings was imposed according to the field capacity (FC). Each pot was weighed at two-day intervals to detect the water loss in the pot and the amount of water reduced was given to the saplings according to the combinations of the treatment. Based on the FC, two different irrigation levels have been applied as non-stress and stress . The start of the irrigation period is set to the level where 40% of the useful moisture is used in the potting soil. The treatments were divided into four main categories, including mineral solution at 0 (without Si or NO) i.e., control; Si: mineral solution + 10 mM Si; NO: mineral solution + 200 µM NO and Si + NO; mineral solution + 10 mM Si + 200 µM. In total, 8 different mineral solutions were performed for the plants under four main categories, which are Non-Stress + Control, Control + Stress, Si + NO n-Stress, Stress + Si, NO + Non-Stress, Stress + NO, Si + NO + Non-Stress, and Stress + Si + NO. In addition, solutions with concentrations of 10 mM Si and 200 µM NO were applied to sapling individually and in combination to reduce the effect of water deficit stress. Si and NO treatments were applied to each sapling plant every two weeks with 200 mL of nutrient solution (50% Hoagland) [The current work was carried out at the Research Center of the Harran University of Agriculture Faculty, Department of Horticulture in 2019. Milord apricot variety grafted on Myrobalan 29 C rootstock was utilized as material. Milord apricot variety was bred by PSB production vegetal in Spain. It has a strong, semi-spreading tree structure. Homogeneous one-year-saplings of the Milord apricot variety grafted on Myrobalan 29 C rootstock were planted in 12 L plastic pots containing peat (Klasmann TS1) in mid-March. Plants were cut three nodes above grafting point. In the experiment, peat growing medium with pH 6.5 and N:P:K at 1.0 kg/moagland) . During 2 [Saplings were harvested at the end of the study (23 July), and the roots were then carefully removed from the pots. Then, root fresh weights (RFW), shoot fresh weight (SFW), shoot dry weight (SDW) and root dry weights (RDW) per sapling plant were performed. For dry weight in sapling, samples were dried at 65–70 °C for 48 h. The image J program measured the leaf area LA of the samples taken from 3 middle parts of the apical shoot of the sapling at harvest. Then, an average value was determined for each treatments and the LA of the saplings was detected. The areas of the leaves transferred to the image J program on the computer were calculated as cm2 . To dete2 .Increme1 value of solution was determined. Then, the same solution was kept on hold at 100 °C for 10 min and the EC2 value of solution was detected. Membrane permeability values of the sapling leaves were calculated based on the following formula [MP was assessed with the method specified by Lutts et al. . Fully d formula .MP (%) LRWC values were conducted according to the method specified by Yamasaki and Dillenburg . First, −2 s−1.SC was detected by the measurements performed between 12.00 and 14.00 h with the leaf porometer  at the same positions of the 5th and 3rd leaves between the middle and peak part of the apical shoot of the sapling selected by chance from all application groups . SC valuThe amount of chl in the leaves were determined by measuring with SPAD-502 Plus device . The SPAD values were detected by two measurement values conducted at the same positions of the 3rd and 5th leaves between the middle and peak part of the apical shoot of the sapling randomly selected from all treatment groups. Then, the average of the SPAD readings were taken and the amount of chlorophyll was determined . −1 leaf fresh weight.LT was detected with an infrared thermometer from the 5th and 3rd leaf parts of the plant randomly selected from the application groups on sunny days . L-ProliMDA content of samples was detected as stated by Bolat et al.  utilizinLeaf samples were then passed through pure water three times and dried with blotter paper. The leaves were kept in an oven at 65–70 °C for 48 h to dry. The leaves were ground in a porcelain mortar and conducted suitable for analysis. In the K, Ca and Mg atomic absorption spectrophotometer , the totTukey’s test. Differences for data at p ≤ 0.05 were considered significant. In addition, a t-test was performed by comparison between the stress and the non-stress irrigation applications in some morphological and physiological properties. The PCA was detected by JMP ). HCA  was detected utilizing a heatmap R package .Analysis of data for all data was detected utilizing the SPSS software  average were determined by 2) in Stress and Non-stress, respectively , from 19.83 to 15.01%, from 38.83 to 43.47, from 73.32 to 79.30 (%) and from 34.57 to 31.92 (°C) for stress and non-stress, respectively. Among irrigation levels, the highest values of SC, Chl and LRWC were determined in Non-stress, while the lowest value was obtained in the Stress condition. Among the treatments, the highest values of SC, Chl and LRWC were determined in Si + NO, while the lowest values were detected in the Control + Stress treatment condition. On the other hand, the opposite occurred in the effects of applications and water stress on MP and LT  in Stress and Non-Stress + NO, respectively (−1) in Stress and Non-Stress + NO, respectively . Regarding 2 in the leaf tissues and also increase in superoxide radicals, which are called oxygen species [Although significant development has been noted in comprehending the response of some plant species to water deficit by applying NO and Si in the last few decades ,8, one q species . Radical species ,31,32,33Based on our findings, NO and Si treatments applied to decrease the negative effect of water stress have positive results on morphological parameters. Many authors have indicated a remarkable improvement in various plant growth parameters with NO and Si treatment in many crop plants such as wheat, cowpea, maize, Arabidopsis, strawberry, and pea under water stress conditions ,7,8. In During the metabolite activities of plants, the uptake of some nutrients in plant cells is important. In our current study, however, P, N, K, Mg and Ca uptake of plants was restricted under water stress conditions , which aIn present study, we expanded upon our previous results concerning the physio-biochemical attributes of NO, Si and Si + NO interactive treatments under water deficit stress in some Prunus species like Mliord apricot. Here, we also present findings on the potential capability of NO, Si and Si + NO treatments to enhance Milord apricot fitness to withstand problematic conditions such as water deficit stress, through multiple possible adverse factors that indirectly or directly result in a better defense strategy to make use of the available water under these conditions. Based on our results, water stress caused a strongly decreasing effect in relative water content of the leaf and gas exchange of leaf stomata. Indeed, significant increases in MP, MDA and L-Proline were observed under stress conditions. Si and NO applications were positive in SFW, SDW, RFW, RDW and LA. On the other hand, Si and NO significantly reduced MP, MDA and L-Proline, and was effective in LWRC, SC, N, P, K, Ca and Mg. Overall, these findings highlight that these applications, especially the Si + NO interactive application, could be considered as a strategy to improve the quantity, quality and yield of many plant species in water deficit stress conditions. Further studies are needed to show whether these findings may be predicted to other tree deciduous species both in the same applications and under the same conditions.


Metabolic syndrome (MetS) is characterized by an association of cardiovascular and diabetes mellitus type 2 risk factors. Although the definition of MetS slightly differs depending on the society that described it, its central diagnostic criteria include impaired fasting glucose, low HDL-cholesterol, elevated triglycerides levels and high blood pressure. Insulin resistance (IR) is believed to be the main cause of MetS and is connected to the level of visceral or intra-abdominal adipose tissue, which could be assessed either by calculating body mass index or by measuring waist circumference. Most recent studies revealed that IR may also be present in non-obese patients, and considered visceral adiposity to be the main effector of MetS’ pathology. Visceral adiposity is strongly linked with hepatic fatty infiltration also known as non-alcoholic fatty liver disease (NAFLD), therefore, the level of fatty acids in the hepatic parenchyma is indirectly linked with MetS, being both a cause and a consequence of this syndrome. Taking into consideration the present pandemic of obesity and its tendency to drift towards a progressively earlier onset due to the Western lifestyle, it leads to an increased NAFLD incidence. Novel therapeutic resources are lifestyle intervention with physical activity, Mediterranean diet, or therapeutic surgical respective metabolic and bariatric surgery or drugs such as SGLT-2i, GLP-1 Ra or vitamin E. NAFLD early diagnosis is important due to its easily available diagnostic tools such as non-invasive tools: clinical and laboratory variables (serum biomarkers): AST to platelet ratio index, fibrosis-4, NAFLD Fibrosis Score, BARD Score, fibro test, enhanced liver fibrosis; imaging-based biomarkers: Controlled attenuation parameter, magnetic resonance imaging proton-density fat fraction, transient elastography (TE) or vibration controlled TE, acoustic radiation force impulse imaging, shear wave elastography, magnetic resonance elastography; and the possibility to prevent its complications, respectively, fibrosis, hepato-cellular carcinoma or liver cirrhosis which can develop into end-stage liver disease. Metabolic syndrome (MetS), also known as insulin resistance (IR) syndrome or Syndrome X (terminology not commonly used as another syndrome X has been documented in cardiology), represents an association of risk factors for cardiovascular (CV) disease (CVD) and type 2 diabetes mellitus (T2DM) that co-occur more frequently than by chance. These risk factors are represented by high blood pressure (HBP), impaired fasting glucose (IFG), increased level of triglycerides (TG), low high-density lipoprotein (HDL) cholesterol levels, and obesity . It is becoming increasingly clear that this constellation of metabolic disorders is connected to IR and is more frequently found in people with abdominal obesity, particularly in those with an excess of intra-abdominal or visceral adipose tissue . IR creaThis article aims to assess the relationship between the MetS and development of NAFLD, as well as the diagnostic procedures for NAFLD, in order to ensure that this condition is identified and treated promptly as to avoid complications such as fibrosis or hepatocellular carcinoma (HCC), which are an important economic burden, but also, in the long run, lead to the patient’s disability, and, therefore, higher costs for the healthcare systems are required.2), HBP with systolic (˃140/90 mmHg). In 2001, the National Cholesterol Education Program Adult Treatment Panel III (ATP) [2, and those from IDF are more suggestive of a BMI of 25 kg/m2. Although they are not as widely used, somewhat slightly different definitions were utilized by other organizations such the European Group for the Study of IR (EGIR) and the American Association of Clinical Endocrinologists (AACE) in 2003. Because of its heterogenous definition and cut-off criteria, the data existing on the epidemiology of MetS differs. It is observed that the prevalence of MetS is higher using AHA and IDF (more sensitive criteria) compared to the ATP III definition, with a ranging prevalence from 12.5% to 31.4% worldwide [The challenge represented by MetS is that various organizations offered slightly different clinical screening parameters and cut-off values for identifying individuals with MetS which are somewhat ambiguous compared to the conceptual description of the MetS. The first formalized definition of MetS was offered in 1998 from a consultation group towards the World Health Organisation (WHO). The WHO diagnosis has mandatory markers of IR  and a minimum of two additional risk factors: low HDL-cholesterol level , high TG levels (˃1.7 mmol/L or >150 mg/dL), obesity  ˃ 30 kg/mInitially, Reaven did not include obesity in his description of syndrome X since he could identify non-obese people with IR and people with obesity who were insulin sensitive. Obesity assessed by BMI alone, is not a predictor of MetS if not correlated with WC, age, gender, and ethnicity, because IR has a strong connection with visceral adipose tissue. It is important to identify people with adipose tissue that is distributed in deep compartments because adipocytes from deep compartments are more metabolically active compared with superficial adipocytes and are correlated with IR . In thisNAFLD refers to the presence of fat in the liver (˃5–10% of hepatocytes are fatty) which is not associated with other known causes of steatosis such as: alcohol , viruse2, with diagnosis of NAFLD and MetS, that conventional diet (CD) 43 patients, Mediterranean Diet (MD)—high meal frequency, 43 patients, and MD—physical activity (PA), 42 patients, decreased the intrahepatic fat content and liver stiffness alongside with BMI, insulin, HbA1c, diastolic BP, HDL-C and ALT after 12 months as seen in Montemayor et al. reported  in a stuKonieczna et al.  reportedVan Kleef et al.  reported2, a clinical indication that excludes many NAFLD patients as seen in Recently, Lassailly et al.  reportedIn a study of 40 patients with obesity who underwent bariatric surgery, Pedersen et al.  concludeNewsome et al.  studied Regarding the other novel antidiabetic non-insulinic drug , MirarchAbout Vitamin E use in liver involvement, Vilar-Gomez et al.  reportedAs we previously emphasized, NAFLD is an entity which includes both NAFL and NASH; the difference between them being the presence of different grades of inflammation and architectural remodelling, for example, fibrosis. Rapid detection of individuals with severe fibrosis is essential for clinical therapy since they have a higher risk of developing life-threatening complications such as HCC or oesophageal varices. To diagnose NAFL, it is important to confirm the presence of hepatic steatosis either by imaging or histology, but the diagnosis of NASH ultimately requires a liver biopsy, which remains the gold standard for characterizing liver histology alterations. NAFL is described by convention, as the existence of 5% hepatic steatosis without hepatocyte ballooning, which is a sign of hepatocellular damage . NAFL prMetS was reported to be associated with a greater risk of CVD mortality, especially in case of its independent components such as HBP and IFG . MetS isThe ideal biomarker is a trait that can be objectively assessed, recapitulates typical pathogenic or physiological processes, and evolves in parallel with the improvements and worsening of the disease. Biomarkers can be utilized in NAFLD to diagnose and measure steatosis, assess for the existence of NASH, and quantify fibrosis. It is important to identify which patients are associating features that lead to the progression of liver disease because of the specific treatment and the high risk of developing cirrhosis and its complications, including liver-related mortality . The mosAssessment of steatosis: in clinical practice, scores for the identification of steatosis have not yet attracted significant attention because diagnosis of NAFLD using recommended imaging criteria is accurate . Scores Assessment of fibrosis: AF in NAFLD is clinically predicted by male gender, Caucasian ethnicity, presence of T2DM, obesity, and elevated aspartate transaminase (AST) or alanine aminotransferase (ALT) levels . AST is AST to platelet ratio index (APRI) takes into consideration the AST and platelets and combines two biological phenomena that happen when NAFL progress to NASH: the increase of AST and, respectively, the decrease in platelet count. It is a handy tool in clinical practice due to its simplicity. The sensitivities and specificities in predicting NAFLD with an APRI threshold of 1.0 and 1.5 were 50.0% and 84.0% and 18.3% and 96.1%, respectively, with a positive predictive value (PPV) of 34% and 56% and a negative predictive value (NPV) of 90% and 79% for AF as seen in Fibrosis-4 (FIB-4) was initially created for patients with hepatitis C and HIV and, eventually, it was discovered that the test was helpful in NAFLD. It uses age, AST, ALT, and platelet count . At a value for FIB-4 1.93, the specificity is 90%, while the sensitivity is only 50% in identifying AF. A FIB-4 index of 1.93 had a 90% NPV and a 36% PPV, while a FIB4 of 2.67 had an 85% NPV and an 80% PPV for detecting AF, as mentioned in NAFLD Fibrosis Score (NFS) is composed of 6 variables, and each of them represents an independent indicator of AF: age, hyperglycaemia, BMI, platelet count, albumin, and AST/ALT ratio. A score lower than −1.45 predicts the absence of AF F3-F4 , whereas a score higher than 0.67 predicts AF . For a value of 1.45, the sensitivity and specificity are 77% and 71% with PPV of 52% and NPV of 88% for detecting AF, as seen in BARD Score is formed by the weighted sum of three variables . A BMI ≥ 28 = 1 point, AST/ALT ratio ≥ 0.8 = 2 points and T2DM = 1 point. A score of 2–4 was associated with 17-fold odds of F3–F4 stages of fibrosis and have a negative predictive value of 97%. For a cut-off of 2, the sensitivity and specificity for detecting AF are 86% and 72%, respectively, with a PPV of 35% and a NPV of 97%, as seen in Fibro test (FT) employs age- and gender-corrected total bilirubin, gamma glutamyl transferase (GGT), 2-macroglobulin, apolipoprotein A1, and haptoglobin measurements. It is important to do a correct anamnesis when using this tool because other conditions interfering with alpha-2-macroglobulin (an inflammatory condition), bilirubin (Gilbert’s), haptoglobin (haemolysis), GGT , can alter the results and give an inaccurate estimation of fibrosis. A cut-off of 0.30 has a negative predictive value of 90% for AF (sensitivity 77%), while a cut-off of 0.70 have a 73% positive predictive value for AF (specificity 98%), as seen in Enhanced liver fibrosis (ELF) is a more recently developed test, after demonstrating that eliminating age from the formula does not change the test’s usefulness. ELF is a more complex score and includes markers related to matrix turnover from serum samples: hyaluronic acid, amino-terminal propeptide of type III collagen, and tissue inhibitor of metalloproteinase 1. A score of 10.51 has a sensitivity of 100% and a specificity of 98% in detecting AF with a PPV of 80% and a NPV of 100%, as seen in Assessment of steatosis: The most extensively used, least expensive, well-tolerated, and secure method for grading and diagnosing steatosis  is conventional US. Despite the great accuracy in the detection of parenchymal fat , severaControlled attenuation parameter (CAP) is a novel US-based technique using a process based on transient elastography (TE) for measuring steatosis. For a grade of steatosis of 5–33% the sensitivity is 73.1% and specificity is 95.2%, the cut-off 327 dB/m for detecting advance fibrosis has a sensitivity of 78% and a specificity of 84% with a PPV of 26% and a NPV of 98%, as seen in Magnetic resonance imaging proton-density fat fraction (MRI-PDFF) is a trustworthy and validated marker of hepatic steatosis, measuring fat in the liver and monitoring patients for therapy efficacy evaluation . The cosAssessment of fibrosis: The techniques, which mostly rely on US and magnetic resonance technologies, are more precise than blood biomarkers but more difficult to use and more expensive in clinical settings .TE; Fibroscan or vibration controlled TE is a US-based method for assessing liver elasticity by using the TE technique . The maiAcoustic radiation force impulse imaging (ARFI) is also a recently developed, US-based technique, which applies vibration to evaluate the stiffness of the tissue by wave speed propagation to estimate liver fibrosis. ARFI is integrated in the regular US device. The short-duration acoustic push pulses induce within tissues shear stress, with intensities depending upon tissue attenuation. The shear stress generates shear waves that propagate, perpendicular to the main US beam, away from the original region of excitation . As the Shear wave elastography (SWE), also known as two-dimensional SWE, is a US-based technique that measure liver stiffness, such as TE, in kPa units, with the advantage of assessment of hepatic parenchyma. At a cut-off of 3 kPa, it shows a specificity of 92% and a sensitivity of 90% in diagnosis of AF with a PPV of 88% and a NPV of 93%, as seen in Magnetic resonance elastography (MRE) is an advanced MR-based technique which can also be performed to measure liver fibrosis. MRE is performed on a regular MRI scanner which has additional hardware and software installed. Mechanical waves at 60 Hz are generated in the liver by a passive driver attached to the body, anterior to the liver . The pasMetS fundamentally represents an association of CVD and T2DM risk factors, characterized by IR. NAFLD can be a cause, but also a consequence of IR and, therefore, it is frequently associated with Mets. NAFL, in association with MetS and T2DM, increases the progression to NASH, augmenting the morbidity and mortality rates. An early diagnosis of NAFLD is a key for an optimal treatment of these patients, in order to minimize their morbidity. Liver biopsy is the gold standard for diagnosis of NAFLD, but because it is invasive, novel developed non-invasive techniques, which use serum biomarkers, and imaging-based biomarkers should be promoted and used on a larger scale, respectively, APRI, FIB-4, NFS, BARD SCORE, FT, ELF, TE, ARFI, SWE and MRE.


Post-stroke dementia (PSD) has adverse effects on the quality of work and life in elderly stroke survivors. There are inconsistent results on the impacts of blood pressure control on the risk of PSD in people aged 65 years and above.This study was performed to explore whether poorly-controlled blood pressure was associated with an increasing risk of PSD.The study population was enrolled from cross-sectional research conducted in 106 communities of rural northern China. In Phase I, a total of 7,448 people aged ≥65 years, including 830 with stroke history, completed a questionnaire, a physical examination, and a cognitive assessment. Phase II further confirmed the diagnosis of PSD. Well-controlled blood pressure was defined as an average systolic blood pressure of <140 mmHg and average diastolic blood pressure of <90 mmHg over two readings in person. Failure to meet these criteria was considered as poorly-controlled blood pressure.vs.15.3%, P < 0.001), be older , and have a worse cognitive level . Compared with well-controlled blood pressure patients, poorly-controlled blood pressure in stroke survivors significantly increased risk of PSD  after adjusting for age, gender, and education.The crude prevalence rate of PSD among stroke survivors aged 65 years and over was 17.8% [95% confidence interval (CI) 15.2–20.4%]. Among the 830 stroke survivors, the proportions of PSD gradually increased with age and the crude prevalence rates for PSD were 10.2% (95% CI 5.6–14.9%), 14.8% (95% CI 10.1–19.5%), 18.8% (95% CI 14.1–23.5%), and 27.4% (95% CI 20.8–34.1%) in subjects aged 65–69, 70–74, 75–79 and ≥80 years, respectively. Participants in the poorly-controlled blood pressure group were more likely to suffer from PSD (28.4 The crude prevalence of PSD among stroke survivors aged ≥65 years was 17.8% at community level. In addition to lower education level and older age, poorly-controlled blood pressure was also an independent risk factor for PSD among the elderly, which is amenable to intervention. Therefore, it is essential to control blood pressure to reduce PSD incidence. Stroke and dementia are both common diseases in aging societies , 2. PeopThe risk of PSD overlaps with the risk of stroke and dementia. Current studies –11 reveaHigh blood pressure, which affects more than 75% of people over the age of 65 years, is the leading risk factor for stroke and many other vascular diseases . Thus, hThis study was conducted in rural Ji County in northern China between April 2019 and January 2020. Using a clustering sampling method, we selected 106 community primary health care centers from 949 villages. All individuals aged ≥65 years in each village (who had been living there for at least 5 years) were selected. Selection was based on the date of birth provided on the residence certificate. Each village had one or two fixed medical staff in the local health centers who were familiar with the health of the villagers. The study was approved by the Committee for Medical Research Ethics at Tianjin Huanhu Hospital and the Tianjin Health Bureau (ID: 2019-40).n = 158), death (n = 11), migration (n = 12), hearing loss (n = 149), aphasia (n = 18), or mental disorders (n = 15), only 7,528 completed the final interview.There were two phases in the cross-sectional, door-to-door, questionnaire-based survey. All interviewers and experts received the same training on collecting information, neuropsychological assessments, and diagnosis, and participated in a retraining course every 2 months. The total number of participants aged ≥65 years in these communities was 7,891 ; howeverIn Phase I, a centralized medical examination at the health station and an in-person survey were conducted by senior neurologists and medical staff in the local health centers.via the Mini-Mental State Examination (MMSE) and Activities of Daily Living (ADL), as well as the Clinical Dementia Rating (CDR)  . The diang (CDR) .Eligible stroke survivors could proceed to Phase II of the study on the same day. The following inclusion criteria were used: (1) age ≥65 years; (2) legally lived in the community for at least 5 years before the study registration; and (3) willingness and ability to participate according to the requirements of the study. Exclusion criteria were (1) known dementia illness history before first-ever stroke; (2) stroke within 6 months; (3) problems affecting cognitive tests, such as severe dysphasia, visual deprivation, hearing loss, and disturbance of consciousness; (4) comorbidities that potentially affect cognitive function, such as malignant neoplasm, serious liver or kidney dysfunction, connective tissue disease, and malnutrition; (5) existing mental disorders; (6) a history of alcohol or drug abuse and poisoning.The second phase was performed by an expert panel. All participants included in this phase were assessed to confirm diagnosis of PSD by obtaining a detailed medical history and performing physical and neurological examinations.Dementia was diagnosed using the Fifth Edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Assessments were based on data obtained from the interviews, health examinations, previous medical records, and tests for cognitive function and functional capacity. The clinical criteria used for diagnosing PSD included a history of stroke and CT/MRI of brain, and dementia symptoms after stroke occurrence lasting for ≥ 6 months .Neurologists adjudicated incident strokes by reviewing medical records  and CT/MRI scans. As part of the routine stroke evaluation for diagnoses in China, patients underwent CT or MRI.The survey of blood pressure control was according to the China PEACE Million Persons Project . Blood pt-tests, Mann–Whitney tests, or χ2 tests as appropriate. We used multiple logistic regression to analyze the association between blood pressure control and PSD. Statistical significance was defined as P < 0.05. All data were analyzed using IBM SPSS Statistics for Windows .Demographics and participant characteristics are presented using descriptive statistics. Demographic variables and risk factors were compared between groups employing n = 395, 47.6%), to have shorter education (5.38 ± 4.34 years), habits of smoking  and drinking , and to suffer from diabetes mellitus , heart disease , and hypertension  than those without stroke .There were 7,891 participants aged ≥65 years old eligible in this study, while a total of 7,448 participants were analyzed after the investigation of Phases I and II , and 830t stroke . Additiovs. 74.51 ± 5.60 years, P < 0.001) than those without PSD. Significantly, participants with PSD had lower educational attainment  and poorer blood pressure control . In addition, the percentage of drinking in PSD was lower than without PSD . There were no differences in gender, marital status, history of smoking, diabetes mellitus, and heart disease between PSD and without PSD groups.According to the PSD diagnostic criteria, 17.8% [95% confidence interval (CI) 15.2–20.4%] of stroke survivors were diagnosed. Participants with PSD were older at interview , be older , and have a worse cognitive level . Compared with the well-controlled blood pressure group, stroke survivors aged 70–74 years (P < 0.05) and ≥80 years (P < 0.01) were more likely to suffer from dementia in the poorly-controlled blood pressure group  in a rural area of northern China, consistent with previous research results. In addition to low education level and old age, poor control of blood pressure was also an independent risk factor for dementia, which is amenable to intervention. Therefore, PSD prevalence was not low among people over 65 years old at community level, and blood pressure control is essential to reduce PSD occurrence among people aged over 65 years.Despite many studies on PSD prevalence, there has been a wide range of results. A meta-analysis by Pendlebury and Rothwell , excludiOur results showed that older age and lower educational attainment were risk factors for PSD, but there was no correlation between PSD and gender. This was similar to previous studies. Most studies showed increasing older age was associated with an increased risk of PSD. A systematic review suggested that the risk of incident dementia elevated in relation to older age especially > 80 years  and age 70–79 years  vs. age 60–69 years . AlthougHypertension is a highly prevalent condition which is an established risk factor for cardiovascular and cerebrovascular disease. In 2020, a meta-analysis  includedIn our study, after adjustments for age, gender, and education, there was an increased PSD risk in those with poorly-controlled blood pressure. Among all stroke survivors, 162 (27.2%) patients had hypertension and poor control of blood pressure, which was lower than previously reported in China , 32. HowIn addition, the relationship between other vascular risk factors and PSD, such as cholesterol level, blood glucose level, are also worth discussing. But unfortunately, our study was a screening study, no cholesterol level data was collected. Van Vliet et al.  have shoThere were some limitations in this study. First, although we made the best use of imaging evidence and medical records to identify stroke events with the help of community physicians, some important stroke characteristics  were not always available. Second, since we did not perform position emission tomography or cerebrospinal fluid examination on all participants, other types of dementia types such as Alzheimer's disease and dementia with Lewy bodies could not be completely excluded from the included PSD patients. Moreover, MMSE is a short test. Although it is commonly used in cognitive screening, the exact cognitive states according to MMSE score is not accurate enough. If we can follow up further, it will be more meaningful for the diagnosis and prognosis of PSD.We found that the crude prevalence of PSD among stroke survivors aged 65 years and over was 17.8%  in a rural area of northern China. In addition to lower education level and older age, poorly-controlled blood pressure was also an independent risk factor for PSD among the elderly, which is amenable to modification. Therefore, it is essential to control blood pressure to reduce PSD incidence. A prospective cohort to explore the relationship between blood pressure control and dementia is necessary in further research, which may contribute to the secondary prevention of dementia.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The study was approved by the Committee for Medical Research Ethics at Tianjin Huanhu Hospital and the Tianjin Health Bureau (ID: 2019-40). The patients/participants provided their written informed consent to participate in this study.HW and JG contributed to analysis and interpretation of data and wrote original manuscript. ZR reviewed and revised the manuscript. YLü, JN, XM, PC, YLi, BG, YY, YLv, ZR, SL, and X-DW did the investigation, data management of the center, and revised the manuscript. YJ designed of study, supervised the research process, and revised the manuscript. All authors contributed to the article and approved the submitted version.This work was supported by the National Natural Science Foundation of China [Grant Number 82171182], Science and Technology Project of Tianjin Municipal Health Committee [Grant Numbers ZC20121 and KJ20048], and Tianjin Key Medical Discipline  Construction Project (No. TJYXZDXK-052B).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


FKBP14-kEDS. The latter was initially overlooked due to the pathogenic significance attributed to the duplication and to the fact that, at the time of the first diagnosis, this specific form of kEDS had yet to be discovered. The patient’s progressive kyphoscoliosis and severe joint laxity were the clinical features that prompted the patient’s physiatrist to reassess the genetic work-up. This extreme latency caused inaccurate management in the patient’s follow-up program, which ultimately may have resulted in preventable clinical complications. This report underlines the importance of remaining up-to-date with patient status, reviewing old cases, and relying on specialist advice to reach a correct diagnosis.Kyphoscoliotic Ehlers–Danlos syndrome and 17p13.3 microduplication share multiple clinical features such as muscle hypotonia, cleft palate, and growth impairment. This paper describes a patient who was first diagnosed with the duplication and a decade later also with  When confronted with complex phenotypes, geneticists often decide to use broad genetic testing as opposed to specific gene sequencing. This has the advantage of identifying rare and less-known alterations that may be deemed pathogenic and explain part or all of the patient’s clinical features. In most cases, the patient will have been correctly diagnosed. However, although rare, the co-existence of genetic syndromes should be considered in patients whose phenotype is only partly explained by the first pathogenic finding.Chromosomal region 17p13.3 contains many low-copy repeats, which make it particularly unstable and susceptible to rearrangements by non-allelic homologous recombination determining either deletions or duplications. Miller–Dieker syndrome  is one of the best-known examples of a genetic disorder associated with the microdeletion of chromosome 17p13.3.Although less common, microduplications have also been described . PAFAH1B1 (OMIM #601545) to YWHAE (OMIM # 605066). The patients can be categorized into two classes  17p13.3(390601_1131255) × 3 dn), containing seven known OMIM genes , and which was considered pathogenic. The duplicated genes were At the age of 12, a physiatrist decided to have the patient re-evaluated by a geneticist. At this time, the girl had a weight of 43 kg (75–90° centile), a height of 159 cm (>97° centile), and a cranial circumference of 55.9 cm (>97° centile). Facial features included a long flat face, a short philtrum, and a hypoplastic malar bone. Her skin was soft in texture. The patient had recently undergone a cardiological examination by which a dilated pulmonary artery was noted, while a spine MRI and electrophysiological assessment of the limbs were found to be normal. Our case study shows several clinical features attributable to both chromosome 17p13.3 duplication syndrome and kEDS .FKBP14-kEDS [FKBP14 associated with a new variant of kEDS [FKBP14-kEDS are severe generalized hypotonia at birth that improves in childhood, delayed motor milestones, progressive kyphoscoliosis, joint hypermobility without pronounced contractures, foot deformities, and a normal or decreased ratio of lysyl pyridinoline to hydroxylysyl pyridinoline in urine. Minor criteria include hyperelastic skin, easy bruising, myopathy, and congenital hearing impairment [As reported in other cases of P14-kEDS , due to  of kEDS . Major dpairment ,12,14. AABR has been reported as a candidate gene whose aploinsufficiency could cause cleft palate, the pathogenetic variants in other duplicated genes are reported to be causative of recessive diseases [FKBP14 and kEDS by Baumann et al. [As the joint laxity and the scoliosis became more apparent, however, a differential diagnosis, or a double diagnosis, should have been considered. While the cleft palate, muscle hypotonia, abnormal growth, and some dysmorphic aspects have frequently been described in both conditions ,15, the diseases ,17,18,19n et al. , which dAccurate diagnosis is key to the correct management of patients. This should be focused on musculoskeletal, cardiovascular, ophthalmological, and auditory systems as proposed by Giunta et al. ,14. MoreFrom a musculoskeletal point of view, management advice includes physiotherapy, physiatry, proprioception exercises, radiologic documentation of the spine in view of the progressive kyphoscoliosis, regular follow-up by an orthopedic surgeon, bone densitometry evaluation, sleep study in case of severe muscle hypotonia , study oFKBP14-kEDS, arterial dissections and a pseudoaneurysm rupture have been described in two adults and one child, respectively [FKBP14-kEDS, at the molecular level, FKBP22 interacts with type III and type VI collagens, which are considered central in the pathophysiology of the vascular type of EDS11.From a cardiovascular perspective, management procedures include (1) echocardiographic measurement of aortic root size and assessment heart valves at diagnosis or by the age of 5 years, 2) echocardiographic follow-up every 2–5 years even if initially normal, and (3) blood pressure measurement and control which can reduce the risk of arterial rupture . As for  echocardectively ,25,26. HTherefore, patients with undiagnosed EDS can develop otherwise preventable musculoskeletal and vascular complications that strongly impede quality of life and, in some cases, may be life-threatening.FKBP14-kEDS. The microduplication was diagnosed via CGH-array analysis after an extensive neuromuscular workup due to their severe muscle hypotonia. As a result of overlapping features with kEDS and the yet-undiscovered FKBP14-kEDS, it was only years later that the other underlying condition was investigated and diagnosed. The latter was first suspected by the geneticist, after a referral by the patient’s physiatrist, who was unconvinced by the severity of the joint laxity and the kyphoscoliosis. Relying on the experience of specialists such as physiatrists and orthopedics is invaluable for effective differential diagnosis.This paper describes an individual diagnosed with a 17p13.3 microduplication and FKBP14-kEDS should be updated as soon as cases reported in the literature increase.Although cures for most genetic conditions are still unavailable, correct diagnosis can help by giving the family and the patient realistic prospects and by informing correct management. Without the latter, predictable and treatable diseases may arise and progress until it is too late, where musculoskeletal and vascular complications are particularly threatening if left unattended. Specific guidelines regarding the management of