BackgroundIntraocular pressure (IOP) is a highly heritable risk factor for primary open-angle glaucoma (POAG), with at least 27 related genes; however, we are still not aware as to which receptors or genes that the main components of cannabis use to lower IOP.MethodsIn the current study, we used data from the UK Biobank (UKBB) to assess the relationship of growth arrest-specific 7 (GAS7) with IOP and cannabis in 37,046 subjects. GAS7, at chromosome 17p31.1, is quite close to a cannabis receptor at chromosome 17p31.3. For comparison, we chose a second IOP/glaucoma gene, CDKN2B-AS1 on chromosome 9p21.3, with no known relationship to cannabis. In addition, we examined the effect of CB1, GPR18, and cannabis on IOP; these two genes are associated with cannabis IOP reduction in mice.ResultsTotal cannabis use versus IOP and genotypes of GAS7 SNP rs9913911 in the 37,046 subjects showed significant variation . Carriers of the GAS7 rs9913911 minor allele G had lower IOP with increased cannabis use. Total cannabis use versus IOP of genotypes of CDKN2B-AS1 SNP rs944801 in 37,046 subjects had IOP variability with cannabis use that was insignificant (p=0.138). We analyzed the relationship of CB1 SNP rs806365 and GPR18 SNP rs3742130 with cannabis use and IOP, which was insignificant. CB1 and GPR18 are probably not involved in cannabis-associated human IOP reduction, unlike what has been reported in mice.ConclusionCannabis-based treatments, which apparently act on the GAS7 gene, can be utilized to reduce IOP. However, their disadvantages outweigh their advantages, which was not the case when the initial reports of marijuana's effects on IOP were published in the 1970s. Hence, cannabis-based glaucoma treatments are now of questionable value. Cannabis has a long and colorful history stretching back thousands of years. The main psychotropic element in cannabis is thought to be 9-tetrahydrocannabinol (THC). In 1971, Hepler and Frank published their first study that established that cannabis inhalation reduces intraocular pressure (IOP) , but we CB1 receptors are the best-characterized cannabinoid receptors. Because cannabinoid CB1 receptor agonists lower IOP in mice, THC might work via CB1 receptors, which are widely distributed in the brain and eyes. CB1 receptors govern critical physiological systems such as pain, emotion, locomotion, and memory. The cannabinoid signaling system contains other receptors, such as GPR18. In a study of mice, Miller et al. found that THC lowers IOP by activating CB1 and GPR18 in a sex-dependent manner .Growth arrest-specific 7 (GAS7), one of the genes that influence IOP, is found in a chromosomal area previously identified by a glaucoma linkage study and subsequently by a genome-wide association study (GWAS) . GAS7, aIn the current study, we used data from the UK Biobank (UKBB) to assess the relationship of GAS7 with IOP and cannabis. For comparison, we chose a second IOP/glaucoma gene, CDKN2B-AS1 on chromosome 9p21.3 [The UKBB is a large prospective observational study of men and women. Participants were recruited from across 22 centers located throughout England, Wales, and Scotland between 2006 and 2010 and continue to be longitudinally followed for the capture of subsequent health events . This meOur UKBB application was approved as UKB project 57245 . Our analysis included all subjects with glaucoma and cannabis-smoking information. POAG diagnosis was ascertained using the 10th Revision of the International Classification of Diseases (ICD-10), H40.1. The age when glaucoma was diagnosed was collected from data field 4700. Cannabis information was recorded in the UKB category 143, data field 20453, ever taken cannabis. A touch screen posed the question, "Have you taken CANNABIS , even if it was a long time ago?" Answers available were no; yes, 1-2 times; yes, 3-10 times; yes, 11-100 times; yes, more than 100 times.Data processing was performed on Minerva, a Linux mainframe with Centos 7.6, at the Icahn School of Medicine at Mount Sinai. We used PLINK, a whole-genome association analysis toolset, to analyze the UKBB chromosome files  and the The mean age of 37,046 subjects was 56 ± 8 years; 54% of them were female, and 46% were male; 95% were white British. Of note, 633 of the subjects had POAG. The four SNPs analyzed are detailed in Table Figure Figure To test the relationship of rs9913911 and rs7518099 with cannabis use and IOP, an analysis of covariance between rs9913911 and rs7518099 was performed, with age-weighted least-squares regression using the univariate general linear model of SPSS. IOP was the dependent variable, rs9913911 and rs7518099 were fixed factors, and cannabis use and the presence or absence of POAG were covariates. The interaction of rs9913911 and rs7518099 was significant (p=0.014). In other words, the overall results in Figure To test the relationship of CB1 SNP rs806365 and GPR18 SNP rs3742130 with cannabis use and IOP, an analysis of covariance between rs806365 and rs3742130 was performed, with age-weighted least-squares regression using the univariate general linear model of SPSS. IOP was the dependent variable, rs806365 and rs3742130 were fixed factors, and cannabis use and the presence or absence of POAG were covariates. The rs806365 genotype had no significant effect on IOP (p=0.083), and the rs3742130 genotype had no significant effect on IOP (p=0.831) either. The interaction of rs806365 and rs3742130 was not significant (p=0.574). In other words, CB1 and GPR18 are probably not involved in cannabis-associated human IOP reduction, unlike what has been reported in mice [The optic nerve, specifically the lamina cribrosa, has a high level of GAS7 expression. The lamina cribrosa is the connective tissue network that the nerve fibers pass through to create the optic nerve and is likely the primary location of glaucomatous optic nerve injury. The ciliary body (CB), the secretory neuroepithelium that creates aqueous humor, has moderate to high GAS7 expression. The trabecular meshwork (TM), which is the primary tissue involved in aqueous humor outflow , has a hIt is scarcely unexpected that CB1 and GPR18 are implicated in cannabis-induced IOP reduction in mice but not in humans, as the UKBB results imply. Humans, rats, and mice have almost the same number of genes, according to a genome analysis conducted by 20 institutions from six nations. Humans and rodents, on the other hand, descended from a common ancestor 80 million years ago, with rats and mice diverging between 12 and 24 million years ago . CB1 andCannabinoids or marijuana reduce IOP as well as do most standard glaucoma treatments. This is true whether the cannabinoids are taken orally, intravenously, or inhaled, but not when they are directly applied to the eyes. In both glaucoma patients and healthy people with normal IOP, smoked or eaten marijuana, THC and synthetic cannabinoids in pill form, and intravenous injections of many natural cannabinoids all reduce IOP considerably. A single dose of marijuana or cannabinoid has maintained this effect for three to four hours in most trials .However, inhaling cannabis smoke is injurious to the eye. In the case of glaucoma, the manifestations are different from those of inhaled tobacco smoke. Cannabis reduces IOP but accelerates glaucoma development. Cannabis does not increase the risk of glaucoma. Cigarette smoking increases the risk of glaucoma and significantly accelerates glaucoma development. But the early use of cannabis leads to the development of glaucoma earlier in life .Cannabis has other drawbacks as well. It lowers blood pressure and has psychological effects that some individuals, especially the elderly, find unpleasant. After taking cannabis, patients may claim that their hearts pound or race, and that they feel uncomfortably tense. All these effects could be particularly dangerous for patients who are at risk of cardiovascular disease and stroke; also, lower blood pressure may diminish blood supply to the optic nerve, negating the benefits of lower IOP. Finally, because of their short duration of action, cannabis-based drugs must be taken up to eight times per day, which most patients are unlikely to do. Currently available medicines reduce IOP just as well and require only one or two doses per day. This is a significant distinction because, due to the degenerative nature of glaucoma, patients must maintain constant IOP control .Our study has some limitations. The normal IOP is 10-21 mmHg. The difference in means associated with cannabis and the GAS7 rs9913911 alleles represents a small band within this range. It is possible that the observed difference is significant because of the large sample size, but too small to be clinically relevant. Moreover, the cannabinoid cannabigerol is a highly potent alpha2-adrenoceptor agonist  and mighCannabis-based treatments, which may interact with the GAS7 gene, can be utilized to reduce IOP. However, their disadvantages exceed their advantages, which was not the case when the initial reports of marijuana's effects on IOP were published in the 1970s. Earlier, only a small number of medicines were available to reduce IOP, all of which had serious negative effects. More effective pharmaceuticals with fewer side effects have since supplanted these drugs, and cannabis-based glaucoma treatments are now of questionable value.


The objective of the study is to develop a nomogram for estimating three- and five-year survival rates in mucinous breast cancer patients.  Between 2010 and 2016, the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) were searched as a data source for patients associated with mucinous breast cancer (MBC). A total of 3964 patients were recruited after screening. The multivariate Cox model and the univariate Kaplan-Meier (KM) approach were employed to evaluate the independent prognostic markers, followed by developing a nomogram for estimating three- and five-year survival rates in MBC patients. Consequently, the consistency index (C-index) was employed to assess the predictive accuracy of the generated nomogram. P < 0.05). The nomogram was finally developed based on the underlined factors. Furthermore, the C-index of 0.803 and reliable calibration curves were obtained in the nomogram's assessment.  Age, race, T stage, M stage, surgery, and radiotherapy were all independent predictive biomarkers for the MBC patients ( In patients with mucinous breast cancer, the proposed nomogram provides a viable tool for accurate prognostic prediction. In clinical practice, it could serve as a personalized diagnosis tool, estimate prognosis, and help in suggesting treatment plans for patients with MBC. Mucinous breast cancer (MBC) is a rare and unusual type of breast cancer that manifests itself primarily by a huge percentage of extracellular mucins , 2. It aNomograms have been developed as the new standard for predicting the occurrence and prognosis of certain cancers, and most cancer types have established prognostic nomograms , 9. SuchThe data for the current study were attained from the SEER database of the US National Cancer Institute (NCI), and the data were obtained by SEER Stat 8.3.8 software.The data of MBC patients in the SEER database from 2010 to 2016 were collected. Inclusion criteria were as follows: (1) ICD-O-3 Hist/behave, malignant = “8480/3: mucinous adenocarcinoma”; (2) patients newly diagnosed with MBC; (3) patients with breast cancer as the only primary tumor; (4) patients with complete general clinicopathological information; (5) patients with complete follow-up . The exclusion criteria were given as follows: (1) male MBC patients; (2) confirmed patients of postmortem examination and death report; (3) patients with missing information and survival time less than 1 month .Extract the patient's age, race, marital status, tumor location , histological grade, TNM stage (7th edition AJCC-TNM staging system), ER status, PR status, HER-2 status, surgery, radiotherapy, chemotherapy, survival data, and other information.R software. First, univariate analysis was conducted to evaluate the factors affecting the survival prognosis of patients in the modeling group, and variables that showed statistical significance on univariate analysis were also involved in the multivariate Cox proportional hazards regression (CPHR) model to determine the final independent prognostic factors, the effect of independent prognostic factors on the survival rate of MBC patients was shown by the KM method, and then, the nomogram was constructed using R software, and the consistency index was calculated, and the correction curve was drawn. The Bootstrap method was used to conduct internal and external validation for the modeling group and the validation group, respectively. In the calibration curve, the closer the curve is to the ideal 45° reference line, the closer the predicted value is to the actual observed value. R software (version 4.0.2) (http://www.r-project.org/) was employed to conduct the statistical evaluations.Patients were randomly split into modeling and validation groups using n = 2,992, 75.4%), more than one-half were Grade I , and more than 90% were N0, M0, ER (+), PR (+), HER-2 (−). Other clinicopathological features are shown in From 2010 to 2016, the SEER database yielded 3,964 eligible female MBC patients . It summarizes the sociodemographic and clinicopathological features of the two groups in P < 0.05) but not to histological grade, lesion location, PR status, ER status, or HER-2 status (P > 0.05), as indicated in Univariate analysis of the survival of 2,776 MBC patients in the modeling group revealed that the 3- and 5-year survival rates of patients were linked to their age, ethnicity, marital status, T stage, N stage, M stage, surgery, radiotherapy, and chemotherapy (P < 0.05). The KM curve was used to demonstrate the impact of independent prognostic factors on MBC patient survival rates, as indicated in Figures x-axis) represents time in months, and the vertical axis (y-axis) shows the probability of survival or the proportion of people surviving. A vertical drop in the curves indicates an event.R software. The predictive nomogram for the 3- and 5-year OS rates of MBC patients is shown in overall survival (OS).Age, ethnicity, T stage, M stage, radiation, and surgery were among the statistically significant prognostic factors in the multivariate CPHR model. A nomogram was constructed using The higher the total score, the worse the survival prognosis. The nomogram in R software was 0.803 (95% CI: 0.772–0.834) for the modeling group and 0.817 (95% CI: 0.768–0.866) for the validation group, suggesting that both had good predictive values and good discriminative ability. The bootstrap method was used for internal verification and external verification of nomogram. The self-sampling number B = 1,000. We established a nomogram model integrating independent predictors of OS  to provide a visual statistical predictive tool for the survival of patients with MGCTB. We established a nomogram model integrating independent predictors of OS  to provide a visual statistical predictive tool for the survival of patients with MGCTB. We established a nomogram model integrating independent predictors of OS  to provide a visual statistical predictive tool for the survival of patients with MGCTB. We established a monogram model integrating independent predictors of OS  to provide a visual statistical predictive tool for the survival of patients with MBC. A calibration curve of the nomograph was drawn to evaluate the consistency between the observed and estimated survivals. The C-index calculated by MBC is a kind of breast cancer that is quite uncommon. It affects 1%–6% of all initial breast tumors.  RelativeIn this study, we analyzed multiple possible prognostic factors in MBC patients, and the results showed that age, ethnicity, T stage, M stage, surgery, and radiotherapy were all independent factors for patient survival prognosis. In our study, 68.1% of patients were over 60 years of age, and the prognosis was best for people aged 40–59 years, and previous studies have shown that MBC is common in older patients, and its incidence generally peaks after menopause . PatientThe predictive importance of tumor size in MBC patients is a point of contention. Patients with tumors greater than 2 cm were previously advised to take adjuvant chemotherapy, according to NCCN recommendations. However, the recommendations have been modified so that only lymph node involvement is considered chemotherapeutic, regardless of the T stage. While tumor size has been linked to the diagnosis of less aggressive tumors, its predictive value has been questioned due to the inclusion of extensive extracellular mucins in tumor size measurement . As a reAt present, the treatment modalities for MBC patients are mainly surgery, chemotherapy, radiotherapy, and endocrine therapy. The choice of surgical approach also has a considerable influence on the subsequent treatment options of patients and the survival prognosis of patients. In this study, 3,817 patients (96.2%) received surgical treatment, and the nomogram showed that the prognosis of patients who received surgical treatment was better than that of patients who did not receive surgery. It has been shown that patients treated with breast-conserving surgery in stage T1-2 MBC have a better prognosis than those who undergo mastectomy, particularly in patients aged 50–79 years;  however,However, this study has several limitations. First, important details such as treatment information  are missing in the SEER database because most patients with MBC are hormone receptor-positive. Patients who complete local therapy are likely to receive standard endocrine therapy, and the SEER database cannot provide data on endocrine therapy and is difficult to guide physicians in the treatment of patients of the same category. Second, the lack of information in the SEER database may affect the data of the CPHR model , and these important variables should be considered in future studies. Finally, the database does not perform specific pathological classification of MBC, such as pure mucinous breast carcinoma (PMBC) as well as mixed mucinous breast carcinoma (MMBC) , becauseRoutine clinical data obtained from the SEER database were used to develop a useful clinical nomogram that could help clinicians treat MBC in their daily practice. The nomogram incorporates various clinicopathological indicators and can render great help in clinical decision-making thereby enabling individualized therapy and management of MCB patients.The future directions of this work will potentially involve a larger sample size, including more related factors to further screen the independent influencing factors of the prognosis of MBC patients. In addition, we plan to carry out a multicenter prospective randomized controlled study to verify its predictive effect, improve the nomogram prognostic model, and provide a reference for the evaluation of the prognosis of MBC patients as well as the selection of personalized treatment plan.


Spinocerebellar ataxia (SCA) is an autosomal dominant hereditary disease with progressive course, and no causal therapy. Diagnostics are still challenging, due to facility and protocols, and so as in Indonesia. As a national referral center, Dr. Hasan Sadikin Central General Hospital has received a lot of patients from all over Indonesia, particularly from Western Java. Study related to SCA  is still limited in Indonesia. We identified index patients from three families with ataxia, hence intend to determine their clinical and genetic pattern.The hereditary pattern is autosomal dominant. Scale for the assessment and rating of ataxia (SARA) shows mild and moderate ataxia. Inventory of non-ataxia signs (INAS) scores of the patients were 3, 5 and 6. Montreal cognitive assessment-Indonesian version (MOCA-INA) shows only one patient has mild cognitive impairment, despite young age. Barthel index shows 1 subject has moderate dependency. Mutation in Ataxin3 polyQ repeats shows pathologically long CAG repeats, 72,10; 72,10; and 72,23 respectively in mutant and wild type allele.We diagnosed the index patients with spinocerebellar ataxia type 3. This study is the first case series study in Indonesia. The hereditary pattern is clearly shown as an autosomal dominant ataxia. The clinical and genetic profile was varied, and the symptom is progressive and deteriorates overtime, including wide based gait, speech problem, motor and sensor complaint, and cognitive decline complaint. Despite the same polyQ stretch length, the onset and clinical characteristics of patients are diverse. Autosomal dominant, Familial ataxia, Indonesia, Polyglutamine, Spinocerebellar ataxia. The prevalence is 1–5/100000 people, varied upon ethnicity and geographic [SCA3 (a.k.a ATXN3) gene. The length of CAG repeat in wild type ATXN3 is less than 40, and in a patient with SCA the repeat would be more than 40 [Among all 47 types of spinocerebellar ataxia that have been identified, type 1, 2, 3, 6 and 7 are the most common in the world, with type 3 being the most prevalent. SCA is a heterogeneous disease, with complex phenotype and genetics. The degree of clinical symptom related to its anatomy involvement varied from being ataxia only, gait problem, visual problem, dysarthria, dysphagia, cognition problem and motor-sensory problem to name a few. The course of the disease is clearly progressive, with mortality in later stage due to progression which lead to immobility and inability to breathe , 6. Up u than 40 . The mai than 40 . There i than 40 , 10.Diagnostics in developing countries are still a challenging endeavor, due to facility and protocols, and so as in Indonesia. The standard protocols are including clinical finding of ataxia and related sign and symptom, exclusion of a direct or secondary ataxia, a positive family history, and specific gene testing . With liIn Indonesia, epidemiology and genetic study of SCA, is not yet well established. Indonesia is a huge country, geographically and genetically. With more than 1.9 million sq. km area, more than 260 million inhabitants, 17,000 islands and more than 1,000 ethnicity, medical care is an enormous challenge. As a national referral center, Dr. Hasan Sadikin Central General Hospital has received a lot of patients from all over Indonesia, particularly from Western Java, as the highest populated province, with almost 45 million inhabitants. From all patients with ataxia in 2020, we identified index patients from three families with ataxia, and we determined their clinical and genetic pattern.1.1This study investigated three index patients from three different families with progressive ataxia, that also appears in other close relative members, from different cities in West Java Province. Patients were de-identified to protect their privacy, without hindering analysis of clinical information. Before come to our center, the patient had limited prior medical evaluation exposure, moreover genetic evaluation.1.2Three index patients in their 30s from different families came to us with a chief complaint of unsteady walking and gait problems, with similar history in other family members. History, physical and neurological examination, INAS, SARA, MOCA-INA, Barthel Index, pedigree analysis, and SCA panel analysis were done for those index patients. Pedigree analysis was done, history was taken from the subject and digging the family history for ataxia complaint in the family . PatientThe symptoms are progressing by age, starting from their 20s for patient #1 and #3 and in teenage for patient #2. The symptoms accompanied or followed by slurred and scanning speech, dizziness, choking, numbness, and nystagmus in patient #1; dizziness, motor problem, speech problem, and choking in patient #2. In patient #3 it was followed by choking, spinning dizziness, cognitive problem, horizontal nystagmus, left NVII palsy, tongue atrophy, and paresis. All patients showed disturbed coordination and increased physiological reflexes.The patients have graduated from high school and university, this proves that they have good cognition to begin with to finish their education.The history, physical and neurological examination are presented in 1.3To show the severity of ataxia in these index patients, SARA was utilized. SARA of these patients show all patients have ataxia in different categories. SARA scores were 4, 9 and 14 which means categorized as mild ataxia, mild ataxia and moderate ataxia, respectively, as shown in 1.4Lately, patients with SCA also showed and proven to have extracerebellar pathology involvement. INAS was used to provide structured information of non-ataxia signs in ataxia patients. This score can be used as a simple semi-quantitative variable for extracerebellar involvement in SCA. Scores for the patients were 3, 5 and 6, which gave clues that there are extracerebellar involvement in these patients. A detailed description of INAS domain is as shown in 1.5To provide a sensible daily independency from help, Barthel index was employed. In these index patients, only patient #2 showed a moderate dependency, while the rest was deemed to be able to live independently as depicted in 1.6Pedigree analysis was done to evaluate the pattern of inheritance, the number of family members with symptoms, and the position of these index patients in their own respective family. After history taking and pedigree analysis it is known that the pattern of inheritance is an autosomal dominant in all three families. Family 1, consists of 12 family members from 4 generations, with 3 family members showing symptoms. Family 2, consists of 24 family members from 3 generations with 6 family members showing symptoms. Family 3, consists of 26 family members from 3 generations, with 9 family members showing symptoms .1.7Access to genetic evaluation and facility is still scarce in Indonesia. Only certain facilities in certain cities able to do routine examinations. Hence lesser number of facilities are able to do development and establish new genetical evaluation protocol. Our facility is equipped with molecular genetic instruments that enable us for genetic evaluation and sequencing, which may be considered essential in an advanced facility, but scarce in developing countries. These instruments are enabling us to establish new protocols in diagnosing SCA and sequencing polyQ repeats.ATXN3 (SCA3) with pathologically long CAG repeats. The repeats in mutant and wild type allele were 72, 10; 72, 10; and 72, 23, respectively. The details were shown in We did a SCA polyQ repeat analysis, it showed that these 3 index patients have a mutation in ATXN3. However, the lower allele in patient #3 is 23, different to patient #1 and #2 . Although onset and clinical signs varies, the clinical findings and progressivity are classic for spinocerebellar ataxia, with unsteady walk as the first sign followed by slurred and scanning speech, dizziness, cranial nerve palsy, ophthalmoplegia, paresis, and numbness , 14, 15.The clinical severity shows a prodromal, mild, and moderate ataxia for patient #1, #2 and #3. Despite the early onset of patient #2, after some physical rehabilitation some function could be maintained, so the severity is not so bad compared to patient #3. Some extracerebellar structural involvement also appears and as it was shown from INAS analysis results . IndepenFamily history showed the pattern of inheritance is autosomal dominant. With no generation skipped and both male and female are affected. Most of SCA is autosomal dominant, only a small number is recessive, yet the number is growing.in-house primer (supplementary table), we found out that all these three index patients have CAG repeats expansion in ATXN3 (SCA3), a gene that encodes Ataxin3. SCA3 also known as Machado-Joseph disease, this SCA type is the most prevalent SCA and present with progressive ataxia and plasticity [After SCA panel analysis, using mostly our asticity .In our index patients, age of onset was 18 for patient #1, 14 for patient #2 and 27 for patient #3. This is rather early compared to means from a cohort in a study which is 20–50 year-old, mean 37 year old , but is In this study, CAG expansion analysis was performed by using PCR followed by Sanger Sequencing methods. With this method we would be able to analyze the length and the pattern of repeat sequences more precise, compared to other available methods, such as using an internal size marker in the Genescan 500LIZ method , 20. TheThe length of polyQ repeats inversely correlates with the disease onset, and severity. However this is also affected by other factors. Patient #2 showed the earliest onset among these 3 index patients. All patients have contiguous CAG repeat length above pathogenic threshold , 23, 24.Although the total length of CAG repeats of all three index patients are all the same which is 72, however the age of onset and severity are different. We are still studying these families to know more about the factors behind the difference in the clinical severity and onset between patient #1, #2 and #3, although they have the same number of repeats. These variations of age of onset and severity are also depicted in a study in mainland China which enrolled almost 400 patients . Jiao etAdding to the effort of the neurologist, geneticist, epidemiologist and other scientist on elucidating spinocerebellar ataxia in Indonesia, this study of SCA3 index patient is a very important study to get a comprehension of ataxia epidemiology in Indonesia. Further study to understand more about clinical phenotype, progressivity and the genetic feature of the relatives of this index patient is warranted. An endeavor to devise plans and protocols on how to identify and manage SCA patients in Indonesian or South East Asia or developing countries with its own intricate demography, geography characteristics is possible and indeed a certain necessity.2.1On behalf of the family, we are relieved thatthe mystery of these clinical features appeared in our family have started to be revealed. These symptoms, now diagnosed as spinocerebellar ataxia type 3, was before considered as a curse to our big family, and were not known to us before being evaluated here. We hope after this, although still no definitive treatment available, more of our family members will be evaluated. This endeavour indeed gives hope that we could be helped, together in facing this condition with the doctors.""2.2Ethical clearance was obtained from Universitas Padjadjaran Research Ethics Committee no 0718071150, informed consent was obtained from all respective patients. All related international and privacy protocols have also been obeyed.33.1Phenotyping by clinical evaluation, and neuropsychological studies was performed in the affected subjects at the Department of Neurology, Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin Central General Hospital, Indonesia. Tools of ataxia that used were classical and well-established, including inventory of non-ataxia signs (INAS) for non-cerebellar signs, which is a classical method to evaluate non-ataxia sign for non-cerebellar sign , 29; sca3.2TM2000.DNA isolation was isolated from 3 ml blood using Quick-DNA Miniprep isolation kit (Zymo research) according to manufacturer protocols. DNA concentration was measured using Nanodrop3.3PolyQ repeat expansion analysis for SCA 1, 2, 3, and 6 were performed using polymerase chain reaction (PCR) method followed by Sanger Sequencing . 50–100 3.4To ensure a standard and concise method of writing a case report, CARE checklist is used in writing this article.All authors listed have significantly contributed to the investigation, development and writing of this article.Fundamental Research Fund no. 1827/UN6.3.1/LT/2020 for Tri Hanggono Achmad from the Directorate General of Higher Education, the Ministry of Education and Culture/ National Research and Innovation Agency (BRIN), the Republic of Indonesia.This work was supported by The authors are unable or have chosen not to specify which data has been used.The authors declare no conflict of interest.No additional information is available for this paper.


Energy, exergy, and exergoeconomic evaluations of various geothermal configurations are reported. The main operational and economic parameters of the cycles are evaluated and compared. Multi-objective optimization of the cycles is conducted using the artificial bee colony algorithm. A sensitivity assessment is carried out on the effect of production well temperature variation on system performance from energy and economic perspectives. The results show that the flash-binary cycle has the highest thermal and exergy efficiencies, at 15.6% and 64.3%, respectively. The highest generated power cost and pay-back period are attributable to the simple organic Rankine cycle (ORC). Raising the well-temperature can increase the exergy destruction rate in all configurations. However, the electricity cost and pay-back period decrease. Based on the results, in all cases, the exergoenvironmental impact improvement factor decreases, and the temperature rises. The exergy destruction ratio and efficiency of all components for each configuration are calculated and compared. It is found that, at the optimum state, the exergy efficiencies of the simple organic Rankine cycle, single flash, double flash, and flash-binary cycles respectively are 14.7%, 14.4%, 12.6%, and 14.1% higher than their relevant base cases, while the pay-back periods are 10.6%, 1.5% 1.4%, and 0.6% lower than the base cases. In recent decades, increases in world population and energy demand have led to increases in fossil fuel consumption, leading to greenhouse gas emissions and related global warming and climate change, as well as stratospheric ozone layer destruction. The use of renewable energies and modern technologies with lower environmental impacts is an option to address these problems. Geothermal energy is a promising renewable energy for generating electricity from low-temperature heat sources. Geothermal energy includes several advantageous features, such as reliability of supply and sustainability, with a temperature range varying from 50 to 350 °C ,2,3.Coskun et al.  proposedZare  assessedalgorithm II (NSGA-II). Fiaschi et al. [Calise et al.  performei et al.  performei et al.  studied i et al.  conducte2S and CO2. Ehyaei et al. [Ozkaraca  examinedi et al.  carried i et al.  studied i et al.  conducteAbdolalipouradl et al.  evaluateStudying four different geothermal configurations from exergy, exergoeconomic, and exergoenvironmental impact viewpoints;Comparing the main economic parameters of these system configurations, including levelized cost of electricity, pay-back period, and electricity cost;Comparing the exergoenvironmental impacts of the configurations through exergoenvironmental impact improvement and exergetic sustainability indexes;Optimization of all configurations by the artificial bee colony algorithm to find the best operation and modify systems based on the optimization.In this study, four geothermal power cycles are evaluated from the perspectives of energy, exergy, exergoeconomic, and exergoenvironmental impact. The thermodynamic modeling is performed with MATLAB using Refprop 9.1 . Simple All cycles operate under steady-state conditions ;Potential and kinetic energies are negligible ;The ambient temperature and pressure are fixed at 298.15 ectively ;The pump and turbines have fixed isentropic efficiencies ;Pressure losses in pipes and all components are negligible .Mathematical modeling is carried out in accordance with the first and second laws of thermodynamics, using mass, energy, and exergy balance equations. Diagrams of the considered geothermal configurations are given in General mass and energy rate balance equations follow:Here, subscripts Here, itten as ,31:(4)exk can be written as:Moreover, the exergy efficiency for device Here, The k can be written as [Exergoeconomics is a powerful and influential technique, driven by a combination of economic and exergy concepts, that helps researchers better understand systems from energy and economic viewpoints. Exergoeconomics permits economic designs of energy systems that are not obtainable by common economic modeling . In the itten as ,34:(9)C˙Here, itten as ,34:(10)CIn the exergoeconomic analysis of each system, there is dissipative equipment such as the condenser, valves, and so on, which are components without product in terms of total exergy. In general, for productive devices, any exit and inlet flow materials are product and resource. The product of dissipative components cannot be expressed in terms of total exergy. For a dissipative component, such a condenser, the cost balance should be defined as follows :(11)C˙e,The component in this equation is a fictitious cost-rate-associated dissipative device. For the condenser as dissipative equipment, g factor . This apkth stream of the cycle M) costs :(12)Z˙k=kth component Here, d 7446 h ). The puessed as ,36:(13)CHere, h device . Thus: is applied to consider annual inflation. This index is updated to the year 2020 ,41:(19)PThe geothermal well drilling cost for Iran can be determined from :(20)WellThe LCOE (levelized cost of energy) is an important economic indicator. Low-cost electricity generation can be lucrative for investors in a specific period, which relatively low LCOE value can convince the investors to finance an energy system . The LCO follows :(22)PBP=The pay-back period is calculated according to corporate tax rates and average electricity prices for Iran’s industry.Analyzing the geothermal power plants in terms of environmental impacts besides energy and economic assessments is important. The exergoenvironmental impact factor is an indicator that represents the environmental impact of the power cycle due to irreversibilities during the power plant operation that can be calculated as follows ,49:(23)fThe exergoenvironmental impact index is an indicator that represents how environmentally damaging a system is. It can be written as ,49:(24)θThis indicator shows if an energy system damages the environment or not. An environmentally friendly system should have lower exergoenvironmental impact index values. Exergoenvironmental impact improvement is another index that indicates the relation between the environment and the energy system. From an environmental point of view, a desirable energy system has a higher value of exergoenvironmental impact improvement. This factor can be expressed ,49:(25)θAnother important indicator is the exergetic stability factor, which can be written as follows ,49:(26)fHere,  follows ,49:(27)θFor a favorable energy system, this index should be as high as possible.All cycles considered here are optimized from energy and economic viewpoints with the artificial bee colony algorithm. This algorithm has been selected for optimizing the cycles as it has some advantages, such as the ability to handle the objective cost, flexibility, the ability to explore local solutions, broad applicability, robustness, and complex functions. Two objective functions are considered: exergy efficiency and product electricity cost. The final goal of optimization is minimizing electricity cost, and maximizing efficiency. Product electricity cost could be considered as a thermo-economic objective function. However, based on the optimizing process, the optimum point for electricity cost was not corresponding with exergy efficiency optimum values. As exergy efficiency depends on destruction and losses, however, electricity cost is affected by PEC and other economic element variations besides the thermodynamic performance of the cycle. The advantage of this multi-objective optimization, compared with single objective optimization, is better performance in both thermodynamic and economic aspects. Considering just product electricity cost for a single objective optimization helped to minimize it, but harms exergy efficiency. The decision variables and their constraints in the optimization process are listed in Furthermore, the single flash cycle has the shortest pay-back period. The impact of the production well temperature on LCOE for the cycles is shown in The optimization results show that the LCOEs of the simple organic Rankine, single flash, double flash, and flash-binary cycles at the optimum point are 6.2%, 3.2%, 1%, and 1.4% lower than the base case, respectively. Moreover, the pay-back periods for the simple organic Rankine, single flash, double flash, and flash-binary cycles at the optimum point are 10.6%, 1.5% 1.4%, and 0.6% lower than the base state, respectively.In the present study, energy, exergy, and exergoeconomic analyses of various geothermal power plant configurations are performed. Modeling is carried out in MATLAB, and mass and energy balance equations are employed. The considered geothermal power cycle configurations are simple organic Rankine, single flash, double flash, and flash-binary. Multi-objective optimization of these configurations is carried out with the artificial bee colony algorithm. A sensitivity analysis is performed of the effect of production well temperature variations on the energy, exergy, and economic parameters of the systems. The results show that the flash-binary cycle has the highest thermal and exergy efficiencies among these cycles, at 15.6% and 64.3%, respectively. The highest generated power cost and pay-back period are related to the simple ORC. It is seen that an increase in the production well temperature raises the exergy destruction rate for all configurations. However, the electricity costs and pay-back periods decrease. Further, for all cases, the exergoenvironmental impact improvement factor decreases with production well temperature. However, in the double flash cycle, the exergoenvironmental impact improvement factor rises temperature to 470 K, and declines thereafter.The turbine is observed to have the highest destruction rate in all cycles, with the exception of the evaporator having the highest destruction rate for the simple ORC. Moreover, the lowest exergy efficiency for all cases is associated with the condenser. At optimum state, the exergy efficiencies of the simple organic Rankine, single flash, double flash, and flash-binary cycles are found to be 14.7%, 14.4%, 12.6%, and 14.1% higher than the corresponding base states, respectively. The optimization results show that the LCOE of the simple organic Rankine, single flash, double flash, and flash-binary cycles at the optimum point are 6.2%, 3.2%, 1.0%, and 1.4% lower than the base case, respectively. Moreover, the pay-back periods for the simple organic Rankine, single flash, double flash, and flash-binary cycles at the optimum point are 10.6%, 1.5% 1.4%, and 0.6% lower than the base state, respectively.


The fluorescent tracer was pH-sensitive and emitted an intense fluorescent signal at pH 8–10. Then, it was applied to monitor the fatliquoring process in real-time. Compared with Sudan IV or Nile Blue sulphate dyeing tests, this fluorescent tracing technique could conveniently visualize and quantify the penetration and distribution of fatliquor in leather process.Fatliquoring is one of the most important processes in leather making, in which the collagen fibers are split effectively, while the crust acquires a good softness and mechanical strength. The effectiveness of fatliquoring depends not only on the variety and dosage of fatliquoring agent but also on its distribution in hierarchical collagen fiber layers. Up to now, the research about the mass transfer of fatliquoring agent in leather is very limited because quantifying the distribution of invisible fatliquor in leather is very difficult. In this paper, a fluorescent tracing technique based on modified castor oil was established and send used to investigate the mass transfer of fatliquor in leather. The crucial fluorescent tracer was synthesized favorably by the reaction of castor oil, successively with maleic anhydride and 5-aminofluorescein, which was confirmed by FTIR,  Fatliquoring is an indispensable process in leather manufacturing that plays a key role in giving the leather satisfactory flexibility and keeping its mechanical properties ,2. GenerIt should be noted that the improvement of the fatliquoring agent in the mechanical properties of leather is strongly associated with its distribution in the crust. As a special natural protein matrix, leather is different from the textile fabrics of cotton and linen. The thickness, compactness and random-woven property of leather have a significant effect on the penetration and distribution of the fatliquoring agent and other leather chemicals . AdditioTherefore, the investigation of the mass-transfer processes of the fatliquoring agent in wet blue, as well as its distribution, are crucial to understanding its structure–activity relationship, which is very important for designing and developing new fatliquoring agents. However, the research in this field is mainly focused on developing new kinds of fatliquoring agents and rarely focuses on their mass transfer and distribution in wet blue. It is limited to the shortage of effective and real-time tracing technique for fatliquoring agents. Scanning electron microscope-energy dispersive X-ray (SEM-EDX) analysis is a semi quantitative method for mapping the composition of metal elements such as chrome and aluminum in leather samples . UnfortuThe fluorescent tracing technique is an effective and reliable analytical method with a high sensitivity in detecting target material ,10,11,12Castor oil, as one of the few vegetable oils naturally containing hydroxyl groups, is a renewable raw material widely used in the preparation of bio-based polymers, such as polyesters, polyurethanes, adhesives, and so on ,16,17. IIn this paper, a fluorescent tracing technique based on castor oil was established for investigating the mass transfer and distribution of fatliquor in leather. Firstly, carboxylate castor oil (CCO) was prepared by the reaction between castor oil and maleic anhydride. Then, a fluorescent tracer was synthesized by the reaction of CCO with 5-aminofluorescein (AF). Finally, the mass transfer of sulfated castor oil containing 0.5% fluorescent tracer in goat wet blue was investigated in detail.2O3 content, 25%) was supplied by Brother Enterprise Holding Co., Ltd. , and a technical grade non-ionic degreasing agent  was offered by Leahou Light Industrial of New Material Co., Ltd. . Formic acid, sodium formate, acetic acid, sodium carbonate, dichloromethane, ethyl alcohol, acetone, hydrochloric acid and sodium hydroxide were analytical reagents provided by Tianjin Fuyu Fine Chemical Co., Ltd. .Analytically pure castor oil , maleic anhydride, dimethylformamide, butoxyethanol and chemical pure sulfated castor oil  were supplied by Sinopharm Chemical Reagent Co., Ltd. . The following chemicals: 1-(3-Dimethylaminopropyl)-3-ethylcarbodiimide hydrochloride (EDC), 5-aminofluorescein (AF), Sudan IV and Nile Blue sulphate, were purchased from Macklin Biochemical Co., Ltd. . Goat skin in a wet blue state was obtained from Shandong Juncheng Leather Co., Ltd. . A technical-grade basic chromium sulphate  for 1 min to prepare a fluorescent fatliquoring agent, which was named AFSCO and used as common anionic fatliquoring agent.2 wafer for FTIR spectra analysis, respectively. Their infrared spectra were obtained by TENSOR-27  over a range of 500–4000 cm−1 with a nominal resolution of 2 cm−1 at room temperature.The dried castor oils, CCO and AFCO were dropped on the BaF3 solvent in a 5 mm diameter sample tube for NMR of 1H , Germany) analysis.About 15 mg of castor oil, CCO and AFCO, respectively, were dissolved in 0.5 mL of CDClAbout 10 mg of castor oil, CCO and AFCO, respectively, were sealed in an aluminum pan with an empty, sealed aluminum pan as the reference. The DSC curves of the above oil samples were conducted on DSC250  in the temperature range from −80 °C to 80 °C with a constant heating rate of 5 °C/min under nitrogen flow.v/v) ethanol solution to a concentration of 50 mg/L, whose pH was adjusted by using 0.1 mol/L HCl and 0.1 mol/L NaOH to 6, 7, 8, 9 and 10, respectively. The fluorescence emission spectra of the solutions above were measured with an excitation wavelength of 486 nm using a fluorescence spectrophotometer , CA, USA).The AFCO was dissolved in a 75% . The slice was loaded on a glass slide and immersed in a diluted alkali solution at pH 10 for 30 s. Then, the section of the sample was observed using an inverted fluorescence microscope  to locate AFSCO in leather. Meanwhile, the Image J software was used to analyze the fluorescence micrograph, in order to censure the relative contents of AFSCO in the cross section of leather.v/v) ethanol solution and acetone, 0.5 g of Sudan IV was dissolved. The slice was immersed in the above-mentioned Sudan IV solution to be stained for 1 min, and then washed successively with 50% (v/v) ethanol solution, 30% (v/v) ethanol solution and deionized water. On the other hand, the slice was immersed in 10 g/L of Nile Blue sulphate solution at 60 °C for 10 min, and then washed twice with deionized water, which was followed by differentiating for 30 min in a 1% (w/w) acetic acid solution. Finally, the photomicrographs of the stained slices were taken using a digital microsystem .Additionally, leather slices were stained with Sudan IV or Nile Blue sulphate, and their processes were as follows. In a mixed solution of 70%  of fatliquoring agent in this experiment was insufficient for its even distribution on the whole section of the leather. It can also be inferred that the mass transfer rate of the fatliquoring agent penetrating from the flesh side was 4–5 times higher compared to the grain side.Aside from the effect of time, the dosage of fatliquoring agent was an important factor that greatly influenced the quality of leather. Thus, the distribution of fatliquoring agents with different dosages was investigated further. The fluorescence images and quantification analysis are shown in 1H NMR spectra and DSC curves of the starting material and product proved that the fluorescent molecule had been grafted successfully onto castor oil. The AF-labeled castor oil was pH-sensitive and a strong fluorescent signal would be obtained at pH 10. Based on the AF-labeled castor oil, a fluorescent tracing technique, for visually investigating and quantifying the mass transfer of fatliquoring agent in leather, was established. Compared with Sudan IV and Nile Blue sulphate staining methods, the penetration and distribution of fatliquoring agents in leather could be analyzed preferably by using the fluorescent tracing technique. This technique can be used as a real-time monitor for investigating and quantifying the mass transfer of fatliquoring agent, which is beneficial for lucubrating the fatliquoring mechanism and its structure–activity relationship of fatliquor.Firstly, an AF-labeled castor oil was synthesized by the reaction of castor oil sequentially with maleic anhydride and 5-aminofluorescein. The FTIR spectra,


The vascular bundle plays an important role in nutrient transportation in plants and exerts great influence on crop yield. Maize is widely used for food, feed, and fuel, producing the largest yield in the world. However, genes and molecular mechanism controlling vascular bundle-related traits in maize have largely remained undiscovered. In this study, a natural population containing 248 diverse maize inbred lines genotyped with high-throughput SNP markers was used for genome-wide association study. The results showed that broad variations existed for the vascular bundle-related traits which are subject to genetic structure and it was suitable for association analysis. In this study, we identified 15, 13, 2, 1, and 5 SNPs significantly associated with number of small vascular bundle, number of large vascular bundle, average area of single small vascular bundle, average area of single large vascular bundle, and cross-sectional area, respectively. The 210 candidate genes in the confidence interval can be classified into ten biological processes, three cellular components, and eight molecular functions. As for the Kyoto Encyclopedia of Genes and Genomes analysis of the candidate genes, a total of six pathways were identified. Finally, we found five genes related to vascular development, three genes related to cell wall, and two genes related to the mechanical strength of the stalk. Our results provide the further understanding of the genetic foundation of vascular bundle-related traits in maize stalk. Maize is the most widely planted crop in the world and provides a large part of food for animals and human as well as materials for deep processing and energy. According to the forecast of the United Nations, the world’s population will exceed nine billion and global demand for maize will double  by 2050.Vascular bundles consist of xylem and phloem, two differentiated conductive tissues, and undifferentiated cambial or procambial stem cells. Vascular bundles provide mechanical support for plants. In maize, appropriate strength and tenacity would help the plant stand against winds and decrease the loss caused by lodging. Moreover, vascular bundles function as “flow” in the “source-flow-sink” system and transport photoassimilates produced by leaves (“source”) to the fruit (“sink”) and transfer water and salt from roots to the whole plants. Previous studies have observed significant correlation between the vascular bundle system and maize yield .MP, PHB, PHV, AtHB15, and REV  has become an efficient tool to capture functional genes and favorable haplotypes for interested traits in maize . For maiA natural population panel containing 248 diverse maize inbred lines was used as research materials provided by the China Agricultural University and National Maize Improvement Center of China. The 248 maize inbred lines panel included not only some excellent back bone elite inbred lines in China but also some high-quality inbred lines introduced from abroad. The detailed information on this natural population can be found in One week after pollination, three individual plants with typical growth were selected for each inbred as three biological replicates. For each replicate, cross-section slices from the uppermost internode were manually made. The slices were stained with 5% (g/ml) m-trihydroxybenzene and concentrated hydrochloric acid . Then, tPhenotypic data were processed with the Microsoft Excel 2010, and descriptive statistical analysis and ANOVA were carried out with the IBM SPSS statistics v21.0 software . The broon BLUP;  values uThe DNA of 248 maize inbred lines was extracted from fresh leaves with the CTAB method . The seqp ≤ 1/GWAS was performed to identify the SNPs significantly associated with vascular bundle-related traits using 83,057 SNPs and the BLUP values of the 248 maize inbred lines. GWAS was performed with the FarmCPU model implemented in the GAPIT package in the R software, taken both K and Q matrix into account to decrease spurious association . Then, wr2 = 0.1). Then, we searched the flanking 120 kb upstream and downstream of each significant loci for candidate genes according to B73 reference genome version v2. The annotation of candidate genes was obtained from the MaizeGDB and NCBI.Linkage disequilibrium (LD) decay of the same population was analyzed in the previous studies . The stuSubstantial variation was observed for vascular bundle-related traits in different maize inbred lines . The staIn the analysis of variance for the five traits, highly significant variations for genotypes (G), environments (E), and genotype-by-environment interaction were found . This inr = 0.58, p ≤ 0.001), NLVB , ASVB , and ALVB . NSVB was positively correlated with NLVB  and ASVB positively correlated with ALVB . No significant correlations were detected between the vascular bundle area and the number of vascular bundles, except for the correlation between NLVB and ASVB .We calculated the BLUP values for each trait and observed significant correlations among them. CSA was positively correlated with NSVB , P group, and Mixed group, respectively , 2014. Tp-value which was recommended using the GEC software was 2.46E-5. Thus, the threshold is –log10 (2.46E-5) = 4.61. In total, we identified 15, 13, 2, 1, and 5 SNPs significantly associated with NSVB, NLVB, ASVB, ALVB, and CSA, respectively, based on –log10 p = 4.61  genes in maize stem, root, and leaf tissue affected the mechanical strength of maize stem. However, the expression was the highest in the vascular systems. The role of the BK2 genes in secondary wall formation is consistent. All in all, further studies are needed for the functional validation of these candidate genes to discover the possible mechanism of vascular bundle regulation.Two candidate genes were found to be related to the mechanical strength of stem. GRMZM2G167520 encoded brittle stalk-2-like protein 6, and GRMZM2G167497 encoded brittle stalk-2-like protein 7. The original contributions presented in the study are included in the article/HW and JG conceived the ideas, designed the methodology, and revised the manuscript. YZ conducted the field trials and collected the data. PH, LZ, WS, HL, and YH took part in experiment and analyzed the data. YZ and PH wrote the manuscript. All authors have read and approved the final manuscript.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.


Obesity is a disease characterized by an excessive accumulation of body fat,which is harmful to health, and it has grown significantly in the past years inthe majority of countries. The surgery should be recommended to those patientswith obesity who did not succeed in conservative clinical therapy after arigorous analysis by a multidisciplinary team. The aim of this study was to compare metabolic results, weight loss, andparameters associated with obesity in the preoperative and postoperativeperiods of patients treated with bariatric surgery. This was a retrospective, descriptive, cross-sectional, and quantitativestudy through consultation medical records. Data were collected from May toSeptember 2020 from individuals treated with bariatric surgery in a periodof 15 years (from 2003 to 2018). A comparative and descriptive statisticalanalysis of anthropometric, metabolic, biochemical, and associatedmorbidities was performed. The majority of patients were female (68.50%). In both sexes, the highestprevalence was found in the age group of 30-39 years and more than half hadgrade III obesity. The surgical technique used was gastroplasty withRoux-en-Y gastric bypass. After 4 months, there was a significant reductionin the lipid profile, anthropometric parameters, and liver enzymes in bothsexes, which remained decreasing till the end of the first year, with markedimprovement in the metabolic syndrome (MS). The positive impact resulted from gastroplasty in terms of weight loss,reduction of body mass index, and lipid profile is quite relevant after 4months and it is maintained until 1 year after the procedure, showingbenefits in reducing the risk factors of the MS. This disease is responsible for a series of healthcomplications that directly affect the quality of life and the life expectancy ofindividuals affected by it.According to the Ministry of Health, Brazil, in 2016, noncommunicable diseases wereresponsible for 74% of the total deaths, which were caused mainly by cardiovasculardiseases (28%), neoplasms (18%), respiratory diseases (6%), and diabetes (5%)2 or BMI>35 kg/m2 who already presented certain pathologies caused oraggravated by obesity, according to the recommendations in the resolution Nº2.131/2015 from the Federal Council of Medicine (CFM), in which 21 comorbidities areestablished. In addition to these indications, it is important to note the failurein clinical obesity therapy for at least 2 yearsBariatric surgery is indicated for people with BMI >40 kg/m22 and those who were diagnosedwith refractory type 2 diabetes mellitus (DM) by two endocrinologists could undergothe surgery, which is then classified as a metabolic surgery in this situation, withRoux-en-Y gastric bypass (RYBG) being the first choice for the treatmentThis requirement does not apply to individuals with BMI >50 kg/m,,This intervention promotes dietary restriction through structural changes in thegastrointestinal tract. Its performance has been increasing currently and it hasbeen considered an efficient method for the treatment of morbid obesity and for thelong-term control of weight. In addition, it has also gained importance in thecontrol of diabetes, reduction of risk factors for cardiovascular diseases and othercomorbidities related to obesity, and the treatment of individuals with refractorymetabolic syndrome (MS),The surgery should be recommended to those patients with obesity who did not succeedin conservative clinical therapy (diet and medications) after a rigorous analysis bya multidisciplinary team, who will evaluate the nutritional status, psychologicalprofile, and conditions. After the procedure, the patient must follow medical andnutritional recommendations, which should be complemented with a correct andindividualized diet plan, nutritional supplementation, and physical activity. Thisis necessary because the success of the surgical therapy essentially depends on theemotional equilibrium and the changes in lifestyle and nutritional habits of anindividualSince the beginning of the therapy, the patients must be aware of their diagnosis ofdisease and be informed about the risks, benefits, and consequences of the surgery.Therefore, the aim of this study was to compare the metabolic results, weight loss,and parameters associated with obesity in the preoperative and postoperative periodsof patients treated with bariatric surgery.This was a retrospective, descriptive, cross-sectional, and quantitative studyperformed in an internal medicine clinic at the Hospital Memorial Arthur Ramos. Thisclinic conducts an average of eight bariatric surgeries monthly, which are performedby the same professional doctor and nutritionist, and is located in the city ofMaceió, Alagoas.Data were collected in the period between May and September 2020, using the medicalrecords of patients treated with bariatric surgery in a period of 15 years between2003 and 2018. The inclusion criteria for this study were as follows: every patientwhose medical record contained complete data from 4 months before and after thesurgery should be included in data collection and 162 patients were selected fromthese data. However, only 96 patients had data from 1 year after the surgery and,therefore, were used in the evolution analysis.12, other vitamins, transaminases (AST and ALT), alkalinephosphatase, and gamma-glutamyl transferase (GGT); and (d) metabolic parameters.These blood parameters were ordered by the surgeon or other doctors from the team.The variables collected were from the preoperative and postoperative periods. It wasidentified by the presence of associated morbidities  during the preoperative period and hypovitaminosis, which werecorrected (within limitations) before the surgical procedure.A standard protocol created by the nutritionist was included the following items: (a)sociodemographic data; (b) anthropometric parameters ; (c) biochemical parameters: hemoglobin,hematocrit, total proteins, albumin, serum iron, ferritin, folic acid, calcium,vitamin B2), eutrophic (BMI between 18.5 and 24.9kg/m2), overweight (BMI between 25 and 29.9 kg/m2),obesity class I (BMI=30-34.9 kg/m2), obesity class II (BMI=35-39.9kg/m2), and obesity class III (BMI >40 kg/m2).The classification of obesity, according to the BMI, followed the criteriarecommended by WHO and the Brazilian Association for the study of obesity andMSTo recognize the presence of MS, a recommendation of the Brazilian Society ofCardiology was applied, which considers the NCEP-ATP III parameters and defines thissyndrome with the presence of three or more criteria: central obesity (>102 cmfor men and >88 cm for women), HDL cholesterol (<40 mg/dl for men and <50mg/dl for women), triglycerides ≥150 mg/dl (or treatment for hypertriglyceridemia),blood pressure (BP) (SBP ≥130 mmHg and/or DBP ≥85 mmHg); or treatment for arterialhypertension and blood glucose ≥100 mg/dl (or treatment for DM)® program. For allstatistical analyses, the level of significance was determined when p<0.05. Thedescriptive analysis was presented in absolute and percentage frequencies. Thepaired t-test was used to compare the means of anthropometric, biochemical, andmetabolic variables in the preoperative and postoperative periods. Pearson’sχ2 test was used to measure the association between MS variablesduring the preoperative and postoperative periods.The data were input in the Microsoft Excel 2010The design of this study followed the ethical guidelines according to Resolution466/12 from the National Council of Health, and the research project was approved bythe Research Ethics Committee (CEP) of the Centro Universitário Tiradentes-UNIT-AL(number 4.014.670).Of all 162 patients analyzed, 111 were females and 51 were males. In both sexes, thegreater number of bariatric surgery was recorded between the ages 30 and 39 years,of which 41.50% were women and 39.20% were men . The surA reduction in MS was noticed in 37% of patients in both sexes only for 4 monthsafter the surgery .The comparison between the mean results of total weight and BMI of patients, duringthe preoperative and postoperative periods, revealed a reduction with a significantvalue in both sexes, and it continued to reduce for up to 1 year  and 6.Regarding the evaluation of metabolic parameters, there was a reduction in HDL levelsin both sexes for 4 months after the surgery ; however12,there was almost no reduction in the fourth month; however, after 1 year, it wasobserved a reduction only in women. Meanwhile, folic acid demonstrated an increaseduring all the periods analyzed for both sexes  presented a significantreduction in both sexes for 4 months after the intervention. Total proteinsexhibited a small increase in men in the first 4 months and an insignificantreduction after 1 year. Among women, there was less reduction in both periods;however, these parameters remained in the normality range for both sexes. Hematocritand hemoglobin did not show relevant reductions in their values after 4 months,whereas ferritin demonstrated a greater reduction. Regarding vitamin Bth sexes  and 6.,,The Brazilian Institute of Geography and Statistics (IBGE) states that, in thecountry, obesity was more than doubled in the population aged 20 years or above in2019A meta-analysis of 89 studies performed in other countries about the impact ofgastroplasty in the obesity treatment showed that the mean age of patients was 38years and that more than one-third of them were femaleIn addition to epidemiological data, which proved a growth and a prevalence ofobesity in women, some studies also suggested that other factors might explain thepredominance of bariatric surgery in women, such as personal aesthetic motivationsand stigma of the society that worships beauty ideals of thin women. Different fromwomen, men tend to search this resource only when there is a compromise in theirhealth and daily physical activities,,When the impact of weight loss after bariatric surgery was evaluated, it was noted inthis study, as well as in many others, that this procedure has been shown to behighly effective2 in BMI in men, during theperiod of 4 months after gastroplasty. Meanwhile, for women, there was a lesssignificant reduction, with a mean loss of 23.36 kg in body weight and 6.02kg/m2 in BMI during the same period. One year after the surgery,there was mean reduction of 52.76 kg in body weight and 17.59 kg/m2 inBMI in men, whereas in women, there was a reduction of 37.04 kg in body weight and14.3 kg/m2 in BMI. In addition, the eutrophic category was reached by31.35% of women and 10.35% of men and more than half of patients reached theoverweight status for both sexes.Regarding the anthropometric data, the results here presented showed a mean reductionof 36.51 kg in body weight and 12.04 kg/m,,These data implied an expressive reduction in cardiovascular mortality and in otherdiseases associated with excess body weight. We highlighted that this resultcorroborates other scientific studies, which identified positive results thatsignificantly reduced BMI only 6 months after gastroplasty,This study showed that 104 (93.69%) of 111 female patients and 48 (94.11%) of 51 malepatients had some kind of morbidity, indicating that obesity is a clinical conditionwhich predisposes the development of other diseases. The most prevalent morbiditiesin men and women, respectively, were hepatic steatosis (80.4% and 70.3%),dyslipidemias (64.7% and 63%), MS (64.7% and 54.45%), arterial hypertension(56.86%), GERD (35.3% and 34.25%), and, DM (33.33% and 21.6%). These results werealso found in other studiesIt is known that the duodenal and jejunal “bypass” performed in the procedureprogressively reduces fasting plasma glucose and improves insulin resistance. Thisintervention has now been called metabolic surgery based on evidence that severalstudies have presented with regard to its efficiency for treating DM and asignificant reduction in MS for both sexes at the end of the first year after theprocedure-which was also evidenced in this researchRecent studies have questioned the mechanism by which patients with morbid obesitycontrol their DM2 after bariatric surgery. In fact, weight loss is partiallyresponsible for reversing DM2. The intestinal derivation, which is performed inthese surgeries, causes an immediate improvement effect and an increase in insulinproduction, due to the accentuated production of glucagon-like peptide-1 (GLP-1) andthe improved action of gastric inhibitory polypeptide (GIP), or glucose-dependentinsulinotropic polypeptide, which contribute to the improvement of plasma glucoselevels and, consequently, of DM2Therefore, the relevant reduction in body weight and visceral fat throughgastroplasty determines, in short term, a positive impact on the control/resolutionof comorbidities associated with obesity, including MS, DM, dyslipidemia, SAH,hepatic steatosis, and cardiovascular diseases, and, as consequence, increases lifeexpectancy. Thus, bariatric surgery, currently, is the choice of treatment forsevere obese people in which behavioral-pharmacological therapy was noteffective12, iron, and folic aciddeficiencies. These deficiencies generally occur because of feeding restrictions,physiological impacts of anatomic changes, as well as food intolerances andnonadherence to therapy with multivitaminsHowever, malnutrition and nutritional deficiency are common after this procedure. InRYGB, there is a higher prevalence of vitamin B12 deficiency can occur as aconsequence of several factors, such as the reduction of gastric production ofhydrochloric acid, which does not promote the conversion of pepsinogen in pepsin,that is necessary for the release of vitamin B12 in protein-rich foods.In addition, intrinsic factor is produced by parietal cells in the stomach. Whenthere is no production of intrinsic factor, or this production is insufficient as ithappens with the reduction of the gastric compartment, there is no absorption ofvitamin B12 at the terminal ileum, which then originates perniciousanemiaConsidering these facts, in this study, patients treated with bariatric surgery wereregularly followed up by a physician and a nutritionist in order to detect possiblenutritional deficiencies and were individually given vitamin and mineral supplementssince the preoperative period. Consequently, it was not observed an expressivereduction in these nutrients. Vitamin B12 can be observed 6 months after surgery; however,in the majority of times, this occurs after 1 year or more, once its liver storageis depleted-which was evidenced in our study for female patientsLow levels of vitamin BDyslipidemia was present in the majority of patients for both sexes in this study andshowed a significant reduction in TC, LDL, and TG during the first year after thesurgery. Meanwhile, HDL demonstrated an increase in its levels for only 4 monthsafter the surgery.,Finally, studies have unquestionably demonstrated the efficacy of gastroplasty in thetreatment of obesityThe results corroborate the importance of persisting in nutritional and behavioralactions for these patients, which will contribute to the achievement and maintenanceof an ideal weight, while avoiding weight regain that may force them to return torisk situations, that is, before the gastroplasty.The positive impact resulted from gastroplasty on weight loss, BMI reduction, andimprovement of metabolic and biochemical parameters is already extremely significant4 months after the surgery, and it is maintained until the end of the first yearafter the surgical procedure, even in patients who did not fit the eutrophiccategory.


Absolute marginal discrepancies (AMD), marginal gaps (MG), and internal gaps (IG) of the crowns, in relation to the master metal die, were evaluated using x-ray nanotomography (n = 16). Next, thirty-two metal dies were fabricated based on the master metal die, and crowns  cemented and divided into four groups of eight each; eight Zi with mechanical aging (MA), eight Zi without mechanical aging (WMA), eight ZLS (MA), and eight ZLS (WMA). Two groups of crowns  were subjected to 500,000 mechanical cycles  followed by axial compressive strength testing of all crowns, until failure, and the values were recorded. Independent sample t tests (α = 0.05) revealed no significant differences between Zi and ZLS crowns (p > 0.05); for both internal and marginal gaps, however, there were significant differences in AMD (p < 0.005). Independent samples Mann–Whitney U and Kruskal–Wallis tests revealed significant differences between the two materials, Zi and ZLS, regardless of fatigue loading, and for the individual material groups based on aging (α = 0.05). Multiple comparisons using Bonferroni post-hoc analysis showed significant differences between Zi and ZLS material groups, with or without aging. Within the limitations of this study, the ZLS crown fit was found to be on par with Zi, except for the AMD parameter. As regards fracture resistance, both materials survived the normal range of masticatory forces, but the Zi crowns demonstrated greater resistance to fracture. The monolithic Zi and ZLS crowns seem suitable for clinical application, based on the fit and fracture strength values obtained.Fit accuracy and fracture strength of milled monolithic zirconia (Zi) and zirconia-reinforced lithium silicate (ZLS) crowns are important parameters determining the success of these restorations. This study aimed to evaluate and compare the marginal and internal fit of monolithic Zi and ZLS crowns, along with the fracture load, with and without mechanical aging. Thirty-two stone dies acquired from a customized master metal molar die were scanned, and ceramic crowns (16 Zi Ceramill Zolid HT Complete coverage ceramic crowns are being routinely used in dentistry as a substitute for the traditional ceramo-metal options for multiple reasons, including fine aesthetics ,2. DiffeMarginal fidelity is a key parameter used to gauge clinical acceptability of fixed restorations, and also of clinical success at post-placement evaluations ,9,17,18.This in vitro study aimed to evaluate the accuracy of fit of CAD/CAM complete coverage monolithic ZLS crowns and compare with monolithic Zi crowns, in terms of marginal gap (MG), absolute marginal discrepancies (AMD), and internal gap (IG) widths between the crowns and the master die (conforming to a mandibular molar tooth preparation), by using nano CT-based analysis. Secondly, the study aimed to assess the fracture resistance of Zi crowns compared to the ZLS crowns, with and without mechanical aging (cyclic loading). The null hypotheses tested were that there would be no differences in the accuracy of fit, in terms of marginal and internal gap, or with respect to the fracture resistance, between monolithic Zi and ZLS crowns. The second null hypothesis was that there would be no difference between the mechanically aged and non-aged crowns, in terms of fracture loads, for both Zi and ZLS materials.+, Amann Girrbach, Pforzheim, Germany) and ZLS . This resulted in two groups of 16 Zi and 16 ZLS die specimens [An ivorine mandibular first molar tooth  was prepared using a high-speed handpiece  and a 3-degree diamond rotary cutting bur  to achieve a 1-mm wide continuous rounded shoulder. An occlusal reduction of 2 mm and 1.5 mm were achieved on the buccal and lingual cusps and a cervico-occlusal wall height of at least 4 mm was maintained on all the axial surfaces of the abutment. The overall occlusal convergence of the preparation was kept below 20 degrees. The prepared ivorine tooth was duplicated and cast using cobalt-chrome (Co-Cr) alloy . The resultant metal master die was polished, finished , and mounted into a machined brass cylinder and held in position with the aid of self-cure acrylic resin  . Thirty-pecimens ,33,34,35+ White, Amann Girrbach) and ZLS  blocks and specific types of milling bits and grinding pins for each material according to the manufacturer’s recommendation. . The stone die was scanned with the wax-up using a laboratory scanner , and 3D scan image created. Next, the two groups of stone dies were scanned using the same laboratory scanner  to generate 32 individual scans (n = 16). The dies were sprayed with occlusal spray  prior to scanning and a silicone platform was created to place the dies in the scanner in the same position for all scans. The wax-up 3D scan image was then superimposed on the individual stone die scans using ‘scan pre-op model’ option to design identical uniformly contoured virtual complete coverage crowns using CAD software , with a 0.05 mm cement space setting. The minimum thickness of the crown was set at 1 mm. The 3D data were then used to instruct a 5-axis milling machine  to mill a total of 16 Zi crowns by dry milling and 16 ZLS crowns by wet milling, respectively, using Zi  prior to fit evaluation, using X-ray nanotomography . The elastic band passed over the occlusal surface of the crown and the abutment cylinder base and aided in preventing any displacement of the crown from the master metal die and in maintaining adequate pressure on the crown during the fit evaluation procedure . For eacThe abutment-crown assembly was carefully positioned perpendicular to the X-ray source using a platform that was used for all the samples to standardize the scan position. The parameters of the nano-CT machine were setup as illustrated in Three different sagittal and coronal slices were selected both bucco-lingually (BL) and mesio-distally (MD), in addition to two slices that were chosen from the mesio-buccal (MB) to disto-lingual (DL) corner and disto-buccal (DB) to mesio-lingual (ML) corner, as shown in The slices were set at equidistant intervals (distances) of 2700 µm, 0.00 µm, and −2700 µm on the 3D model respectively for standardization purposes for all crowns, with 0.00 µm position being the center of the crown. The greatest mesio-distal and bucco-lingual widths of the abutment at the finish line level were 11 mm and 9 mm, respectively. In each of the six bucco-lingual and mesio-distal slices, 10 locations were chosen for measurement of marginal and internal fit ,28,39. AThe locations for internal gap measurement were chosen to be at equidistant intervals of 1.5 mm distance starting from the finish line margin on the axial wall, and from the mesial occluso-axial line angle on the occlusal wall, for any given slice. In the last two slices connecting the different axial line angles, only two locations were chosen at the margins for evaluation of AMD and MG. Hence, for each crown sample, there were 16 AMD and MG values recorded along with 48 internal gap widths in the occlusal and axial regions. All measurements pertaining to the marginal and internal fit of the Zi and ZLS crowns were recorded in µm. All measurements were performed by the same investigator for each of the 8 sagittal slices at 16 marginal locations and 48 internal gap locations. For the AMD and MG, three measurement repetitions were performed at each of the marginal evaluation sites and the average value was used. One pilot sample each of the ZLS and Zi crowns was randomly selected, and AMD and MG values were recorded three times at each marginal location site for a given sagittal slice, prior to the actual marginal fit evaluation to assess intra-operator reliability. The results showed a high intraclass correlation co-efficient of >0.93 for AMD and MG.2 at 10 mm distance . Subsequently, the metal dies were embedded in poly methyl methacrylate resin (PMMA) , contained in a cylindrical brass mold, and vertically positioned until PMMA resin was set for easy handling and retention of the crown-abutment complex when subjected to fatigue and load-to-failure tests. Prior to the actual testing, all 32 samples (16 Zi and 16 ZLS crowns) cemented on abutment metal dies were stored by immersing in distilled water at room temperature for at least 1 week [The 32 crowns that were previously used for marginal and internal fit evaluation were fitted individually on the universal metal die replicas and checked for marginal accuracy and internal adaptation, using visual and tactile examination with dental explorer by applying modified United States Public Health Services (USPHS) and California Dental Association (CDA) criteria for marginal fit assessment of crowns and fixed partial dentures (FPDs). The marginal fit was considered acceptable when there was no visible or presence of a slightly soundable gap, with no penetration of explorer (USPHS), and with or without crevice and catch along margin, but no penetration by explorer (CDA). The internal fit was deemed adequate when the crown was stable on the metal die without any rocking in mesio-distal or bucco-lingual directions. Additionally, silicone fit checker was used on the intaglio surface to further confirm the internal fit. If the crown was found to be of satisfactory fit, it was selected for cementation on individual dies ,42,43,44t 1 week ,49.In each of the crown material groups (n = 16), the specimens were sub-divided into eight samples each. One sub-group underwent mechanical aging (MA) by compressive cyclic loading ,48,50,51Type I: minimal fracture or crack in the crown.Type II: Loss of less than half of the crown.Type III: Crown fracture through midline with half the crown lost.Type IV: Severe fracture of the crown.Following the mechanical aging of eight crowns from each group, all 32 specimens were tested for load to fracture using a universal testing machine  until complete fracture. The compressive force was selected to be at a crosshead speed of 0.5 mm/min until failure. The semi-spherical steel head indenter of 5 mm diameter was placed in the central fossa of the occlusal surface. A thick (0.1 mm) piece of tin foil  ,56,57 waA few samples were randomly selected to analyze the pattern of crack formation in more detail, under the stereomicroscope .Data were analyzed using statistical software  and checked by an independent statistician for accuracy of performed tests and interpretation of results. Mean and SD values of AMD, MG, and IG were calculated. Normal distribution and homogeneity of data for AMD, MG, and IG were assessed using Kolmogorov–Smirnov and Shapiro–Wilk tests and verified. Levene’s test for equality of variances and independent student t-tests were used to analyze the data for AMD, MG, and IG (α = 0.05). For the fracture load values, normality of data was checked again for both material groups, and for the four material sub-groups (based on aging of crown samples). Based on the results, Mann–Whitney U-test and Kruskal–Wallis non-parametric tests were employed to test the effect of ‘material’ and ‘aging’ on the fracture load. The data were further analyzed using Bonferroni multiple comparison post-hoc tests to test the individual differences between and within material groups (α = 0.05).p > 0.05) (p < 0.05) ( > 0.05) . However < 0.05) . With rep < 0.05) (p < 0.05); however, there were no differences found between the aged and non-aged groups within the same crown material, for both Zi and ZLS (p > 0.05). Mechanical aging of the crown specimens did not induce failure in any of the crowns ,48,51, i < 0.05) . To furtIn terms of marginal and internal gap comparison for the two materials, Zi and ZLS, part of the first null hypothesis was affirmed. However, given the significant differences in AMD values between the two material groups, this aspect of the first null hypothesis was rejected. As regards the fracture resistance of the two materials, there were significant differences between Zi and ZLS crowns, in terms of fracture resistance, with or without mechanical aging, supporting the rejection of this null hypothesis. However, since there were no differences between aged and non-aged groups of both crown materials in terms of fracture resistance, the second null hypothesis failed to be rejected.The marginal gap found in this study for monolithic Zi crowns (37.7 ± 11.7 µm) was comparable with the mean ± SD values reported in other recent studies assessing similar restorations, as follows: 44.5 ± 7.9 µm , 53 ± 2 As for the ZLS crowns, the mean AMD values (128.1 ± 49.1µm) found in this study closely matched the results (148 ± 11 µm and 132.1 ± 39.4 µm) obtained in recent papers ,67. HoweOverall, the mean marginal gaps in this study for both Zi and ZLS crowns were well below the clinically acceptable level of 120 µm proposed by McLean and Fraunhofer, for favorable prognosis of restorations. The vertical marginal gaps were also in the range reported for ceramic crowns (3–174 µm) generally, and below the threshold of 80 µm reported for CAD/CAM ceramic crowns in recent systematic reviews . The meaThe increased gap in the occlusal part of the crown compared to the axial and marginal gap was consistent with the findings in many other studies ,37,65 thA cast metal die was used as a master model in this study for evaluation of marginal and internal fit, based on several other papers that had used similar types of dies for fit evaluation of ceramic crowns ,55,68,70In the current report, an upgraded version of micro-CT, the nano-CT, was used in the evaluation of crown fit accuracy. Fit measurements were carried out at a total of 64 sites for each crown specimen, for both marginal (16 sites) and internal gaps (48 sites), based on earlier studies ,55,63. TIn this study, the fit measurement prior to cementation eliminated the influence of luting cement as a variable; however, this could be considered as a minor limitation, as the test condition did not replicate the clinical situation completely. The milled ZLS crowns were crystallized and glazed in this investigation. Some recent reports have demonstrated notable differences between the marginal gaps of pre-crystallized versus post-crystallized lithium disilicate (LDS) CAD crowns ,71. The 2) in the glass matrix aiding in the transformation of the metastable tetragonal phase into a stable monoclinic phase, hence preventing the formation and propagation of the crack. The crown failure pattern noted in this study for ZLS crowns corroborated with the findings of another recent paper [In this paper, the fracture loads for both Zi and ZLS crowns (with or without cyclic loading) were higher than the values reported in most available studies and also exceeded the maximum recorded bite forces (800–1000 N) in the literature ,73,74. Hnt paper  that alsAs regards the fracture loads of monolithic Zi crowns, the outcomes of this study concur with the findings of previous investigations ,55,79 thIn the present report, both Zi and ZLS crowns showed no significant differences between the mechanically aged and non-aged crown specimens, in terms of load-to-failure values, similarly to the results reported in other recent investigations ,56. HoweThere are some deficiencies in this study that deserve discussion. Firstly, although the crown specimens were subjected to artificial aging (dynamic loading) prior to the load-to-fracture tests, they were not thermocycled in this study. A UTM set up was used for conducting the cyclic fatigue loading and static load-to-fracture tests under dry conditions, thus precluding the thermocycling of crowns. The use of a chewing simulator or other suitable device in lieu of or in addition to the UTM would have allowed for the entire thermocycling-mechanical loading (TCML) procedure to be carried out, simulating the clinical situation more closely. Additionally, the crowns post-cementation were placed in water storage for a week before the cyclic loading tests. The clinical environment could have been better mimicked with a longer water storage time and by also replicating the effect of LTD  for the Zi crowns ,83. SecoThe AMD values obtained in this study were somewhat a reflection of both marginal gap and overhang combined. Most of the crown samples in both material groups demonstrated positive overhangs, whereas negative overhangs, if any, were observed at very few measurement locations in this investigation. However, these differences were not evident in the AMD values, as all values were positive, regardless of an overextended or underextended crown margin. The lack of delineation between the two types of horizontal discrepancies could be seen as a minor limitation of this paper. From a clinical point of view though, horizontal discrepancies either in the form of over-contour or step are both considered unacceptable, and the notable differences between the marginal gap and AMD values detected in this study, for both Zi and ZLS crowns, clearly identify this aspect.Currently, CAD/CAM techniques have found widespread application for all types of prostheses—fixed, partial, and completely removable, with different types of ceramic and polymer-based materials ,15,16,86p > 0.05); however, significant differences were found in the absolute marginal discrepancies between the two materials (p < 0.05).There were no significant differences between the Zi and ZLS crowns in terms of marginal and internal gaps .There were significant differences in fracture loads between the Zi and ZLS crowns, regardless of mechanical aging (Within the limitations of this study, it can be concluded that:In summary, the ZLS crowns exhibited clinically acceptable marginal and internal gaps. The fracture load values of ZLS crowns, despite being lower than the monolithic Zi crowns, complied with the acceptable limit for use in clinical practice.


Neurodevelopmental disorders are psychiatric diseases that are usually first diagnosed in infancy, childhood and adolescence. Autism spectrum disorder (ASD) is a neurodevelopmental disorder, characterized by core symptoms including impaired social communication, cognitive rigidity and repetitive behavior, accompanied by a wide range of comorbidities such as intellectual disability (ID) and dysmorphisms. While the cause remains largely unknown, genetic, epigenetic, and environmental factors are believed to contribute toward the onset of the disease. Autism Susceptibility Candidate 2 (Auts2) is a gene highly associated with ID and ASD. Therefore, understanding the function of Auts2 gene can provide a unique entry point to untangle the complex neuronal phenotypes of neurodevelpmental disorders. In this review, we discuss the recent discoveries regarding the molecular and cellular functions of Auts2. Auts2 was shown to be a key-regulator of transcriptional network and a mediator of epigenetic regulation in neurodevelopment, the latter potentially providing a link for the neuronal changes of ASD upon environmental risk-factor exposure. In addition, Auts2 could synchronize the balance between excitation and inhibition through regulating the number of excitatory synapses. Cytoplasmic Auts2 could join the fine-tuning of actin dynamics during neuronal migration and neuritogenesis. Furthermore, Auts2 was expressed in developing mouse and human brain regions such as the frontal cortex, dorsal thalamus, and hippocampus, which have been implicated in the impaired cognitive and social function of ASD. Taken together, a comprehensive understanding of Auts2 functions can give deep insights into the cause of the heterogenous manifestation of neurodevelopmental disorders such as ASD. Neurodevelopmental disorders are a group of diseases characterized by deficits in the functions of the brain that affect a child's behavior, memory, or ability to learn, including intellectual disability (ID), autism spectrum disorder (ASD), attention-deficit hyperactivity disorder (ADHD) and so on . The symhttp://autismkb.cbi.pku.edu.cn). The proteins encoded by the high-risk genes include synaptic receptors and cell adhesion molecules such as NRXN, scaffolding proteins and the actin cytoskeleton such as SHANKs, as well as transcription factor such as Auts2 , #14262) was first identified as the genetical cause ASD in a pair of monozygotic twins . In addiAuts2 gene is located on chromosome 7q11, span 1.2 Mb. It has 19 exons, coding for a protein with 1,259 amino acids in humans. The sequence is 62% conserved between zebrafish and human, and 93% between mouse and human. Sequence analysis showed that the Auts2 protein has a PY (Pro-Tyr) motif, eight CAC (His) repeats, two proline-rich domain, several putative SH2, and SH3 domains, kinase phosphorylation sites, as well as N-glycosylation sites , 41. Simin vitro resulted in delayed neuronal differentiation, and mutations in the sequence specific to the long isoforms led to accelerated differentiation. The short isoform was also more expressed than the long one in embryonic human brain  and short isoforms , 28, 40.kDa and sInterestingly, Auts2 has one of the highest intronic RNA level in fetal brain . MoreoveThe function of different isoforms can be executed through the interaction with diverse partners during transcriptional regulation, as well as other cellular process. The short isoform of Auts2 was found to be exclusively expressed in the nucleus , 40. MorThe transcription of Auts2 is regulated by several genes indicated in ASD. For example, methyl CpG binding protein 2 (Mecp2), a gene implicated in Rett-syndrome and ASD, represses the expression of Auts2 in both mouse and human brain , 32. T-Bin vivo, as well as how this could contribute to the etiology of ASDs caused by Auts2-mutation?Auts2 was found to regulate neuronal differentiation through histone modifications, an epigenetic mechanism. The short isoform of Auts2 can bind to two polycomb proteins, PCGF3, and PCGF5, and be part of polycomb-repressive complex 1 (PRC1) for suppressing gene expression , 35. AftEnvironmental chemicals and maternal health factors have been associated with increased risk of ASD . Exposurin vitro and in vivo  within neural circuits have been proposed as one of the causes of autistic behaviors , 58. Incvia activation of Rac1 and suppresses filopodia via down-regulations of Cdc42. Genetic ablation of Auts2 in vivo impairs both migration and axon elongation of cortical neurons (In addition to transcriptional regulation, Auts2 is present in cytoplasm and can regulate cytoskeleton through Rho family GTPases. It induces lamellipodia  neurons . These o neurons , 63. DurIn developing mouse brain, Auts2 mRNA is highly expressed in the frontal cortex, olfactory bulb, hippocampus, dorsal thalamus, inferior colliculus, and substantia nigra. The expression of Auts2 mRNA in the brain was very strong by E16, then decrease to a low level after postnatal day 21 , 40. In From circuit level, the frontal cortex, hippocampus, and cerebellum have all been implicated in the impaired cognitive function of ASD –67. ATN One of the main challenges in the field of neurodevelopmental disorders is to precisely link the genetic cause with the pathophysiological changes of the nervous system. To understand the function of each gene that associated with neurodevelopmental disorders is a unique entry point to elucidate the progress of the diseases. Patients with Auts2 mutation or variations showed a broad range of symptoms, including ID and ASD, consistent with the heterogeneity of neurodevelopmental disorders. Auts2 is a key-regulator of the transcriptional network during brain development. It can control the expression of transcription factors, cell adhesion, and axon guidance molecules, as well as proteins important for synaptic functions. Moreover, through binding Polycomb proteins and forming functional complex, Auts2 participates in the epigenetic modulations, which may mediate the effect of environmental or maternal factors on brain development. In addition, Auts2 regulates the neuronal migration and neuritegenesis by cytoskeleton remodeling. Furthermore, Auts2 controls the number of excitatory synapses to achieve precise E/I balance in the central nervous system . A few kLX and WX designed the study. LX, WX, and PW wrote the paper. XY, LLi, and LLiu provided insightful discussion for the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.