This retrospective chart review study explored the etiology, use, and yield of the etiological investigations of 651 children and adolescents diagnosed with borderline intellectual functioning (BIF). Neurological, neurodevelopmental, or neuropsychiatric comorbidities were frequent, and in 23%, the BIF diagnosis evolved into an intellectual disability (ID) by the time of discharge. A primary etiological cause was found in 37.6%, the most prevalent causes being pre- or perinatal conditions, genetic syndromes/chromosomal abnormalities, fetal exposure to maternal substance use, cerebral dysgenesis, and neurological diseases. In total, 79.1% of patients went through one or more investigations during their follow-up. The best etiologic yield leading to a diagnosis in this study population was with exome sequencing, a specific gene panel, microarrays, electroneuromyography, and brain magnetic resonance imaging (MRI). Etiological investigations were performed more frequently among those children receiving an ID diagnosis. Yet, there was no statistically significant difference in the proportion of abnormal findings between the BIF and ID groups. This may mean that the current strategy for determining the need for etiological investigations or current means to gain an etiology is still indecisive. Considering that BIF is defined to include individuals performing between normal cognitive functioning and mild ID, this implies that the prevalence would be anywhere between 7 and 14%. Thus, it could be argued whether in-depth etiological investigations may be justified in cases other than ID in this age group of children over five. With these children and adolescents, the clinicians have to discern between those with a normal variation and those having major difficulties in adaptive behavior affecting everyday life in order to specify and prescribe the rehabilitation or other measures needed. We advocate for a targeted etiological search after careful history-taking and neurological examination. National guidelines that take into account the severity of developmental delay are warranted. Borderline intellectual functioning (BIF) is defined as a neurodevelopmental disorder comprising individuals performing between normal cognitive functioning and mild intellectual disability (ID), defined as having an IQ test score of one to two standard deviations below average in the range of 70 to 85 and of having difficulties in adaptive behavior affecting every area of life ,2. In thThe etiology of BIF is considered variable and heterogeneous. For instance, prematurity, asphyxia, intrauterine growth restriction, central nervous system malformations and infections, genetic factors and chromosomal disorders, pre-eclampsia, maternal alcohol or drug use during pregnancy, child neglect, and environmental deprivation have been recognized as causing cognitive compromise ,17,18,19The wide-ranging underlying etiology poses a challenge for clinicians with respect to the choice and extent of investigations to undertake. Recently, in child neurology and the developmental pediatric field, good practice guidelines or evidence-based recommendations for etiological evaluation have been developed ,24,25,26This study provides a retrospective review of patient reports recorded during an 11-year period between 1 January 2010 and 31 December 2020 comprising the 651 consecutive children and adolescents (1481 appointments) who were monitored by Päijät-Häme Central Hospital’s  neuropediatric developmental unit and who had received an ICD-10 diagnosis of F83 or F81.3 by the age of 18 years or by the time of discharge. The patients’ age had to be ≥5 years at the time point the data were extracted. The data were reviewed by a single investigator (HS) from the comprehensive digital patient reports. The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the local research ethics committees of Helsinki University Hospital and Päijät-Häme Central Hospital (D/2603/07.01.04.05/2019).The data comprised the following: demographic information; age at initial evaluation and cause of referral; pre-, peri-, and postnatal birth history; maternal pregnancy history; patient and near family (first- and second-degree relatives) history; the etiological and comorbid diagnoses, ; and the etiological investigations conducted and results gained by the extract date .Patients under school age presenting with developmental delay were evaluated by the pediatric neurologist, neuropsychologist, speech therapist, occupational therapist, and physiotherapist. The diagnosis F83 was given if there was a delay of more than 1.5 standard deviations below the mean of the norm-referenced standardized tests in two or more developmental domains. Patients attending school and having learning difficulties were evaluated by a neuropsychologist and pediatric neurologist. The diagnosis F81.3 was given for school-aged children or adolescents when two or more cognitive domains were delayed at least 1 to 2 standard deviations below the mean of the norm-referenced standardized tests, the situation did not fulfill the criteria for ID, and the child`s difficulties were not caused by a poor learning environment or a psychiatric disorder. The standardized neuropsychological tests were the Wechsler Preschool and Primary Scale of Intelligence (WPPSI-III), the Neuropsychological Test for Children’s Finnish version (NEPSY-II), and the Wechsler Intelligence Scale for Children (WISC-IV), and, in addition, the Social Responsiveness Scale (SRS-Fin), the Strengths and Difficulties Questionnaire (SDQ-Fin), and the ADHD Rating Scale-IV were used when appropriate. The tests for each participant were chosen individually according to age and profile. Moreover, as part of the diagnosis process and follow-up, information was gathered from the parents, the day care personnel, schoolteachers, and the child`s personal therapists.During the selected inspection period, individual physicians carried out their own history collection, physical examinations, and a selection of specific investigations at their own discretion based on the suspected etiology. Thus, the exact indication for each investigation could not systematically be determined from the charts. The biochemistry tests mainly included blood count, electrolytes, glucose, lactate, venous blood gas, calcium, creatine kinase, vitamins B12 and D, and thyroid, liver, and kidney function tests. The metabolic screening comprised organic acids (urine), oligosaccharides (urine), amino acids (plasma and urine) and/or glycosaminoglycans (urine), and occasionally the creatine/guanidine acid-ratio, acylcarnitines, or sialotransferrins. Genetic testing included karyotype/microarray and/or Fragile-X or specific single gene or gene panels. Neuroimaging was mostly performed with magnetic resonance imaging  and, on occasion, with computed tomography (CT). Neurophysiologic testing comprised electroencephalogram (EEG) and occasionally electroneuromyography (ENMG), visual evoked potential (VEP), or electroretinogram (ERG). The test results and the imaging and neurophysiological findings were categorized as normal or abnormal.Descriptive statistics were generated for the whole group. Categorical variable frequencies were counted and tabulated. The mean, median, and range were calculated for numerical variables. For categorical data, the difference in proportion between the subgroups with and without an intellectual disability was tested with Fischer`s Exact Test. Statistical analysis was performed using R version 4.0. (R Core Team).A total of 651 subjects were included, of which 411 were male, and 240 were female. This corresponds to a male/female ratio of 1.7:1. The mean age at the time of data extraction was 13.7 years (with a range of 5.2 to 27). One hundred patients (15.4%) were of immigrant background. The primary reason for the referral was recorded for 552 (84.8%) cases: language delay, 274/552 (49.6%), gross motor function, 138/552 (25%), fine motor function, 58/552 (10.5%), and learning or attention difficulty, 82/552 (14.9%). The mean age when being referred to the primary care level therapist was 3.4 years (with a median of 3 and a range of 0.1 to 15), and to the multidisciplinary neurodevelopmental clinic, it was 5.4 years (with a median of 5 and a range of 0.1 to 17). At the point of data collection, the head circumference data were reported for 455 patients: 42/455 (9.2%) were microcephalic, and 16/455 (3.5%) were macrocephalic. Thirty-nine patients had problems with vision , and twenty had problems with hearing.In 149/651 (23%) cases, the BIF diagnosis evolved into an ID by the time of discharge. Neurological, neurodevelopmental, or neuropsychiatric comorbidities were frequent: 254/651 (39%) were diagnosed with attention-deficit hyperactivity disorder; 150 (23%) with an anxiety disorder or the equivalent (panic disorder and selective mutism); 104 (16%) had conduct problems; 89 (13.7%) had autistic features or autism spectrum disorder ; 72 (11.1%) had socioemotional difficulties; 53 (8.1%) had symptoms of depression; 46 (7.1%) had Tourette, Tics, or obsessive-compulsive features; and 7 (1.1%) had psychotic symptoms. Twenty-nine (4.5%) were reported as having severe difficulties in reading comprehension and twenty-five (3.8%) in sensorimotor coordination (dyspraxia) or speech. The somatic neurological complaints were epilepsy in sixty-seven (10.3%), headache/migraine in thirty-five (5.4%), cerebral palsy/movement disorder/ataxia in twenty-one (3.2%), and pain in six (0.9%).Overall, a primary etiological cause was found in 245/651 cases (37.6%) . Vulnerap = 0.0048) and neurologic conditions  were the statistically significantly more prevalent etiological causes among those who had received the diagnosis of an ID by the time of the data extraction.The number of patients whose parents reported neurological or neuropsychiatric morbidities in the first- or second-degree relatives is shown in A total of 515/651 (79.1%) patients went through one or more investigations during their follow-up. The number and types of investigations performed, abnormal findings, and findings relevant to the etiology and yield of different investigations are shown in The brain MRI was normal in 189/263 (71.9%) patients. Of the 74 abnormal MRI scans, 31 led to or affirmed an etiological diagnosis; the rest of the scans contained non-specific findings. All noted abnormal MRI findings are presented in A normal EEG was found in 253/382 (66.2%) patients. In four cases, an abnormal EEG led to defining the etiology . Most of the abnormalities noted in the EEG were due to epilepsy or other neurological conditions affecting the brain  and, thus, did not add to the etiological BIF workup . A concop < 0.0001), metabolic screening , and genetic studies  were performed more often among those who had received the diagnosis of an ID compared to those diagnosed with BIF. The prevalence of abnormal findings in metabolic screenings was higher in the ID group, whereas abnormal findings in the biochemistry tests and genetic studies were more common in the BIF group. The differences were not statistically significant. Likewise, EEG  and MRI  were performed more often among those who had received the diagnosis of an ID by the time of the data extraction. However, the prevalence of normal and abnormal EEGs and MRI findings did not differ significantly between the groups.Biochemistry tests , which concurs with the yields of 31–55% found by other etiological studies in a single pediatric neurology practice ,21,23,27The main etiological causes identified in our study were pre- or perinatal causes and genetic syndromes/chromosomal abnormalities, followed by fetal exposure to maternal substance use, cerebral dysgenesis, and neurological conditions. This is similar to the findings of other reported series ,21,23,27In our study population, the best etiological yield was gained with genetic testing: exome sequencing , targeted specific gene tests or panels , and microarray . The decisions to conduct exome sequencing or a specific gene panel were made together with a medical geneticist. Moreover, in situations with uncertain microarray results, the medical geneticist was consulted. In Finland, universal national health insurance covers the medical provision; thus, the more expensive possibilities could be utilized.In our institute, the microarray gradually substituted the G-banded karyotype from 2011 onward, and since 2014, it has been the first line investigation in genetic testing. As Fragile-X syndrome (the most common genetic disorder after Down syndrome causing ID) is not detected by microarray, the Fragile-X-test (FMR1-gene) should be remembered with patients having autistic or hyperactive behavior and dysmorphic features, such as an elongated face, broad forehead, large protruding ears, and prominent jaw. The low yield in Fragile-X in our study was a surprise as none of the 182 participants tested were carrying the mutation. This may be because of excluding the individuals already having the diagnosis of ID. However, males with clear suspicion and females with a family history of Fragile-X should be tested.The general diagnostic yield in G-banded karyotype studies has been 4–18.6%, in Fragile-X-test, 2% , in micrThe yield of 11.8% in the brain MRI was lower than expected. The indications for the MRI were not always clearly stated in the charts, but many of the neuroimaging investigations in our study appeared to be performed because of abnormal EEG findings. However, all three tuberous sclerosis patients, 3/5 neurofibromatosis type-1 patients, and 11/16 with motor disorders  had abnormal MRI findings contributing to the etiology. Studies on neuroimaging, including CT but mostly MRI of the brain, evaluated the yield in both selectively and non-selectively performed investigations ,24,27,30MRI abnormalities are frequently not sufficient to determine the underlying etiology, although they are useful in the process of diagnosis; the distinction between these two factors is not always established in the studies when evaluating the factual yield . The valStudies on the diagnostic yield of routine metabolic tests in children are scarce, quoting the yield ranging from 0.25% to 5% even in the era of newborn screening ,24,32,33The role of EEG is mostly either affirming or helpful with differential diagnoses, as uncontrolled epilepsy or epileptic encephalopathies, such as the Landau–Kleffner syndrome or continuous spikes and waves during sleep, can be associated with regression or delay in development or speech, and some metabolic or autistic conditions may be associated with seizures ,34. In oThere were several limitations in this study. Firstly, the data were collected from a single neuropediatric setting; therefore, the generalization to other populations may be limited. Secondly, though collecting the data prospectively, the analysis was conducted retrospectively. Thirdly, not all the patients in the selected BIF cohort were investigated with etiologic tests, and the intensity of the diagnostic workup depended on the physician in question, albeit having general directional guidelines. Thus, incomplete clinical documentation and the data available on, e.g., dysmorphic features, abnormal status findings, and indications for tests, prevented an analysis of probable predictive factors. Additionally, the indication of the examinations is not clear, and it is difficult to know the exact sensitivities of neuroimaging and genetic testing in children with BIF. However, this may reflect common practice. In addition, data on, e.g., custody, fostering, or need for housekeeping aid or other social support was not available.When investigating children and adolescents with BIF, comprehensive clinical assessment with history-taking and multidisciplinary examination, together with monitoring the patient´s developmental trajectory, remains core to planning investigations. Recent evidence demonstrates that early genetic testing for those with unexplained global developmental delay, regardless of the severity of the situation, should be among the first-line investigations if another more obvious cause is not present . With thHow severe the degree of delay should be in order to start investigations is under debate and may depend on cultural aspects or resources available. Achieving an etiological diagnosis may also be important for providing a prognosis and discussions of probable recurrence risk, providing possible treatment, rehabilitation, or support in school, and peer support and avoidance of unnecessary or potentially more invasive and expensive diagnostic tests. Considering that BIF is defined to include individuals performing between normal cognitive functioning and mild ID having an IQ test score in the range of 70 to 85 implies that the prevalence would be anywhere between 7 and 14% . With thThis being said, it could be argued whether in-depth etiological investigations may be justified in any other cases than in IDs in this age group of children over five. In this study, analyzing the subgroups with IDs or BIF at the time of discharge revealed a significant difference in the frequency of performing different etiological testing but did not allow further conclusions on whether the diagnosis affected the clinicians´ decision of selecting and performing investigations. It should be noted that etiological investigations were performed more routinely among those children having an ID diagnosis. In contrast, the investigations within the group with a BIF diagnosis were conducted only if deemed necessary. Yet, there was no statistically significant difference in the proportion of abnormal findings between the two groups. At least partly, this may be due to the rarity of abnormal findings, which calls for research with a larger sample group. There also remains the possibility that since the investigations were not routinely conducted, some proportion of etiological causes were missed in the BIF cohort. However, in conclusion, we advocate for a targeted etiological search after careful history-taking and neurological examination. In children and adolescents with BIF, monitoring the patient´s developmental trajectory, e.g., repeating neuropsychological testing in order to diagnose a later ID, may point toward planning further investigations. The biochemistry screening could be conducted mostly for exclusion purposes. EEG could be performed when seizures or regression in development occur, and MRI in targeted cases of seizures or hard neurological signs. The more expensive further etiological investigations with genetic studies (microarray and exome) could be speared for those with dysmorphic or syndromic features or for those diagnosed with ID. National guidelines, which take into account both natives´ and immigrants’ genetic backgrounds and the severity of developmental delay, are warranted.


M age = 39.57, SD = 5.74). The findings of study 1 indicate that a single-session ACT intervention represented an insufficient dosage to reduce stress and experiential avoidance. Study 2 investigated a brief telehealth ACT intervention (delivered via a video conferencing platform and lasting approximately four hours) targeting stress and increased psychological flexibility. Participants (N = 12 people with an IBD diagnosis and mild to extremely severe stress) completed baselines lasting from 21 to 66 days before receiving a two-session ACT telehealth intervention supplemented by a workbook and phone consultation. Approximately half of participants experienced reduced stress, increased engagement in valued action, and increased functioning. Despite shortcomings such as missing data and the context of COVID-19, the present findings suggest that brief ACT interventions in this population may be effective and economic, though further research and replications are necessary.Psychological intervention targeting distress is now considered an integral component of inflammatory bowel disease (IBD) management. However, significant barriers to access exist which necessitate the development of effective, economic, and accessible brief and remote interventions. Acceptance and commitment therapy (ACT) is a therapy with demonstrated acceptability and a growing evidence base for the treatment of distress in IBD populations. The present paper trialled two brief ACT interventions via randomized multiple baseline designs. Study 1 trialled a single-session ACT intervention (delivered face-to-face and lasting approximately two hours) targeting stress and experiential avoidance, respectively. Participants were seven people with an IBD diagnosis who presented with moderate to extremely severe stress (five females, two males;  Inflammatory bowel disease (IBD) is a diagnosis encompassing numerous chronic diseases impacting the human bowel, including Crohn’s disease (CD) and ulcerative colitis (UC). The impact of IBD is wide-ranging and symptoms include diarrhoea, rectal bleeding, unintended weight loss, and fatigue, while IBD also confers an increased risk of certain cancers ,2. Co-moMyriad interventions are available to intervene with stress in those diagnosed with IBD, ranging from psychoeducational programs, stress management and relaxation strategies, hypnotherapy, mindfulness-based stress reduction treatments, and cognitive behavioural therapy (CBT) ,19. GracMore recently, studies have investigated the impact of acceptance and commitment therapy on psychological suffering in those experiencing chronic health conditions. Acceptance and commitment therapy (ACT) is a process-orientated therapy that proposes psychopathology or psychological suffering emerges from psychological inflexibility whereby individuals’ efforts to control, escape, and avoid unwanted thoughts and feelings act as a barrier to valued and effective behaviour . ACT aimInitial evidence suggests ACT may be an appropriate intervention to target psychological suffering in people with an IBD diagnosis. For example, the ACT process of cognitive fusion—the tendency to perceive and act on thoughts through a context of literality—has been observed to be negatively associated with psychological and physical health in IBD and mediates the relationship between chronic-illness-related stigma and psychological QoL ,32. MoreDespite the promise of interventions such as those employed by Wynne et al., such intensive and medium- to long-term interventions may not always be suitable. Reasons for this range from limited clinical and economic resources in healthcare systems, willingness to access psychological support, and feasibility for people with IBD themselves . Such chGiven the barriers to extended forms of psychological support, brief and low-intensity interventions are needed which are relatively low-cost, evidence-based, and produce reductions in stress, depression, and anxiety in people with IBD that are clinically meaningful. The present paper intended to understand the required dosage to reduce psychological distress in people with comorbid IBD. Given its significant prevalence and impact on QoL and disease activity, stress was given the greatest focus with a lesser focus on depression and anxiety. Under the present research, two cohorts of patients with an IBD diagnosis were delivered a single-session and two-session ACT intervention, respectively. Both interventions were trialled via single-case experimental designs (SCEDs) which facilitate the investigation of individual benefit and risk conferred by the brief ACT interventions and generalizable intervention effectiveness. Given existing findings on ACT for IBD populations and brief ACT interventions, it was predicted that the interventions would produce reduced stress and increases in psychological flexibility on daily ecological-sampling-style measures of both and validated questionnaires measuring stress ,37,46,50The following describes two studies trialling a single-session and two-session telehealth ACT intervention, respectively, and commences with methodological and analytic detail shared by both studies. This is followed by methodological detail, results, and discussion specific to studies one and two, respectively.The present study employed a single-case experimental design (SCED) wherein each participant is treated as an individual study. In doing this, SCEDs provide evidence of the effectiveness of interventions, drawing on substantially fewer participants than nomothetic approaches (such as RCTs) ,56,57,58The temporal onset of ACT interventions was randomized with the aid of the web-based tool “Research Randomizer” . RandomiThe present SCEDs were conducted at a single academic teaching hospital in Dublin, Ireland, between October 2019 and August 2021. The teaching hospital in question hosts the Centre for Colorectal Disease and is considered a centre of excellence in the treatment and management of colorectal diseases including IBD. At the time of participation, all participants received care at the hospital’s gastroenterology service.Ethical approval was granted by the institutional ethics committee  and exemptions from full ethical review were granted at University College Dublin, Dublin, Ireland .Prospective participants aged 18–65 with mild stress or above as measured by the DASS-21 and a histological and radiological diagnosis of Crohn’s disease or ulcerative colitis were eligible to participate . ProspecRecruitment was led by IBD specialists at the above-named academic teaching hospital in September 2019 and January 2021. Said IBD specialists were briefed by the first, second, and second-last authors regarding inclusion and exclusion criteria and participation activities. Said IBD specialists subsequently broached participation with those attending their clinics. It was made clear to all prospective participants that refusal to participate would not impact their care in any manner. Those who remained interested were screened per the stress inclusion criteria with those eligible being permitted a further week to consider participation.Two measures of stress were employed in both experiments, namely DASS-21 and an adapted “Stressometer”. DASS-21 was administered on three occasions: screening, week zero , and at the end of the study. The adapted “Stressometer” was completed daily in an ecological-sampling-style format with the measure and response delivered via SMS .The DASS-21 was employed as a measure of stress, depression, and anxiety. The measure includes three seven-item scales assessing each construct. Respondents report the extent to which they experienced various symptoms of stress, depression, and anxiety over the past week on a four-point Likert scale. Responses ranged from 0  to 3 (applied to me very much or most of the time) with the measure taking approximately ten minutes to complete. The measure has been observed to be valid, reliable , and have a well-supported three-factor structure, and has been trialled in clinical and non-clinical populations ,63,64,65An adapted form of the “Stressometer” was employed to assess stress daily in an ecological-sampling-style manner. As such, the measure was intended to capture stress in vivo while also minimizing the assessment burden (taking less than one minute to complete). The “Stressometer” is a validated and responsive measure of stress in people with IBD . The adaPlease reply with the number between 0 and 10 that best describes the stress you have experienced today (where a score of 0 indicates “No stress” and a score of 10 indicates “Extreme Stress”).Intervention protocols were developed by the first, third, and last authors. All three have experience in delivering ACT interventions, and authors one and three have completed 18-month trainings in ACT and mindfulness-based interventions (MBIs) and training in counselling and clinical skills. The last author is a peer-reviewed ACT trainer who provided their expertise during protocol development and provided supervision to the first author during study 1 and to the first and third authors during study 2.In addition to the above steps to maximize treatment integrity, audio recordings of intervention sessions were kept with participant consent. Randomly selected sessions were subsequently assessed for treatment fidelity using the ACT Fidelity Measure (ACT-FM) . The assp values via robust, non-parametric permutation tests and calculates three robust effect sizes : median difference between conditions, Ruscio’s A , and Hedge’s g , 95% CR , p = 0.8287, generalized OR = 1.05, 95% CI , 95% CR .Following quantitative analysis of stress data, it was observed that one of seven participants (see P(A < B) = 0.471, 95% CI , 95% CR , p = 0.6665, generalized OR = 0.89, 95% CI , 95% CR .Quantitative analysis of EA data demonstrated that three of seven participants saw reduced EA  demonstrated reduced stress as measured by the adapted “Stressometer”, and three participants demonstrated reduced stress on DASS-21 . Of note, the same three participants demonstrated reduced EA on the daily single-item measure of EA. Zero participants demonstrated reduced EA as measured by the AAQ-II. Meanwhile, participant 1 demonstrated deterioration in daily single-item measures of stress and EA. Moreover, they observed increased stress as measured by the DASS-21 (moving into the extremely severe range) although this increase did not meet the criteria for reliable or clinically significant change. Despite individual improvement for some participants, visual analysis, quantitative analyses, and particularly meta-analysis across participant effect sizes—when taken as a whole—suggest that a single-session ACT intervention is an insufficient dosage of ACT to effect a change in stress and EA as experienced by people with IBD.Previous studies of ACT interventions for IBD have suggested ACT to be an acceptable and potentially effective intervention for stress, depression, and anxiety ,37. HoweIn addition to dosage, a heavy emphasis on valued action is proposed to be an integral component of brief ACT interventions ,47. For The limitations of study 1 largely centre on the measures employed. Firstly, measures of EA may have been unable to accurately capture EA or the breadth of psychological flexibility. Regarding the AAQ-II, recent concerns have been raised regarding what it truly measures. Indeed, it is suggested that the AAQ-II may represent distress rather than EA or indices of psychological flexibility and inflexibility ,90. WhilTo conclude, study one suggests that a single-session ACT intervention of two hours in duration is largely insufficient to affect a reduction in stress, experiential avoidance, and other forms of distress for people with IBD. In response to the findings, interpretation, and limitations of study 1, study 2 employs a higher dosage ACT intervention which places greater emphasis on valued action and employs more valid and multifaceted measures of psychological flexibility.M age = 36.42, SD = 11.16). Further participant details and baseline characteristics are available in The recruitment strategy described under While the institutional context for study 2 remained the same as study 1, it is of note that the study was conducted during the COVID-19 pandemic. When the research commenced (4 May 2021), strict restrictions were in place to curb the spread of COVID-19. For example, work from home orders were in place, non-essential retail was prohibited from trading, individuals from different households were not permitted to socialize indoors, domestic and international travel were prohibited, etc. Commencing on 17 May 2021, these restrictions were lifted on a phased basis such that substantial limits to social, family, and working life had been removed by the conclusion of the study.Per the discussion of study 1 and limitations raised, alternative measures of PF were employed for study 2.At the beginning and end of the study, the Comprehensive assessment of Acceptance and Commitment Therapy processes (CompACT) was administered as a measure of PF. The CompACT is a 23-item measure of PF which consists of three subscales, namely, openness to experience, behavioural awareness, and valued action. The CompACT takes approximately ten to fifteen minutes to complete. The CompACT is considered a reliable  and valid measure of psychological flexibility with factor analysis supporting the three-subscale factor structure ,94. MoreThe brief acceptance measure (BAM) is a SCED-oriented three-item measure of psychological flexibility including openness to experience, awareness, and valued action and typically takes up to three minutes to complete ,96. EachThis short scale asks how you have been today, please select a number anywhere along each scale, based on your own sense of which statement best describes how you have been. Today I have been…(a) Struggling with my thoughts, feelings or physical sensations1 2 3 4 5 6 7 8 9 10Open to my thoughts, feelings, or physical sensations(b) Acting without awareness1 2 3 4 5 6 7 8 9 10Acting with awareness(c) Not pursuing things that matter to me1 2 3 4 5 6 7 8 9 10Pursuing things that matter to meGiven the potentially confounding impact of COVID-related distress, a measure of the same was included, namely the COVID Stress Scales (CSS). The CSS is a 36-item measure of COVID distress. The CSS asks respondents to rate the extent to which they have experienced a range of distress symptoms and phenomena on a scale of zero to four with a score of zero denoting “not at all” and a score of four denoting “extremely”. While the CSS is a novel measure, initial data suggest that the CSS is reliable  and valid . While aA brief adherence measure was included to ensure participants understood the intervention. The adherence quiz included eleven multiple-choice items, each of which asked about the six core ACT processes individually and the overall key messages of the ACT intervention. One point was awarded per correct answer with possible scores ranging from 0 to 11. For example, one item checks the participants’ understanding of cognitive defusion, as follows (wherein the most appropriate response is d):“Fusion is:(a) Thinking that our thoughts and reality are one and the same(b) Seeing the world from your thoughts rather than observing your thoughts(c) when stuck in our thoughts which tends to take us out of the present moment(d) All of the above”Two telehealth intervention sessions were delivered by the first and third authors and under the supervision of the last author. Given the COVID-19 pandemic and accessibility, these sessions were delivered via the widely available video conferencing platform Zoom. Intervention sessions were typically two hours in duration .An ACT for IBD workbook.A brief phone call follow-up consultation .The intervention trialled under study two attempted to provide greater exposure to ACT or to administer a greater dosage of ACT to participants. The intervention consisted of three primary components:The telehealth ACT intervention protocol mirrored that trialled under study 1 and is summarized in Session two occurred approximately seven days later and commenced with an exercise designed to ground the participant and promote engagement in the intervention session ahead. The ACT matrix exercise was repurposed in study 2 and employed as a case conceptualization tool. At the start of session 2, the interventionist summarized the information gathered and content covered in session 1 using the ACT matrix to facilitate this. Participants were subsequently guided in an exercise to promote compassionately responding to oneself  = −1, P(A < B) = 0.331, 95% CI , 95% CR , p < 0.0001, generalized OR = 0.55, 95% CI , 95% CR .Following quantitative analyses of stress data, it was observed that 6 of 12 participants  = 1.5, P(A < B) = 0.635, 95% CI , 95% CR , p = 0.2025, generalized OR = 1.74, 95% CI , 95% CR .Following quantitative analyses of openness to experience data, it was observed that 5 of 12 participants  = 1, P(A < B) = 0.686, 95% CI , 95% CR , p = 0.1039, generalized OR = 2.18, 95% CI , 95% CR .Analyses of awareness data suggest that 6 of 12 participants  = 1, P(A < B) = 0.711, 95% CI , 95% CR , p = 0.0041, generalized OR = 2.46, 95% CI , 95% CR .Following quantitative analyses of valued action data, it was observed that 7 of 12 participants , 5 of 12 demonstrated increased openness to experience , 6 of 12 demonstrated increased awareness , and 7 of 12 demonstrated increased engagement in valued action  on single-item measures of stress and PF. Moreover, three participants  demonstrated reliable improvements in DASS-21 measured stress . Participant two demonstrated a reliable improvement in anxiety. Neither reliable nor clinically significant changes were evident in DASS-21-measured depression, and facets of CompACT-measured PF. Deteriorations were evident for 4 of 12 participants  and 2 of 12 participants  on single-item-measured openness to experience and awareness, respectively. However, findings must be approached with caution given significant missing data for some participants  and the minimal variation in participant 8’s data. Meta-analysis across participants suggested reductions in stress and increased valued action as a function of the intervention.Improvements in openness to experience, awareness, and particularly stress and valued action are broadly congruent with the existing literature on brief interventions and improvements early in therapy. For example, sudden improvements for 40 to 60% of clients following brief interventions and initial therapy sessions are a well-observed effect in the cognitive behavioural therapies ,42,43,44Despite between 40% and 58% of participants experiencing improvements across various stress and psychological flexibility outcomes, many participants experienced minimal change or saw deterioration following exposure to the ACT intervention. While assumed to be exclusively beneficial, psychological, and behavioural therapies may on occasion confer deterioration and harm ,105,106.While approximately half of the participants experienced improvements in stress and valued action, these trends were not reliably matched by reliable and clinically significant changes in DASS-21-measured stress and CompACT-measured PF. This discordance between daily single-item indices of stress and PF and established measures of the same suggests that changes in single-item measures were of a small magnitude. While changes for some participants were statistically significant, these changes may not be associated with clinically meaningful change. However, it could be argued that a change of this magnitude such that participants’ scores fall into the range of healthy peers may be unreasonable given the persistence and impact of lifelong illness in the form of IBD . MoreoveThe strengths of the present studies centre on the design used and the approach to data sampling. Firstly, single-case experimental designs facilitated the investigation of two novel and brief ACT interventions. Given the novel nature of the interventions and the paucity of evidence for their use in populations of people with IBD, it was important to be enabled to assess both the benefit and risk conferred by exposure to the brief interventions. Such investigations  are typically not feasible via nomothetic group-based designs . MoreoveA limitation of the present study was the absence of a comparator intervention. As such, improvement may simply reflect the receipt of an intervention rather than the active components of the intervention being studied. However, we argue that the findings of study 1 attenuate this limitation somewhat given that the delivery of an intervention, in that case, did not convey significant improvement. A second limitation was that existing psychological diagnoses and the receipt of psychological support were not screened for. No participants disclosed existing conditions or the receipt of psychological therapy ; however, some may have chosen not to disclose this information. As such, some effectiveness or lack thereof of the interventions trialled under studies 1 and 2 may be attributable to concurrent therapies and undisclosed mental health conditions. While not a limitation per se, an important caveat to the findings of study 2 was the evolving COVID-19 situation. As noted under A further limitation centres on the generalizability of findings. While adequately powered for SCED methodology and employing a relatively large number of participants and data points (many SCEDs include three or fewer participants and three datapoints per phase), the samples for studies 1 and 2 remain relatively small and homogenous  ,84. WhilThe present studies lend further evidence that brief, telehealth ACT interventions with blended delivery components including workbooks and phone consultations are feasible for people with long-term health conditions and, specifically, IBD. Moreover, the findings of study 2 suggest such brief, blended and remote interventions to be potentially efficacious.The present study saw interventions delivered by interventionists with training in ACT and counselling and clinical skills. Interventionists, however, did not have recognized professional training in clinical psychology, psychotherapy, or counselling. As such, it may be feasible for psychology graduates or other allied health professionals to deliver this intervention (or similar interventions) within healthcare services catering to people with IBD. As such, future research should investigate the feasibility and efficacy of this approach to intervention delivery given the potential for improved access to psychological therapies for people with IBD.Future research should replicate the methodology of the present studies and investigate the acceptability and efficacy of these and other blended components. For example, other adjuncts might include digital self-help programs, bibliotherapy, or chatbot-delivered interventions. Lastly, further research is necessary to elucidate factors that influence suitability for brief interventions. As observed in study 2, approximately 40% to 58% of people with IBD may benefit from a brief ACT intervention. Future research is necessary to better identify those who may benefit most to facilitate the prescription of the same.Although attenuated by concerns around missing data and variation in the data, the context of COVID-19, and measures of experiential avoidance, the present findings provide insight on appropriate dosages of ACT to effect changes in stress and psychological flexibility in people with IBD. While seemingly feasible, it appears that little benefit is conferred via a single-session ACT intervention. Meanwhile, a two-session telehealth ACT intervention supplemented via an ACT workbook and follow-up phone call appears to be somewhat effective for people with IBD. However, further replication and study is warranted including triaging those best suited for such interventions.


Blood was collected for analysis 24 h before, immediately after, and 24 h after the run. Kynurenic, xanthurenic, quinolinic, and picolinic acids levels were significantly increased after the run in the control group, but the effect was blunted by vitamin D supplementation. Conversely, the decrease in serum tryptophan, tyrosine, and phenylalanine levels immediately after the run was more pronounced in the supplemented group than in the control. The 3-hydroxy-l-kynurenine levels were significantly increased in both groups after the run. We conclude that vitamin D supplementation affects ultramarathon-induced changes in tryptophan metabolism.In humans, most free tryptophan is degraded via kynurenine pathways into kynurenines. Kynurenines modulate the immune system, central nervous system, and skeletal muscle bioenergetics. Consequently, kynurenine pathway metabolites (KPMs) have been studied in the context of exercise. However, the effect of vitamin D supplementation on exercise-induced changes in KPMs has not been investigated. Here, we analyzed the effect of a single high-dose vitamin D supplementation on KPMs and tryptophan levels in runners after an ultramarathon. In the study, 35 amateur runners were assigned into two groups: vitamin D supplementation group, administered 150,000 IU vitamin D in vegetable oil 24 h before the run ( Tryptophan (TRP) is an essential amino acid required for several biological processes, including protein, serotonin, and melatonin biosynthesis. Most of the serum TRP is degraded via kynurenine (KYN) pathways. The conversion of TRP to KYN is mediated by the enzymes TRP 2,3-dioxygenase (TDO) or indoleamine 2,3-dioxygenase (IDO). In skeletal muscle, the enzymatic activity of these two enzymes is low. Hence, during exercise, KYN is likely produced outside the muscle and then imported into it .l-KYN (3-HK) and picolinic acid (PA), and an increase in KYN serum levels has been observed after different types of exercise [N-methyl-d-aspartate receptor, dysregulates glutamate release and uptake by neurons and astrocytes, and stimulates lipid peroxidation [Within skeletal muscle and other tissues, KYN is metabolized into kynurenic acid (KYNA), anthranilic acid (AA), and xanthurenic acid (XANA), quinolinic acid (QA), 3-hydroxy-exercise ,2. On thexercise . In addiexercise . Conversxidation ,7.The TRP metabolism can be modified by inflammatory cytokines . It has Recently, we have demonstrated that vitamin D supplementation reduces ultramarathon-induced inflammation . The antFurthermore, it has been suggested that vitamin D represses tryptophan hydroxylase (TPH1), thus making TRP available for the KYN pathway . Both KY3 before the ultramarathon. During the initial site visit, data on the subject’s age, body composition, and height were collected. All runners were examined by a professional physician. A venous blood sample was obtained before the ultramarathon start, and immediately after and 24 h after the run, to evaluate the effect of a high dose of vitamin D on ultramarathon-induced changes in the KYN metabolism. Due to the fact that the size of the female population taking part in the ultramarathon run—and in the study—did not allow for the construction of the experimental group, the above study applies only to men.The study was designed as a double-blind, randomized, controlled trial with parallel groups. Participants were randomly assigned to two groups: the supplementation group and the control group. The supplementation protocol involved the administration of a single high dose of vitamin DAll laboratory analyses were performed at the Gdansk University of Physical Education .n = 16; aged 42.40 ± 7.59 years) and control , according to the eligibility criteria presented elsewhere [Thirty-five amateur male ultramarathon runners who took part in the Lower Silesian Mountain Run Festival Ultramarathon Race participated in the study. All participants had been informed about the study procedures prior to enrollment, but they were not aware of the study aims or the supplementation schedule. The minimal population sample size allowing for the appropriate power of the study of interactions between the effects was 28 subjects, as calculated using GPower ver. 3.1.9.2 software. The runners were randomly assigned to two groups: experimental  based on the Cooper test, and relevant information related to the time period preceding the research and sport performance.The basic anthropological characteristics of the participants are presented elsewhere , and incAccording to the medical declarations and diagnostics carried out prior to the qualification for the study, none of the runners had a history of known diseases or reported any intake of medication due to illnesses during the 6 months before the experiment. On the measurement days, each participant was asked to adopt a similar eating pattern based on a randomized diet adjusted for their sex, age, work, and physical activity. All study protocols have been accepted by the Bioethics Committee for Clinical Research of the Collegium Medicum University of Nicolaus Copernicus (decision number KB-124/2017) and conducted according to the Declaration of Helsinki. The study is a registered clinical trial (NCT03417700).Written informed consent was obtained from all study participants prior to the study, who were also informed about the possibility of the withdrawal of consent at any time and for any reason.3  to all participants in the experimental group 24 h before the start of the ultramarathon. The control population received a placebo solution whose taste (anise), color, and consistency matched those of the vitamin D solution (pure vegetable oil solution). The participants and researchers had no knowledge of the groups and differences in the supplementation procedures.Vitamin D supplementation involved the administration of a single high dose of vitamin D® Sarstedt AG&Co, Nümbrecht, Germany) without anticoagulant for serum separation (the tubes contained a coagulation accelerator). The serum was separated using standard laboratory procedures, aliquoted, and frozen at −80 °C until further analysis [® 4500 (Sciex) coupled with ExionLC HPLC system) according to Rola et al., 2020, with minor changes. KYN metabolites were also analyzed using LC-MS/MS, according to Midttun et al., 2009.Blood samples (9 mL) were collected three times: 24 h before the run, immediately after the run (up to 5 min after the run), and 24 h after the run. Venous blood samples were collected into Sarstedt S-Monovette tubes , water , and formic acid . All solvents were LC-MS grade.3 and 24,25(OH)2D3 (after a correction for changes in plasma volume). The following KYN metabolites were analyzed: 3-HK, KYN, KYNA, PA, QA, TRP, and XANA.The following vitamin D metabolites were analyzed: 25(OH)DOn the day following the first blood sample collection, physical examination, and supplementation protocol, all study participants took part in the Lower Silesian Mountain Run Festival (19 July 2018). The start and finish points were in the town of Lądek Zdrój . The running festival took place in the Kłodzko Land (latitude of 50° N), and consisted of seven mountain trails, with the maximum course length of 240 km, maximum altitude of approximately 1425 m MSL, and minimum altitude of approximately 261 m MSL. The entire altitude range was approximately 1164 m, and the total ascent and descent was 7670 m. The run started at 18:00 h. The temperature during the run varied from 18 °C at the start point to 4 °C on the top of the Śnieżnik Mountain. The sky was overcast for most of the run.UM: 24 h before, immediately after, and 24 h after the run) on KYN metabolites and physical characteristics in relation to vitamin D supplementation . In case of significant interaction, Tukey’s post hoc test was performed to assess differences in specific subgroups. The effect size was determined by eta-squared statistics (η2). Values equal to or more than 0.01, 0.06, and 0.14 indicated a small, moderate, and large effect, respectively. All calculations and graphics preparation were carried out using Statistica 12 software . Differences were considered statistically significant when p ≤ 0.05.Descriptive statistics included mean ± standard deviation (SD) for all measured variables. Two-way analysis of variance (ANOVA) with repeated measures (2 × 3) was performed to investigate the effect of the ultramarathon run 2D3, p < 0.05). The initial serum levels of 25(OH)D3 and 24,25(OH)2D3 were comparable in both groups.The analysis of serum levels of vitamin D metabolites revealed their significant increase immediately after, and 24 h after, ultramarathons in both study groups. However, considering the hematocrit-adjusted data, the changes noted in the supplementation group immediately after the run (25(OH)DUM on all analyzed KYN metabolites was detected. A significant increase in the serum levels of 3-HK (129.97%), KYN (11.20%), KYNA (137.03%), PA (115.38%), QA (29.58%), and XANA (64.28%) was observed immediately after the run in placebo. In addition, two-way ANOVA revealed a significant effect of the group factor and a significant interaction of the group factor and UM for KYNA, PA, QA, and XANA. The levels of KYNA, PA, QA, and XANA immediately after the ultramarathon were significantly increased  only in the runners in the C group. The serum levels of the mentioned markers immediately after the run were significantly different between the groups (The analysis and changes in KYN metabolite levels induced by the ultramarathon run are presented in e groups .group and UM factors for PHE, TRP, and TYR (Further, two-way ANOVA indicated a significant interaction of the  and TYR . We dete and TYR .Further, analysis of the KYNA/KYN and KYN/TRP ratios revealed a significant effect of the UM factor on these ratios . HoweverIn the present study, we demonstrated that a single high dose of vitamin D significantly influences the TRP metabolism after an ultramarathon run and changes KYNA, QA, PA, and XANA concentrations. The single high dose can influence exhaustion and possibly protect from known adverse effects of some TRP metabolites on the central nervous system and circulation .In vitamin-D-supplemented athletes, the decrease in serum TRP levels was more pronounced that that in the control group , but theThe effects of vitamin D supplementation on TRP metabolism are puzzling. First, in the supplementation group, the decrease in serum TRP levels after the run are more pronounced than that in the control group . During We have previously demonstrated that high doses of vitamin D effectively reduce ultramarathon-induced inflammation . InflammA small portion of serum TRP is metabolized in the central nervous system into serotonin . It has The main limitation of this study is that activity of enzymes involved in TRP metabolism has not been measured in skeletal muscle and white blood cells.Overall, we have shown that vitamin D supplementation which increases its blood concentration significantly reduced the ultramarathon-induced increase in KYNA, QA, PA, and XANA. These findings implicate that vitamin D supplementation can significantly modify TRP metabolism during exercise, can influence exhaustion, and possibly protect from known adverse effects of some TRP metabolites on the central nervous system and circulation.


Most malignant hematological diseases are generally a consequence of acquired mutations or rearrangements in cell replication processes. Acute myeloid leukemia (AML) is a clinically and molecularly heterogeneous disease that results from acquired genetic and epigenetic alterations in hematopoietic progenitor cells. Despite the advances made in understanding the pathogenesis of this disease, the overall survival of patients remains very low due to the high relapse rate. Pharmacogenetics and massive sequencing studies have allowed the identification of new recurrent mutations with significant prognostic impact in AML; furthermore, it seems likely that whole genome sequencing will soon become a standard diagnostic test, which will allow the molecular diagnosis of patients. Therefore, it is necessary to develop molecular targets that open new therapeutic perspectives and allow individualized treatment of patients with this aggressive disease. Chronic myeloid leukemia (CML) is the first neoplastic disease for which a characteristic genetic alteration was described. It has, by definition, a genetic marker, the BCR::ABL1 rearrangement, as a consequence of the t9;22 translocation. Its study is essential for the diagnosis of this entity and also for monitoring the response to treatment. Drugs known as tyrosine kinase inhibitors (TKIs) that target the BCR::ABL1 protein  are the conventional treatment of CML, representing a change of paradigm in the management of oncohematological patients. BCR::ABL1 oncogene, which results in the synthesis of a protein with increased tyrosine kinase activity, the BCR::ABL1 protein, whose resulting leukemic activity leads to a significant expansion of the erythroid, granulocytic and megakaryocytic progenitor populations, with reduced sensitivity of the progenitors to the regulation of the process of hematopoiesis [Chronic myeloid leukemia (CML), also known as myelogenous or chronic granulocytic leukemia, is defined as a clonal hematologic malignant neoplastic disease of pluripotent stem cells classified according to the latest WHO classification of 2008 within the group of chronic myeloproliferative neoplasms (CMPN) . The preopoiesis . The cauopoiesis ,5.BCR::ABL1 fusion gene. A thorough initial evaluation of both the disease and the patient is necessary. Regarding the characteristics of the disease, a good morphological and genetic study is essential. It is required to pay special attention to comorbidities that can be aggravated by the treatments. We have helpful tools to predict the prognosis and make therapeutic decisions. Therefore, it is advisable to use a prognostic score; the most widely used in our setting is the SOKAL index. In 40% of the cases, the disease is diagnosed by chance when performing a hemogram for other reasons and in asymptomatic subjects. In 50% of patients, mild to moderate symptoms appear, such as asthenia, anorexia, weight loss, night sweats, spleen enlargement, and anemia. About 85% are diagnosed in the chronic phase of the disease. It is characterized clinically by a bi- or triphasic course. The patient may present in any of these phases, although the most common is the debut as chronic phase (CP), in which the manifestations derived from myeloproliferation  are easily controlled with different therapeutic agents, allowing patients to lead a practically normal life. However, the natural evolution of the disease leads to the appearance, after a variable period of between 3 and 6 years, of the terminal phase or blast crisis (BC), characterized by a clinical picture of bone marrow failure, similar to that of acute leukemias and generally refractory to treatment [Diagnosis of CML requires the presence of the reciprocal translocation between chromosomes 9 and 22, t, which results in the chimeric reatment .Acute myeloid leukemia (AML) is a clonal heterogeneous disease resulting from the clonal expansion of immature cells of myeloid lineage (blasts), which infiltrate the BM, peripheral blood, and other tissues. Most cases of AML are of unknown etiology. However, a higher incidence has been reported in patients with certain chromosomal alterations  or with a history of myelodysplastic syndrome or chronic myeloproliferative syndrome. It has also been related to some environmental factors such as ionizing radiation, exposure to benzenes, and previous treatment with alkylating agents or topoisomerase inhibitors . AML is We chose to review these diseases because CML was the first oncohematological disease in history with a specific therapeutic target, the fact that revolutionized targeted oncohematological treatments . In thisPubMed search included the keywords: “Acute myeloid leukemia” and “Chronic myeloid leukemia” with “polymorphisms”, “toxicity”, and “response”. Data regarding gene, SNP, drug, pathology, population, level of evidence PharmGKB, clinical application, allele, phenotype category (response or toxicity), year of publication, and the number of patients were recorded.The main goal of treatment is to try to cure the disease or prolong the chronic phase during which patients can lead a normal life as much as possible. In the early 1980s, the mainstay of treatment was using drugs such as busulfan, hydroxyurea, interferon, or low-dose cytarabine. Before the introduction of imatinib, life expectancy of 10 years was less than 10%. Thanks to therapeutic advances and the introduction of tyrosine kinase inhibitors (TKIs), CML has been transformed from a fatal disease to a chronic disease. Control of the pathology is achieved in about 95% of patients, which has significant health and pharmacoeconomic impact.The treatment of AML has evolved considerably over the last decades, and current regimens consider a more individualized treatment. The goal is to achieve complete response (CR) and eliminate minimal residual disease (MRD) to prevent disease recurrence. CR is morphologically defined as the presence of <5% blasts in blood and BM, with the recovery of cell counts in the haemogram. However, remission does not imply a cure, as much tumor mass may remain even after CR is achieved. Except for acute promyelocytic leukemia (APL), which has drugs with an established therapeutic target. Treatment is based on intensive chemotherapy regimens, which do not apply to elderly patients or those with significant comorbidities. The standard regimen is divided into two main phases: an induction phase (to achieve CR) and a post-remission phase  . The indInter-individual genetic variability is one of the factors that could influence susceptibility to develop CML and response to treatment, although very limited information is available. Genetic variability is a measure of genetic differences between individuals and between populations of the same species. It is based on the fact that within individuals of the same species, there are natural variations in the genome that produce differences at the genotypic and phenotypic levels. The natural variations in the genome that constitute modifications of the DNA sequence in individuals of a species are called polymorphisms ,52.BCL2 rs1801018 was significantly associated with CML susceptibility in both individual and haplotype studies. Patients with the BCL2 risk allele had a 1.3- to 1.7-fold increased risk of developing CML. In a later work [In contrast to other malignancies, there is limited information available on the influence of SNPs on susceptibility to develop CML. In this study ,54, a toter work  by the sABCB1, which expels imatinib from the interior of hematopoietic cells [Between 25–30% of CML patients do not achieve optimal response to imatinib treatment. One of the potential causes of resistance includes variations in the distribution mechanisms of imatinib from oral intake to the interior of leukemic cells. In this regard, several studies have been published that analyze the impact of interindividual variability in genes involved in drug metabolism and, therefore, in treatment outcomes and aim to identify potential markers in the pharmacokinetics and pharmacodynamics of imatinib. Such markers could predict for each individual the lack of efficacy of the drug or excess drug toxicity, developing personalized treatment guidelines. Most pharmacogenomics studies have been performed on the human organic cation transporter 1 transporter OCT-1, which internalizes imatinib into the target cell BCR::ABL1 , and on ic cells . The impic cells . Most ofic cells ,59,60,61ic cells . The conic cells .ABCB1 (MDR1), imatinib is a substrate of P-protein-mediated efflux, which in turn is encoded by this gene. Variation in the function of this gene could explain the variability of responses to treatment, as SNPs in ABCB1 could alter the function of the protein and thus influence drug absorption and elimination [ABCB1 expression in the advanced stages of CML, as well as the relationship between higher ABCB1 expression and a lower rate of imatinib resistance [ABCB1 expression with imatinib responsiveness [Concerning mination . Some stsistance ,65,66. Tsistance ,67. Nevesiveness .ABCG2 is a constitutively expressed ATP-binding cassette transporter that protects against xenobiotic molecules with a unique structure and function. Also known as breast cancer resistance protein (BCRP), ABCG2 is a multi-drug transporter with physiological roles in many tissues, including the mammary gland and the blood-brain, blood-testis, and maternal-fetal barriers. ABCG2 transports uric acid and plays an essential role in the pathology of gout. Similar to its functional homologues ABCB1 and ABCC1, ABCG2 also has a notorious function in extruding antitumor drugs from various cancer cells, which can result in multidrug resistance, a severe obstacle in cancer treatment [ABCG2 in complex with the anticancer drugs imatinib and mitoxantrone. However, it remains unclear which residues are involved in specific drug-ABCG2 interactions and how larger drugs can be accommodated and transported by ABCG2 [ABCG2 expression appears to be involved in TKI resistance. The ABCG2 34G/A and 421C/A variants were studied in Malaysian CML patients and found to have a better response to imatinib in carriers of the A34A421 dipotype [The reatment ,69. A reby ABCG2 . The ABCdipotype . A meta-dipotype .ABCG2 haplotype  associated with a significantly higher cumulative incidence of major molecular response (CI-MMR) in the 400 mg/d imatinib treated patients. Patients carrying this ABCG2 haplotype in the 400 mg arm were observed to achieve similar CI-MMR rates as patients randomized to the 600 mg/d imatinib arm. Thus, response to imatinib may be influenced by constitutive haplotypes in drug transporter genes.Bruzzoni-Giovanelli et al.  identifiBCL2L11 gene polymorphisms (BIM) and the risk of relapse after discontinuation of imatinib [BCL2L11 deletion polymorphism had a higher risk of relapse than in other cases. Confirming these results in other series could be of great clinical interest [At present, it is not possible to anticipate which patients in deep molecular response will relapse if TKI treatment is discontinued. Remarkably, a recent study found an association between imatinib . Thus, pinterest . A studyinterest ,77.ERCC1 gene polymorphisms were significantly associated with response to imatinib treatment. Thus, there was a higher rate of CCR and MMR in those patients with TT genotype compared to those with CT and CC [T and CC .UGT1A1) activity. Several studies describe the relationship between the UGTA1 genetic polymorphism and the increased risk of hyperbilirubinemia. The study by Abumiya et al. [UGT1A1 *6/6* or *6/*28 genotypes was higher than those with UGT1A1 *1/*1, *1/*6, *1/*28, or *27/28* genotypes. As a result of hyperbilirubinemias, the daily dose of nilotinib for patients with UGT1A1*6/*6 or *6/*28 genotypes is approximately 300–400 mg/day, lower than for patients with UGT1A1 *1/*1, *1/*6, *1/*28, or *27/*28 genotypes (600 mg/day). In this study, all patients who received a lower dose of nilotinib achieved a higher molecular response (MMR) at 12 months, which is predictive of longer progression-free survival. Another study by Shibata et al. [UGT1A1 polymorphisms are important determinants of severe nilotinib toxicity in Japanese patients.It is noteworthy that the increased risk of hyperbilirubinemia is caused by nilotinib, because it inhibits human uridine diphosphate-glucuronosyltransferase , such as t, inv(16), and t, the latter being responsible for the PML-RAR-α gene fusion characteristic of acute promyelocytic leukemia (APL). Class III mutations include those of the MLL gene and different chromatin-modifying genes, all of which have a poor prognosis, and mutations in DNA methylation genes, such as IDH1/2, which have a favorable prognosis. Finally, class IV mutations such as those in the nucleophosmin gene NPM1 confer a favorable or intermediate prognosis. Many of these molecular markers are currently being studied, and some have become a therapeutic target [Cytogenetic and molecular techniques are essential for diagnosis, subtype categorization, individualization of treatment, and prognosis . Thus, wc target .At present, the study of genetic polymorphisms in genes involved in metabolism, transport, proliferation, and apoptosis is one of the most interesting research lines to identify biomarkers associated with CML.BCR::ABL1 are the most common and best-known cause of TKI resistance. Their origin is unclear, although there are indications that they are a consequence of gene instability caused by the presence of BCR::ABL1 [The kinase domain of the BCR::ABL1 protein extends from amino acid (Aa) 242 to 493. The site of TKI binding is key to the protein’s function. Mutations in the ABL kinase domain of CR::ABL1 ,83. MoreCR::ABL1 . The mosCR::ABL1 .With imatinib mesylate, the P-loop mutations have a poor prognosis, and T315I confers absolute resistance. In general, the appearance of a mutation after treatment with imatinib mesylate confers a slightly lower response rate to the second inhibitor.With second and third-generation inhibitors, the presence of the T315I mutation also confers complete resistance to dasatinib, nilotinib, and bosutinib, so these are not recommended for use as this clone is being selected. In contrast, ponatinib is active in CML with this mutation .With the use of new TKIs, new mutations appear due to the positive selection they exert on clones. This is the case of the F317L or V299L mutations with dasatinib. Some mutations are more sensitive to some inhibitors than others. This is an example of the P-loop mutations slightly more sensitive to dasatinib. Y253H, E255K/V and F359C/V are insensitive to nilotinib and E255K and V299L to bosutinib. If a patient has F317L/V/I/C, V299L, or T315A mutations, nilotinib is used rather than dasatinib. If, on the other hand, they have Y253H, E255K/V, or F359V/C/I mutations, dasatinib is recommended over nilotinib . PonatinPharmacokinetically, TKIs are characterized by oral administration, moderate bioavailability, a large volume of distribution, high plasma protein binding, and elimination after metabolism by CYP 450, which is reflected in Imatinib Mesylate: dose-dependent, but it shows remarkable interindividual variation. A plasma value (Cmin) above 1000 ng/mL  is associated with a higher rate of complete cytogenetic response (CCR) and major molecular response (MMR) ,92,93. IThe relationship of high plasma level to toxicities is not consistent; only some toxicities, such as oedema, rash, arthralgia, and myalgia, are associated with imatinib Cmin ,94,95, hSLC22A1 gene), the P-glycoprotein , and the breast cancer resistance protein  [The main TKI transporters are the organic cation transporter member 1  . These tG2 gene) .OCT-1: The entry of imatinib mesylate into the leukemic cell is an active phenomenon dependent on OCT-1, which may be involved in resistance to IM. Patients treated with MI at 400 mg and with low OCT-1 activity have a lower probability of achieving MMR and even lower event-free survival, progression-free survival, and 5-year overall survival. It is unclear whether IM at 600–800 mg completely overcomes the adverse prognostic effect of low OCT-1 activity . Some stAlthough anthracycline and cytarabine combination regimens remain effective in most patients, the variability of outcomes has been primarily associated with the genetic variability of these patients. Several pharmacogenetic studies have analyzed toxicities or health outcomes of polymorphisms in genes encoding transporters, metabolizers, or molecular targets of chemotherapeutic agents . The difAnthracyclines: drugs characterized by cardiotoxicity. They can cause congestive heart failure and cardiomyopathy, with dose accumulation being one of the most important risk factors. However, episodes of cardiotoxicity have been observed in patients with unknown risk factors caused by an idiosyncratic reaction. Factors influencing the disposition of anthracyclines in cells and tissues include transporters encoded by ABC family genes. ABCC3 variants in other pathologies have been associated with lower SLE, and ABCG2 variants rs2231137 and rs2231142 with an increased risk of cardiac and pulmonary toxicities [®, and all of them have a level of evidence equal to or less than 3.xicities ,102. Thexicities . All theCytarabine: Cytarabine is a nucleoside analogue that interferes with DNA synthesis and has the main toxic effects of nausea, vomiting, diarrhea, abdominal pain, and bone marrow suppression. Cytarabine uptake into cells is mediated by the SLC29A1 gene, encoding hENT1, which is responsible for transporting about 80% of cytarabine. Different levels of SLC29A1 expression have been observed, and patients with hENT1 deficiency had lower EFS and OS [CMPK1, NME1, NT5C2, NT5C3, CDA, DCTD, CTPS, RRM1, or RRM2 have also been analyzed. Still, most of them have not shown significant clinical relevance [®, they have a grade of evidence equal to or lower than 3.S and OS . To be aS and OS . Howeverelevance , and in Midostaurin: Among the mutations designated as type I mutations, a mutation in the FLT3 gene is present in approximately 30% of newly diagnosed AML. FLT3 is a receptor tyrosine kinase with a significant role in the differentiation, proliferation, and apoptosis of haematopoietic cells. Its activation can result either from internal tandem duplication of amino acids within the juxtamembrane domain of the receptor (FLT3-ITD) or from point mutations in the second tyrosine kinase domain (FLT3-TKD). Approximately 65% of mutated patients have the ITD subtype, which is associated with a worse prognosis (high relapse rate). About 8% of patients have the TKD subtype, which has a controversial but more favorable prognosis [rognosis . In prevrognosis . Midostarognosis . No polyGemtuzumab ozogamicin: Another therapeutic target that has been studied is the CD33 antigen. It is a single-chain transmembrane glycoprotein that is expressed on the surface of normal and leukemic myeloid cells, being present in more than 80% of leukemic cells but absent from pluripotent stem cells. Gemtuzumab ozogamicin is a monoclonal antibody directed against CD33 covalently linked to a semi-synthetic cytotoxic agent. It is used in the treatment of patients with de novo CD-33 positive AML with favorable or intermediate cytogenetic risk in combination with standard chemotherapy. Regarding pharmacogenetic variants, the CD33 rs35112940 variant is implicated in clinical outcomes in pediatric patients [SULT2B1 rs2302948 was associated with a protective factor [patients  and the e factor . In the e factor .Finally, new drugs are being studied, including farnesyltransferase inhibitors, second-generation FLT3 inhibitors such as gilteritinib, quizartinib, and crenolanib, bcl-2 antisense oligonucleotides such as venetoclax, new hypomethylating drugs, daunorubicin and cytarabine as liposomal formulations, and histone deacetylases inhibitors (HDI) such as enasidenib and ivosidenib.The precision medicine achieved through implementing Pharmacogenetics should be a reality in daily clinical practice in Oncohematology. Its implementation represents a definite improvement in treating acute and chronic myeloid leukemia patients, favoring the system’s sustainability by selecting patients and avoiding costly and unnecessary treatments. It also minimizes complications resulting from treatments with little or no chance of response to treatment. The ultimate challenge in pharmacogenetic advances in these pathologies would be to have health outcomes and improve the clinical results of oncohematological patients and their quality and quantity of life.


Many of the metabolites that were significantly altered in tissues were amino acids, with glycine and alanine showing promise as candidate biomarkers of stress. Corticosterone was shown to significantly alter alanine, aspartate, and glutamate metabolism in the liver, breast, and hippocampus, while isolation altered the same pathways, but only in the kidneys and hippocampus. Isolation also significantly altered the glycine, serine, and threonine metabolism pathway in the liver and breast, while the same pathway was significantly altered by heat in the liver, kidneys, and hippocampus. The study’s findings support corticosterone as a model of stress. Moreover, a number of potential metabolite biomarkers were identified in chicken tissues, which may allow producers to effectively monitor stress and to objectively develop and evaluate on-farm mitigations, including practices that reduce stress and enhance bird health.The impact of physiological stress on the metabolome of breast muscle, liver, kidney, and hippocampus was investigated in Ross 308 broiler chicks. Simulated on-farm stressors were compared to a corticosterone model of physiological stress. The three different stressors investigated were: (i) corticosterone at a dose of 15 mg/kg of feed; (ii) heat treatment of 36 °C and 40% RH for 8 h per day; and (iii) isolation for 1 h per day. Liver, kidney, breast muscle, and hippocampus samples were taken after 2, 4, 6, and 8 days of stress treatment, and subjected to untargeted  Gallus gallus domesticus) production [Physiological stress has far-reaching and detrimental effects on all domestic animals, and the adverse impacts of stress on the health of birds is a major issue facing broiler chicken  corticosterone administered at a dose of 15 mg/kg of feed to simulate a physiological stress response ,34,35; (n = 24 chicks); (2) corticosterone stress (n = 24 chicks); (3) heat stress (n = 24 chicks); and (4) isolation stress (n = 24 chicks). The experiment was conducted on three separate occasions , and each treatment time combination consisted of six replicate birds. Two replicate birds were included in each run.The study was designed as a factorial experiment with four levels of stress treatment and four time points, arranged as a completely randomized design . The fouA local hatchery in Lethbridge provided the Ross 308 broiler chicks on the morning that they hatched (day 0). All chicks originated from a single broiler breeder farm, and originated from hens of known health status. Upon arrival at the Lethbridge Research and Development Centre (LeRDC) small animal facility, the chicks were randomly assigned to control, corticosterone, heat, or isolation treatments, and were acclimatized in pairs in individually ventilated cages (IVCs) . Chicks were provided ad libitum access to the same non-medicated starter diet  and sterile water . During w/v). Briefly, digesta was thawed in an anoxic atmosphere, the slurry was transferred into sterile 3 mL syringes (1 mL per syringe), and the syringes were capped in order to prevent oxygen infiltration, and then maintained in a thermos that was pre-heated to 37 °C. Chicks were orally inoculated with the cecal digesta slurry within ≈20 min of removal of the syringes from the anoxic atmosphere. Each syringe was fitted with a flexible disposable PTFE feeding needle  . Individual chicks were gently restrained, their beaks were carefully opened by inserting the feeding needle, and the needle was carefully advanced into the mouth and then guided into the esophagus. Once in place, 1 mL of the cecal slurry was delivered into the esophagus, and the needle was carefully removed. Chicks were observed for 30 min, and none of the birds showed evidence of distress.To establish a uniform enteric microbiota , all chicks were orally administered cecal digesta containing enteric microorganisms on day 1, as described previously , with thExposure of chicks to stressors commenced on day 5, and continued until the end of the experiment . The bir2/min), and were then humanely euthanized by cervical dislocation under general anesthesia. Immediately after death, the head was removed, the cranium was opened, and the hippocampus was removed and snap-frozen in liquid nitrogen. The removal of the hippocampus tissue was based on the domestic chick brain atlas, and in all cases would have included the hippocampus proper as well as part of the adjacent parahippocampalis. Together they form the avian hippocampal formation [Randomly-selected chicks were sampled following 2, 4, 6, and 8 days of stress  . At the ormation ,44. Immeg for 5 min. This washing step was repeated ten times in order to ensure that all glycerol in the filter had been removed [2PO4, 0.5 M K2HPO4, 0.00375 M NaN3, and 0.375 M KF; pH 7.4) was added to the samples at a ratio of 2:1 (volume:mass) and the sample was homogenized using a Bullet Blender tissue homogenizer  with 150 mg of 2-mm-diameter zirconium oxide beads (Next Advance) on setting eight for 5 min. For breast tissue, which was more difficult to homogenize, the same procedure was followed, with the exception that homogenization was performed using a TissueLyser  and a single 6-mm-diameter steel bead for 10 min at 50 Hz. Samples were then centrifuged at 14,000× g for 5 min to pellet cellular debris, and 365 µL of the supernatant containing the small water-soluble metabolites was added to a pre-washed Amicon filter, along with 135 µL of metabolomics buffer. The filters were them centrifuged at 14,000× g for 30 min at 4 °C. For each sample, 360 µL of the filtrate was added to 140 μL of deuterium oxide containing 0.05% v/v trimethylsilylpropanoic acid (TSP) and 200 μL of metabolomics buffer ; TSP was used as a chemical shift reference for 1H-NMR spectroscopy. The solution was vortexed on the high setting, and then centrifuged at 12,000× g for 5 min at 4 °C to pellet any particulate matter. A 550 μL aliquot of the supernatant was placed in a 5 mm NMR tube, and the sample was run on a 700 MHz Bruker Avance III HD spectrometer  for spectral collection.Amicon Ultra-0.5 centrifugal filters with a molecular weight cutoff of 3 kDa  were used. Each filter was washed by adding 500 μL of Millipore water to the filter and centrifuging at 14,000×  removed . ApproxiMetabolite spectra were obtained using the 1-D NOESY gradient pulse pre-saturation water suppression pulse sequence ‘noesygppr1d’ with 10 ms mixing time as previously described . BrieflyThe repeated measure within the mixed procedure of SAS  was used to analyze daily weight gain in chicks; the appropriate covariance structure was selected according to the lowest Akaike’s Information Criterion (AIC). In conjunction with a significant F-test result, least square means were used to compare the stress and control treatments at individual sample times. p-values obtained for metabolomic analyses were Bonferroni–Holm corrected for multiple comparisons. MATLAB was also used to calculate the percent difference of the bins between treatments. The R package, MetaboanalystR (v. 2.0.1) [https://www.metaboanalyst.ca/) [Metabolite spectral bins were subjected to both univariate and multivariate analysis to determine which metabolites were significantly altered between stress and control treatments using MATLAB . The univariate measures were calculated using a decision tree algorithm as described by Goodpaster et al. . The mul. 2.0.1)  was used. 2.0.1) . Metabolyst.ca/) . Pathwayyst.ca/) ; the KEGyst.ca/)  for chicp = 0.042) weight gain in chicks relative to control treatment birds (p < 0.050) of stress on weight gain occurred primarily after 5 days of stress treatment, an immediate impact on weight gain due to both heat  in the liver, kidney, breast muscle, and hippocampus in birds subjected to all three stressors relative to control treatment chicks. The significantly altered bins were then subjected to both unsupervised PCA and supervised OPLS-DA. Examination of all spectral bins for the corticosterone treatment showed no supervised or unsupervised group separation for any of the tissues (data not shown); therefore, an investigation into the multivariate modeling, using the bins identified as significantly altered by either the Mann–Whitney U-test and/or VIAVC, was carried out. This examination of the livers and kidneys in both corticosterone and control treatment birds showed supervised group separation, as well as good model fit (Q2) and variance explained by the model (R2), starting at 2 days and increasing at the 4, 6, and 8 endpoints (p ≤ 0.050) between the control and corticosterone treatments as determined by VIAVC analysis and/or MW U-test. For both the liver and kidney, there was also unsupervised separation between the corticosterone and control treatment birds at all endpoints  U-test revealed that metabolite bins were altered  in the liver of heat treatment relative to control treatment birds, as determined by VIAVC analysis and/or the MW U test was completed using OPLS-DA analysis, and showed good model fit . Examination of metabolite bins that were altered  in the liver and hippocampus of isolation treatment relative to control treatment birds, as determined by VIAVC analysis and/or the Mann-Whitney U test showed unsupervised separation after 6 and 8 days of isolation . PCA score plots of metabolite bins observed to be altered  between the stress and control treatment chicks were subsequently identified using Chenomx, and the concentrations of a large number of metabolites were altered (p < 0.050) in liver, kidney, breast muscle, and hippocampus tissue due to the three stressors , such as valine A. While For the kidney samples obtained from birds administered corticosterone, threonine, malate, anserine, acetylcholoine, acetylcarnitine, and 4-hydroxyproline were all down-regulated A. GlucosIn the breast muscle of chicks administered corticosterone, the amino acid alanine was down-regulated, along with glycero-phosphorylcholoine and N-methylhydantoin, while lactate and sarcosine were up-regulated . In the Metabolomics can provide comprehensive information on how animals respond to changes in environment, diet, pathophysiological stimuli, and genetic modification by providing a snapshot of all the metabolic activity of a biological system ,57,58,59The relative concentration of glycine in the liver decreased in birds that were administered corticosterone relative to control treatment chicks. The observed change in glycine concentrations corresponded to alterations in the glyoxylate and dicarboxylate metabolism pathway, which has previously been shown to be up-regulated in broilers subjected to heat stress . GlycineCollagen is an important structural protein, the most abundant protein in the body, and approximately 30% of the amino acids comprising collagen are glycine residues . The supGlycine is a known oxidant scavenger, and it is essential for the regulation of the redox state of cells ,67,68. AIn most animals including chickens, hydroxyproline is required for the synthesis of glycine. Moreover, up-regulation of hydroxyproline has been observed in response to many different kinds of stress, such as inflammatory and genotoxic stress ,77,78. IClostridium perfringens infection [Reduced crude protein (CP) diets have become more popular for feeding chickens as a strategy to decrease environmental pollution emanating from chicken production, to increase litter quality, and to help reduce feed costs ,80. Glycnfection . Excess nfection , as glycnfection . Another important precursor for glycine is the amino acid serine. If serine is not converted to glycine, it can react with homocysteine to produce cystathionine, a reaction catalyzed by the enzyme cystathionine β-synthase (CBS). Deficiency in CBS activity can lead to increased concentrations of homocysteine and decreased bone quality, making chickens, and layers in particular, more susceptible to osteoporosis and bone breaks . We obseCorticosterone administration resulted in the down-regulation of alanine in the liver and breast muscle. Moreover, alanine was down-regulated in the livers of chicks subjected to isolation stress. The alterations to alanine regulation led to significant alterations to the alanine, aspartate, and glutamate metabolism pathways. Stress causes a decrease in the concentrations of amino acids, particularly in the liver due to an increase in energy demands ,87,88,89Alanine catabolism is enhanced when there is an increased demand for TCA cycle intermediates (mainly pyruvate) for gluconeogenesis . The admWe observed that lactate was initially down-regulated in breast muscle after 2 and 4 days of corticosterone treatment, but was then up-regulated at the day 6 and day 8 endpoints. Lactate is an indicator of poor meat quality associated with a drop in pH and soft meat, which is often the result of rapid anaerobic glycolysis due to stress encountered during transport of broilers to abattoirs . It is nGlutathione (GSH) is an important antioxidant that protects cells from potential oxidative damage and maintains homeostasis ,92,93. IWe observed that stress affected the regulation of threonine in broiler chicks. Threonine is an essential amino acid for broilers, and it is thought to be the third limiting dietary amino acid, behind lysine and sulfur-containing amino acids ,96. ThreBetaine is a derivative of glycine that plays an important role in broiler metabolism by regulating growth, maintaining osmotic pressure, and acting as an antioxidant . BetaineAlthough heat and isolation stress affected the metabolome of other tissues, we observed that breast muscle was not appreciably affected by either heat or isolation stress. Early exposure to elevated temperatures helps birds adapt to heat later in life ,107,108.High concentrations of circulating corticosterone suppress muscle growth and protein synthesis leading to decreased weight gain and increased muscle protein degradation ,114,115,The hippocampus in birds is involved in spatial memory, and it is particularly sensitive to the adverse effects of stress . We obseMany metabolites were significantly affected by corticosterone and simulated on-farm stressors (heat and isolation stress) in broiler chicks, and effects varied across the tissues sampled. An ancillary goal of the research was to identify candidate metabolites for potential use as biomarkers of stress in broiler chickens that could be measured in more accessible downstream substrates, such as blood and feather pulp to allow producers to monitor their flocks for stress, to objectively evaluate mitigations, and to enhance production health. A number of amino acids, particularly glycine, 4-hydroxyproline, threonine, and alanine showed promise as cardinal metabolite biomarkers of stress. Threonine, which comprises 20% of the amino acids in feathers was down-regulated in the kidneys after 2 and 4 days of stress; this could be a promising acute biomarker in both blood and feather pulp. In addition, both 4-hydroxyproline and glycine were down-regulated, with the former occurring after 2 and 4 days, and the latter occurring after 6 and 8 days. These results suggest that 4-hydroxyproline may serve as a more sensitive biomarker of acute stress response, and glycine may be a more sensitive marker of chronic stress. Alanine was down-regulated in the liver after 4 and 6 days, and this suggests that alanine may be a potential biomarker of both subacute and chronic stress. Future research should validate these biomarkers using models of stress-precipitated disease, such as necrotic enteritis. Future studies should also validate potential biomarkers using a multifactorial approach that includes different nutritional regimes and genotypes.