This Research Topic consists of 32 articles, contributed by 283 authors, focusing on recent understanding regarding the impact and management of comorbidities associated with autism spectrum disorder (ASD). This Research Topic sought to answer questions such as: Are standard screening instruments capable of delineating the full range of impairment in ASD without considering comorbidities? Given the difficulties in communication for many ASD patients, what red flags point toward the presence of comorbidities? How do comorbid conditions relate to maladaptive behaviors? How do health care providers grapple with the juxtaposition of intellectual disability (ID), non-verbal clinical care, and comorbidities in ASD? This Research Topic attempted to answer these and other questions while raising awareness on how comorbid conditions increase both mortality and morbidity in ASD.The presence of a chronic disorder that co-occurs, at the same time or in tandem, with a primary disease is a comorbidity. Defining the presence and natural history of comorbidities is important as it serves to better inform treatment and prognosis . For manBy themselves, comorbidities are associated with worse outcomes and increased health needs. The presence of co-occurring medical conditions confers those affected with a higher level of morbidity, increased risk of depression, and reduced level of social well-being . These pThe abundance of chronic conditions  in modern medicine makes comorbidity the norm rather than the exception. In 2014, approximately 42% of adult Americans had multiple chronic conditions . Indeed,In ASD, comorbidities do not occur evenly but tend to cluster into different subgroups. A recent study reported that ASD individuals can be subtyped according to whether they exhibit seizures, multisystem disorders, psychiatric disorders, or whether they lack a defined comorbidity . ExternaMuratori et al.) and their presence may be the best predictor of maladaptive behavior, respective of ASD symptom severity, presence of ID or limitations in adaptive functioning .Comorbidities in ASD manifest as impairments outside of its core diagnostic features; the latter being deficits in social communication/interaction, and restricted, repetitive patterns of behavior, interests, or activities, including sensory processing difficulties . EpilepsThe prevalence of comorbidities varies widely, from study to study, probably pointing to the fact that ASD is not a unitary disorder but a spectrum involving different pathophysiologies. Lumping patients into a single group tends to average out significant differences within a study population. Conclusions from these prevalence studies should be taken cautiously as research designs tend to exhibit multiple limitations. Indeed, when interpreting results, one must consider the variability ingrained in different ascertainment methods and the lack of available specialized consultative care in some study centers. In addition, many prevalence studies on comorbidities use small patient samples and/or fail to address the impact of demographic, socioeconomic, ethnic, and geographical factors on diagnosis.Penzol et al.; Baeza-Velasco et al.). Associated behaviors may exhibit varying relationships to GI symptoms at different ages, a fact having important implications for medical care . In effect, treating GI disorders may help alleviate a broad array of disorders  in the multimorbid ASD patient .In ASD, the expression of comorbidities stemming from any given organ system can take multiple forms. For GI comorbidities this may involve gastroesophageal reflux (GERD), constipation, diarrhea, food allergies, colitis, ulcers, and inflammatory bowel disease . These aSymptoms of comorbidities in ASD may be atypical and are often difficult to recognize . A majorChanges in behavior, even maladaptive behaviors, may indicate an underlying comorbidity. It is common for maladaptive behaviors to mask comorbidities and for these conducts to be dismissed as being either “autistic behaviors” (diagnostic overshadowing) or the result of environmental/sensory stressors. Changes in behaviors may manifest at home, at school, as alterations in every-day situations or as problems in already established personal relationships. Curiously, on some occasions, these behaviors may serve to mask an ASD diagnosis, especially in women. Females with ASD are the great chameleons of diagnostic medicine. They often gain social acceptance through rehearsed mimicry. Those that successfully camouflage their ASD are often misdiagnosed as having a borderline personality disorder, being bipolar or as suffering from major depression [see ]. In theIt is important to be cautious when facing unexplained multi-system involvement in a patient with ASD. Think of an underlying comorbidity if: there are unexplained signs and symptoms (including self-injurious and hetero-aggressive behaviors), in the case of maladaptive behaviors that cannot be contextualized during psycho-educational behavioral assessments , there are changes from baseline , the patient is not responding as expected to therapeutic interventions, has a history of frequent visits to the emergency room, has a history of perinatal complications, or is taking multiple drugs along with over-the-counter (OTC) medications and dietary supplements –23. It iCawthrope). Gender is another non-modifiable factor that may help identify specific comorbidities  or act through sex-related perinatal complications . This modifiable comorbidity, obesity, predisposes an individual to insulin resistance and type 2 diabetes mellitus, hypertension, dyslipidemia, cardiovascular disease, stroke, sleep apnea, gallbladder disease, hyperuricemia, gout, and osteoarthritis. Obesity has emerged as an epidemic among our ASD children who are plagued by both risk factors and an “obesogenic” environment  comorbidities and psychiatric manifestations, (2) anatomical correlates, (3) specific examples, (4) intellectual disabilities, and (5) mechanisms. In the paragraphs below we will summarize each article within its subtopic.1) Comorbidities and psychiatric manifestations: According to Druss and Walker  “having Avni et al.) found that an ASD diagnosis was associated with poorer adaptive functioning skills in a large and well-characterized sample of 260 young people with ADHD/ anxiety symptoms. The study also found that ADHD and anxiety symptoms predicted poorer adaptive functioning skills over and above IQ scores. Diagnosing these comorbidities early on is of importance in improving outcome.Using cross-sectional regression analyses . Results showed that approximately 30% of the subjects exhibited internalizing problems as compared to the 6% that manifested externalizing problems. There was no correlation between CBCL scores and indices of ASD severity. The authors suggest that detection of distinct behavioral and emotional problems in ASD may lead to more specific and individualized treatments.Muratori et al. completed a detailed assessment of the incidence of psychiatric comorbidity (PC) in 989 preschool age children with ASD using the DSM-Oriented Scales of an age-specific version of the CBCL 1.5–5. They compared IQ measures and other characteristics of the children with ASD only and ASD + PC, both mono-comorbid vs. multi-comorbid PC. They reported that 37.8% of the sample had at least one PC in addition to ASD, and that such subjects tended to exhibit lower overall performance IQ and higher ADOS calibrated severity scores. The higher rate of PC was reflective of increased Affective Problems, ADHD Problems, Anxiety Problems, and to a lesser extent Oppositional Problems. When considered together their data suggests that greater consideration of PC should be undertaken when evaluating and developing individual treatment or intervention plans for children with ASD.Roberts et al. followed a large sample of males (n = 74) with fragile × syndrome (F × S) for their developmental and temporal profile of social avoidance during early childhood. Parameters for increased social avoidance predicted elevated ASD severity but reduced ADHD and anxiety within the study population. ASD, ADHD and anxiety symptoms related inconsistently to social avoidance behaviors. The results provide new insights into ongoing debates as to the independence or overlap among these disorders in F × S.Skwerer et al. characterized the profile of co-morbid symptoms of psychopathology and emotion dysregulation in people with ASD with minimally verbal abilities. Correlations were found among ratings of emotional dysregulation, severity scores on co-morbidities and maladaptive behavior ratings, but none of these measures were correlated with ASD symptom severity scores. The number of clinically significant psychiatric symptoms was found to be the main predictor of maladaptive behaviors.Top et al. had three main aims. Firstly, the study reports data on self-report measures of sensory processing, anxious apprehension, and intolerance of uncertainty in three groups; (a) adults with ASD (AUT), (b) individuals with high levels of anxiety (ANX), and (c) neurotypical adults (NT). Adults with ASD scored higher than both other groups on Sensation Avoiding, Low Registration, and Sensory Seeking and scored similar to the ANX group on Sensory Sensitivity and Intolerance of Uncertainty. Anxious participants scored higher than both other groups on anxious apprehension. Significant correlations were reported between sensory sensitivity, anxious apprehension, and intolerance of uncertainty. Secondly, the study reports baseline physiological arousal in each of the three groups through measurements of baseline pupillary size. The AUT group had larger baseline pupil size than the NT group but similar size to the ANX group. However, the ANX group demonstrated decreasing pupil size throughout the experiment, which was not demonstrated by the AUT group. Thirdly and lastly, pupil size did not differ between groups in response to auditory stimuli or in habituation to stimuli over time.The study by Weiss and Fardella studied prior experiences with victimization and perpetration in adults with ASD (n = 45) and a healthy control group (n = 42). The participants filled out questionnaire measures, and the adults with ASD reported higher levels of negative experiences with victimization than the healthy control group. These group differences are not better explained by self-reported abilities in sociocommunicative abilities or emotion regulation difficulties. However, no group difference appeared in relation to experiences with perpetration. Previous studies have tended to focus on specific types of victimization and not perpetration.2) Anatomical correlates: Form and function complement our understanding of each other. This is especially true for multimodal imaging classifiers that combine anatomical, neurochemical and white matter integrity measures in systems-biology-based models that enable health practitioners to better address the underlying causes of disease.Cai et al. investigated structural differences between patients with High Functioning Autism (HFA) vs. Low Functioning Autism (LFA). Using an unbiased whole brain VBM-DARTEL method and a 3T MRI system to assess neuroanatomical differences in Gray Matter Volume (GMV) in various regions of interest (ROIs). They found that LFA and HFA had the same abnormal brain regions, but LFA had more abnormal brain anatomy regions than HFA. Increased GMV in the left Inferior Temporal Gyrus (ITG) were found in both HFA and LFA and increased GMV of the Left Medial Temporal Gyrus (MTG) was found only in the LFA group. Significant negative correlation between Gray Matter Volume of Left Inferior Temporal Gyrus and the score of repetitive behavior was also found, at least among HFA subjects.Dekhil et al. reported on a computer-aided detection and diagnosis system (CAD) for ASD based on anatomical and functional indices of connectivity in brain regions that are commonly abnormal in ASD. The accuracy of a diagnosis was 75% when using fMRI data, 79% when using structural MRI data, and 81% when using a combination of both. By parcellating the data according to brain regions, a personalized brain map can be created that can help target therapeutic interventions.Lukito et al.) compared the neurofunctional correlates of duration discrimination between young adult males with ASD (n = 23), ADHD (n = 25), the comorbid condition of ASD+ADHD (n = 24), and those with typical development . By means of fMRI the authors aimed to study duration discrimination deficits and to test whether those deficits are underpinned by the same or different processes. Using both ROI and whole brain analyses the comorbid ASD + ADHD demonstrated significant under-activation in the right inferior frontal cortex compared to the other groups. The findings suggest that in adulthood, the comorbid ADHD + ASD, but not the pure conditions, demonstrate deficits in a brain region responsible for duration discrimination.Using functional magnetic resonance imaging (fMRI)  decrease in volume of the left inferior frontal gyrus  was found to be driven by ADHD, which was categorical rather than correlative with severity. ADHD alone, ASD alone, and ASDxADHD were each tied to trends in mean curvature changes in multiple different brain regions. The study suggested that the left inferior frontal gyrus might play a role in modulating symptoms of inattention and/or impulsivity in ADHD. Other observations based on cortical thickness and mean curvature, require further attention in studies using a larger sample population.3) Specific examples: Feinstein first defined a comorbidity as, “Any distinct additional entity that has existed or may occur during the clinical course of a patient who has the index disease under study” . This teBaeza-Velasco et al. described the current knowledge on possible links between ASD and joint-hypermobility related disorders. Joint hypermobility occurs in isolation or associated with genetic syndromes especially in collagen related disorders. Connective tissue diseases are frequently a source of joint pain and multisystem involvement. Individuals with ASD have social communication defects that may conceal pain conditions. The authors suggest keeping in mind joint hypermobility and/or collagen related disorders in people with ASD as a source of pain that can, in turn, exacerbate behavioral disturbances.Cawthorpe screened for associations between ASD and a wide range of ICD diagnoses in a pediatric population. Analyses showed differences in terms of strength of associations across age strata suggesting plausible temporal mechanisms. Levels of GI symptoms accounted for unique variance in psychiatric outcomes over and above other factors, linking increased GI problems with increased psychiatric symptoms in children with ASD.De Crescenzo et al. performed a meta-analysis of the literature on ASD symptoms in individuals with schizophrenia. Both disorders share impairments in reciprocal social interaction and social withdrawal, as well as other cognitive symptoms. Furthermore, childhood onset schizophrenia has a high comorbidity with ASD. This study compared ASD scores on the Autism Spectrum Quotient and subscores from 13 studies involving patients with Schizophrenia. Other ASD assessments were also included such as SRS, ADOS-2, CARS, and ASSQ. The evidence from 1958 patients supported the finding of increased ASD symptoms in patients compared to control samples, but fewer symptoms compared to those with ASD diagnosis. This suggest some shared psychiatric vulnerability, which is not surprising given some common genetic underpinnings.Dy and Tanchanco provide the first case report of co-occurring achondroplasia and ASD. Both conditions are common on their own and their coincidental co-occurrence is to be expected. Achondroplasia typically presents with musculoskeletal impairments; however, the presence of delays in other domains of development, particularly social communication, should raise the suspicion of ASD. Recognition is important as early intervention is critical toward addressing the unique needs of such a patient.Ferguson, Dovgan, Severns et al. studied the relationship between nutritional intake and gastrointestinal symptomatology in children with ASD (n = 120). The study found no significant associations between GI symptoms, omega-3 fatty acids and/or other micro- and macronutrients in the diet. The findings suggest a disconnect between dietary changes and GI symptoms in ASD individuals.Ferguson, Hamlin, Lantz et al. examined the relationship between GI disorders, problem behaviors and internalizing symptoms in a sample of 340 children and adolescents with ASD. Externalizing problem behaviors and internalizing symptoms associated with GI problems differ between young and older children with ASD. The results suggest a different relationship of GI symptoms at different ages, a difference which may have implications for the longitudinal follow-up of patients as well as for their treatment.Nor et al. designed and conducted a cross sectional study to assess the prevalence of obesity and overweight among Malaysian ASD children and adolescents. The methods were predominantly psychometric in nature and completed by the children's parents. The reported prevalence in ASD was higher than in the general population matched for age and gender, with higher risk for the older age ones, high maternal BMI, older paternal age, low physical activity, food refusal, and food selectivity. Feeding difficulties, limited variety, and a lack of physical activity was related to higher weight gain.Lindor et al. studied whether the link between greater ASD symptom severity and problem behaviors is moderated by sleep disturbance. The authors reported a positive relationship between ASD severity and problem behaviors for those ASD individuals with mild or no sleep disturbance. By way of contrast, there was no significant relationship between ASD symptom severity and problem behavior among those ASD individuals with moderate-to-severe sleep disturbance. Significant problem behaviors were apparent across all individuals with moderate-to-severe sleep disturbances regardless of the severity of ASD symptoms. The study highlights how profiling of ASD individuals based on their sleeping habits may help identify those prone to clinically significant problem behaviors.Margari et al. examined whether male and female high functioning autism (HFA) patients might develop specific comorbidities phenotypes in this retrospective study. The study evaluated 159 HFA patients  for the presence/absence, type and gender distribution of psychopathological comorbidities , according to DSM-5 diagnostic criteria. The study found a bias, favoring females, in Anorexia Nervosa among HF ASD patients.While sex-differences in ASD has been associated with IQ and cognitive function, Neuhaus et al. studied the records of 2,800 patients with ASD and found that parent-reported GI concerns are present in approximately one third of patients, and that GI symptoms are an independent predictor of internalizing, externalizing, and self-injurious behaviors. They document an increased prevalence of comorbid psychiatric problems in those patients with GI symptoms.Penzol et al. reviewed the prevalence of GI disorders in ASD and described their clinical correlates. The study included all patients (n = 845) with documented information regarding GI disorders (GID) admitted to a general hospital during a span of 3 years. GIDs were present in 30.5% of the patients, the most common complaint being constipation. GIDs were significantly associated with ID, sleep disorders and treatment with psychopharmacological drugs.In a retrospective study 4) Intellectual disabilities: There is a large degree of clinical heterogeneity in both ID and ASD. Their complex interactions and expression may negate the generalizability of observational findings to the general population. Still, this area should be prioritized in research. Their multi-morbidity burden is greater, occurs at a much earlier age, and they are at the receiving end of health service inequalities.Casanova et al. investigated genotype-phenotype correlations in ID. The study selected from a database of patients with ID and comorbidities of ASD, epilepsy, and a group without comorbidities (neither ASD nor epilepsy). These groups were further characterized by secondary manifestations of complex vs. simple facial dysmorphia (CFD/SFD) and neurodegenerative-like features (NLF). Phenotypic analysis showed high frequency of CFD in ID with ASD and NLF in ID with epilepsy. Gene covariation analyses were conducted and revealed ID networks with functional enrichment in relation to CFD and NLF. These findings suggest that clinical features related to ID are predictive of underlying genotype.Miot et al. studied 63 adults with ASD-ID with detailed clinical examinations and screening for comorbidities. Investigators found a large range of comorbidities with a burden similar to those of older geriatric patients. This “premature aging” in adults with ASD-ID positively correlated with age, decreased autonomy, and polypharmacy. The results highlight the need for personalized medical care in this patient population.Paulais et al. aimed to investigate possible cross-cultural differences and, on an individual level, the degree of heterogeneity in the cognitive and socio-emotional levels and severity of ASD symptoms. Developmental profiles of children with ASD + ID across countries showed extremely high heterogeneity in comparison with those of developmentally matched TD children. Profiles of ASD + ID children across countries were also similar to one another. ASD + ID children tended to have their lowest scores in language and vocal imitation. Heterogeneity within profiles was unrelated to country, but a few differences were found between countries in correlations of heterogeneity index with developmental level or developmental quotient. Algerian children had significantly greater differences between cognitive and socioemotional heterogeneity indices. Heterogeneity of profile was not related to age but was negatively related to overall developmental level and positively to severity of ASD.5) Mechanisms: Many comorbidities represent intertwined conditions linked by shared risk factors  and complications. The health profile of affected individuals is compounded by the duration, severity, and presence of other superimposed health conditions.Ashwood reports that soluble TNFR2 levels are significantly decreased in ASD compared to TD controls following PHA stimulation, suggesting, lower TNF-alpha antagonism. Likewise, following PHA stimulation, cell surface TNFR2 was increased compared to controls. Overall, this work suggests that the TNF-alpha pathways, particularly that downstream of TNFR2, may be dysregulated in ASD.Ferguson, Dovgan, Takahashi et al. sampled electrodermal activity (EDA) in eight individuals with severe ASD at a residential facility. The investigators found an anticipatory rise in EDA prior to problem behaviors. EDA may help anticipate and manage problem behaviors while also monitoring the return to baseline.Hirosawa et al. reported higher rates of interictal epileptiform discharges (IEDs) in individuals with ASD compared to TD children. In addition, while IEDs have been reported to negatively impact cognition in TD children, little is known regarding the impact of IEDs in children with ASD. The study included 163 TD children and 107 children with ASD for which 10 min of MEG recording was conducted as well as an assessment of cognition with the Kaufman Assessment Battery for Children (K-ABC). Linear regression was employed to examine the effect of IED frequency on cognitive function. In the TD group, there was a significant negative relationship between mental processing (MPS) and IED frequency, while in the ASD group, a significant positive relationship was found between MPS scores and IED frequency. The authors suggest that the higher frequency of IEDs in ASD implies a local excitatory/inhibitory imbalance in the brain. However, the authors further suggest that this might not be pathogenetic in children with ASD, but instead might reflect epiphenomenal or compensatory processes.Hughes and Ashwood report that antibodies that target Candida albicans, were positive in 36% of children with ASD and 14% of TD controls and GI dysfunction in half of the children with positive findings. The study draws attention to the fungal microbiota of individuals with ASD and the possibility of significant alterations (dysbiosis) in the same. The study provides suggestive evidence of a new microbial risk factor for ASD.Sokol et al. review findings suggesting how secreted APPα and the ADAM family of α-secretases (non-amyloidogenic pathway of βAPP processing) may increase white matter volume in ASD. Recognition of those pathological pathway may lead to new treatment interventions.Tye et al. considered those comorbid conditions that have been repeatedly associated with ASD; epilepsy, sleep, gastrointestinal, and immune functioning. The authors discuss research into potential etiological mechanisms and potential interactions between each comorbidity and ASD. The networks derived from the analysis of abnormal biological profiles may help define potential subgroups and personalize targets for interventions.Tye et al.) which demand special monitoring and long-term follow-up by primary care physicians. If health care providers are to improve outcome, it is imperative to reorient services in such a way so as to better recognize the presence of comorbidities and to refer patients to appropriate professionals. In order to diminish the burden of comorbidities in ASD, management requires a multidisciplinary team approach comprised by parents, special educators, psychologists, and medical specialists (In conclusion, the presence of comorbidities delineates subgroups within ASD that allow us to better define underlying mechanisms, etiologies, and possible genetic/environmental contributions. Comorbidities provide additive risk factors for morbidity and mortality (cialists , 35. We All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The ability to quantify DNA, RNA, and protein variations at the single cell level has revolutionized our understanding of cellular heterogeneity within tissues. Via such analyses, individual cells within populations previously thought to be homogeneous can now be delineated into specific subpopulations expressing unique sets of genes, enabling specialized functions. In vascular biology, studies using single cell RNA sequencing have revealed extensive heterogeneity among endothelial and mural cells even within the same vessel, key intermediate cell types that arise during blood and lymphatic vessel development, and cell-type specific responses to disease. Thus, emerging new single cell analysis techniques are enabling vascular biologists to elucidate mechanisms of vascular development, homeostasis, and disease that were previously not possible. In this review, we will provide an overview of single cell analysis methods and highlight recent advances in vascular biology made possible through single cell RNA sequencing. Recent advancements in single cell analyses have enabled researchers to investigate tissue development, cell heterogeneity, and cellular response to injury and disease in unprecedented ways. Such analyses require continued development of techniques that separate and label single cells isolated from tissues, quantify components in each cell , and analyze resulting data on a single cell level. These bioinformatic pipelines can cluster similar cells, compare gene expression patterns among clusters, and predict their signaling and lineage progression pathways. Comparing individual cells from a tissue-wide perspective has revealed previously unappreciated levels of cellular heterogeneity, identified unknown cell types and elucidated cellular differentiation and interaction pathways.Obtaining such novel insights will be particularly useful for the vascular biology field, as vascular cells are abundantly distributed throughout all tissues and must establish and maintain different functions to ensure tissue homeostasis. Thus, via single cell analyses, we can define tissue-specific phenotypes and functions of vascular cells, and provide needed insight into how they cross-talk with tissue-specific cells .To date, the most abundantly used single cell analysis technique has been single cell RNA sequencing (scRNA-seq) that involves generating barcoded converted DNA from RNA of single cells, transcriptome sequencing, and raw data processing. However, emerging techniques in single cell analysis that are focused on chromatin availability and protein abundance have recently allowed for exciting experiments that will deepen our understanding of vascular cell heterogeneity beyond RNA expression. In this review, we provide an overview of the scRNA-seq process, discuss the unique advantages of single cell analysis that have been used in vascular biology, and highlight emerging new single cell techniques.In the vascular biology field, single cell RNA transcriptome sequencing has become standard for understanding cellular heterogeneity and lineage progression. The first description of whole transcriptome sequencing on the single cell level was published in 2010 by Tang et al., who dissociated cells from tissues, manually selected single cells to isolate RNA and amplify cDNA to sequence the entire transcriptome of each single cell, analyzed the data using basic bioinformatics approaches, and experimentally validated the single cell data : tissue The very first step toward single cell analysis is enzymatic digestion of tissues into single cell suspensions. Isolation of healthy single cells from tissues is required to obtain high quality, reproducible data, and optimizing digestion of specific tissues is critical , 3. OverDelineating the transcriptome of single cells from a population requires a method for identifying sequencing reads generated from each cell. Two methods have emerged as the most-used by researchers: plate-based sequencing (Smart-seq) and droplet-based sequencing (Drop-seq). Smart-seq, as well as more recently developed Smart-seq2 , is a plUnderstanding the data generated from scRNA-seq requires bioinformatics approaches. Many different computational-based methods have been generated for different types of analyses of raw scRNA-seq datasets. Before transcriptome analysis, it would be useful to determine whether the raw sequencing data are of sufficient quality with regard to the raw read output . Thus, using programs such as FastQC (Babraham Bioinformatics) could prevent loss of time and resources on extensive analyses of low-quality sequencing data. Additionally, sequence reads per cell and genomic coverage should be sufficient for each experiment, which can be checked in scRNA-seq analysis programs CellRanger (10× Genomics) and Seurat v3  explain, BWA 2121, and KSimilarities and differences among cells can be visualized and quantified using different methods depending on the desired outcomes. The Seurat v3 program can be used to group cell types into clusters and identify key genes that are significantly different among the clusters , and proIn Situ Hybridization (FISH) employs probes to identify RNA strands in tissue slices, and this technique is the most direct method for validating RNA expression levels in tissues. FISH protocols have now been optimized to identify small populations or low-abundance RNA constructs , has also been difficult to characterize. Pericytes and VSMC derive from multiple embryonic sources and have different phenotypes in adult tissues and disease 7.5–8  via a prulations . Thus, dulations , 40. Towulations . Furtherulations .To form a functional blood circulatory system, primordial endothelial cells must be specified into arterial and venous fates . Arteriain vivo studies including TGF/BMP signaling, Notch activation, and shear stress (Studies using human embryonic stem cells (hESC) and induced pluripotent stem cells (iPSC) can lend further insight into the process of endothelial cell specification in a controlled environment. Endothelial cell differentiation from hESC and iPSC has been described [reviewed in ], and iPr stress , 55, 56.During development, another distinct type of endothelial cells, termed hemogenic endothelial cells, are also specified and give rise to the hematopoietic stem and progenitor cells that serve as the foundation of the hematopoietic system. Hemogenic endothelial cells are known to form in the extraembryonic yolk sac and placenta, as well as within the aorta-gonad-mesonephros (AGM) region of the embryo . The numMural cells, including pericytes and VSMC, are required for blood vessel formation and maturation . Understin vivo (+CD271+CD73−)  . ClearlyVascular cell phenotypes and functions vary among tissues due to tissue-specific microenvironments and requirement for diverse vascular functions , 70. ThiOne very important endothelial specification event occurs in the developing coronary vasculature where it has been shown that endothelial cells from the sinus venosus give rise to the coronary arteries. It was previously reported that sinus venosus endothelial cells proliferate in response to VEGF-C stimulation and migrate in response to shear stress-induced activation of the CXCL12-CXCR4 pathway –73. Howein vivo. Performing scRNA-seq of E14.5 brain endothelial cells, and comparing these data to bulk RNA sequencing of wild-type and Beta-catenin deficient brain endothelial cells, revealed that Wnt signaling is also required for the establishment of barrier function in brain endothelial cells  occurs when an artery and vein are shunted so that blood flow avoids a capillary network. AVF are usually created surgically to improve access for hemodialysis patients with end-stage renal disease . This caLarge arteries are critical for maintaining blood pressure and flow regulation to tissues. Injury to large arteries can include damage to the endothelial cell layer and VSMC-mediated atherosclerotic plaque formation. VSMC contribute to atherosclerotic plaque formation via proliferation and trans-differentiation , and intVascular endothelial and smooth muscle cell heterogeneity is also apparent within arterioles in different tissues, which may also play a role in tissue response to injury. Maintenance of proper blood vessel diameter in arterioles requires signal transduction through G-protein coupled receptors (GPCR), but there are many different GPRC with varying functions and downstream signaling targets . Single Vasculature in tumors is structurally and functionally different from vasculature in healthy tissues. Endothelial cells within tumor blood vessels have increased VEGF and Dll4-Notch signaling, which leads to increased proliferation and permeability, enabling leakage and metastasis –149. TheOccurring in 8.7% of people aged 45–85, Age-Related Macular Degeneration (AMD) is one of the most prevalent disorders that leads to blindness . In AMD,Novel single cell analysis techniques are being continually generated. Advances in sequencing and computational analyses are helping to improve scRNA-seq, but new approaches are not limited to evaluating RNA expression. Chromatin accessibility and high-dimensionality protein assays are also being optimized for single cell analysis. All of these techniques can be combined to understand cell heterogeneity on multiple molecular levels.in situ RNA sequencing (FISSEQ) method starts with fixed cells and tissues, converts RNA to cDNA, and uses sequencing reagents and sensitive confocal microscopy to manually read the sequence  sequencing can determine regions of open chromatin by using transposase to insert specific primers to sequence open regions of DNA . This teSingle cell protein analysis has also had some exciting recent advances. Traditional single cell approaches to protein analysis have used flow cytometry to define populations of cells, but the degree of variation described in flow cytometry experiments is limited by availability of excitation and emission ranges. However, a new method of flow cytometry, Mass cytometry time-of-flight (CyTOF), uses metallic-bound antibodies to read the metal ions attached to cells through the antibody interactions, allowing for many more antibodies to be used in a single experiment . This meSingle cell analysis has revolutionized our understanding of vascular biology. Vascular cell differentiation, functional heterogeneity, and population-specific response to disease have all been characterized in greater detail than previously possible. Such studies have also suggested trends among vascular cells; e.g., endothelial cells appear to have a high degree of heterogeneity, while mural cells exhibit less phenotypic diversity. Additionally, we have gained insights into tissue-specific differentiation of vascular cells that plays a key role in establishing diverse functions including blood-brain barrier, cardiac vascular density and aortic vascular cell responses.The process of vascular cell differentiation (or dedifferentiation) and specialization in development and disease represents a continuum of fate changes, and single cell analysis is particularly well-suited for identifying transitional phenotypes along a trajectory. Additionally, the novel hypothesis that vascular cells in an established plexus may exist in a continuum of arteriovenous identity can be more rigorously tested using advanced single cell analysis . FinallyAdvances in single cell analysis will ultimately improve our ability to maintain health and treat disease. Understanding cell heterogeneity and differential cell population-specific response to disease has large implications for vascular therapies. Targeted medicine approaches can take advantage of vascular cell heterogeneity to manipulate precise cell types for drug delivery or gene therapy –170. ForAll authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Furthermore, there was a trend of more bleeding events in RF patients. CS-treated patients had significantly lower adjusted hazard ratios for death , hospitalizations , clinically relevant bleeding , and major bleeding . Thus, patients who required oral anticoagulation therapy benefitted significantly from being managed in a specialized coagulation service, regardless of their renal function.Oral anticoagulation (OAC) is effective at preventing and treating thromboses and thromboembolism in patients with normal renal function. We aimed to research the impact of severe renal failure (RF) on patient outcome and to determine the potential benefit of caring for these patients in a specialized coagulation service (CS). A total of 1516 usual medical care patients and 756 CS-managed patients of the thrombEVAL multicenter (21 centers), prospective, cohort study (NCT01809015) were analyzed in a 3-year follow-up. Patients with RF  were compared to patients without RF in usual care and a CS. The fluctuations in the international normalized ratios were significantly lower in CS-managed patients, and regardless of treatment in usual care or a CS, the time in therapeutic range was significantly lower in RF patients. Cox regression-adjusted hazard ratios for long-term outcome (1.5, 95% CI: 1.22–1.83,  Oral anticoagulation (OAC) is commonly applied to treat and prevent thromboembolic disease ,2. In paVKAs are still widely used in severe renal failure patients as the risk of stroke or systemic embolism is substantially increased in these patients . HoweverAs data on oral anticoagulation with VKAs in severe renal failure patients are inconsistent and sometimes contradictory, we analyzed data of the thrombEVAL study to determine the impact of severe renal failure on patient outcome. These patients are still widely treated with VKAs as NOACs are not approved for this group of patients. Furthermore, we hypothesized that specific care by a specialized coagulation service would improve the clinical outcome of anticoagulated patients with severe kidney disease.The thrombEVAL study NCT01809015) is a prospective multi-center investigator-initiated cohort study comprising two prospective cohorts: a cohort of patients having received oral anticoagulation therapy in usual medical care (managed by the physician in charge), and a cohort of anticoagulated patients whose anticoagulation therapy was managed by an eHealth-based, specialized coagulation service, which was provided by an outpatient anticoagulation clinic . In. In17]. To account for potential differences in the groups, we used propensity score-weighted cumulative incidence plots to compare all four groups .The composite long-term outcome A was betThis is the first and largest study to show that patients who require oral anticoagulation therapy benefit substantially from being cared for in a specialized coagulation service, regardless of their renal failure status.In the present analysis, patients with severe renal failure had a significantly worse outcome compared to patients without severe renal failure during a long-term follow-up period of 3 years. Even after correction for clinically relevant confounding variables, including antiplatelet use, severe renal failure patients had a significantly worse long-term outcome, which, in our study, was a composite endpoint of clinically-relevant non-major and major bleeding, myocardial infarction, systemic and pulmonary embolism, stroke, and death. Furthermore, as single endpoints, severe renal failure patients experienced significantly more deaths and hospitalizations compared to patients without severe renal failure. Severe renal failure proved to be an independent negative prognostic factor. In general, as has been shown by Prochaska et al., managing patients requiring oral anticoagulation in a specialized coagulation service improved their prognosis . We showIt is well-known that patients with chronic kidney disease have a higher incidence of atrial fibrillation and, in general, a lower life expectancy . The benPatients with severe renal failure are known in general to have a lower time in therapeutic range ,22, whicThe risk of death was much greater in severe renal failure patients, which was attenuated by signing these patients up with a specialized coagulation service. In our study, managing severe renal failure patients in a coagulation service reduced the complication rates of these patients down to the complication rates of patients without severe renal failure in usual medical care.2- or CHA2DS2-VAsc-score exclude renal failure, and efforts to include renal failure in the calculation have not succeeded [The results of our study further emphasize the fact that patients with severe renal failure are a very particular subgroup of patients, characterized by a distinct clinical risk profile. Consequently, the generated study data, excluding this subgroup, cannot be extrapolated to patients with severe renal failure. Even well-established therapies, such as statin therapy in coronary artery disease, do not appear to be effective in chronic hemodialysis patients due to the altered lipid profile of such patients . An inteucceeded . Furtherucceeded .This study has several limitations that merit consideration. First, the study has an all-comer observational design and does not include an intervention. Conversely, this might also represent a strength of the study, as it better approximates real-life situations. There were no scheduled, on-site patient visits; instead, patients were followed up extensively on an annual basis with patient telephone interviews, and checking with family doctors and the residents’ registration office if patients deceased. Second, the thrombEVAL study was not specifically designed to research renal failure patients. Third, assigning the patients of our study to glomerular filtration rate-based strata is not possible since laboratory data on renal function were not recorded. However, currently, a generally accepted, universal definition of renal failure for clinical trials does not seem to exist, as what is considered renal failure varies greatly in most clinical trials or registries. We advocate inaugurating such a definition or the classification of renal failure for clinical trials to allow for a better comparison of renal failure populations among clinical trials. Although our study did not exclude any ethnicities, the study population is mainly Caucasian, and the results may not extrapolate to populations of other ethnic backgrounds. Finally, the generalizability of the findings to other pharmacological agents used for oral anticoagulation therapy  should be done with caution.Patients with severe renal failure have a significantly poorer long-term outcome, an increased rate of hospitalization and death, and showed a tendency to have more bleeding events. Managing patients in a specialized coagulation service resulted in substantial risk reductions across all relevant domains, to the extent that patients with severe renal failure in the coagulation service had better outcomes than patients without severe renal failure receiving usual medical care. Accordingly, patients with severe renal failure should be managed in a specialized coagulation service.


Deep venous thrombosis (DVT) is a commonly encountered diagnosis in clinical practice with a variety of established risk factors. Inferior vena cava atresia (IVCA) is a rare vascular anomaly, but an established risk factor, associated with DVT, found in approximately 5% of cases of unprovoked lower extremity DVT in young adults. Patients who develop DVT are at high risk of long-term complications, including DVT recurrence and post-thrombotic syndrome. Thirty percent of inferior vena cava (IVC) anomalies are associated with hypercoagulable conditions in the younger population, Therefore, a hypercoagulable workup is beneficial in this population. We report a rare case of a 31-year-old male who presented with an extensive DVT of bilateral lower extremities secondary to IVC atresia. The treatment of choice for IVC atresia associated with extensive DVT is catheter-directed thrombolysis (CDT), endovascular IVC reconstruction with nitinol stent, and long-term anticoagulation. Inferior vena cava atresia (IVCA) is a rare vascular anomaly associated with deep venous thrombosis (DVT), found in approximately 5% of cases of unprovoked lower extremity DVT in the younger population (<30 years) . IVCA- aA healthy 31-year-old male with no past medical history presented with low back pain associated with new-onset right lower extremity swelling and numbness. He stated that over the past month, he drove to Canada and took a 10-hour flight to Moldova. Upon return to the US, he went to his primary care provider for lower back pain and was given a prescription for oral diclofenac. Due to persistent severe back pain, he presented to the emergency department and was evaluated. Pertinent physical findings were right lower extremity (RLE) erythema, warmth, and moderate pitting edema along with a positive Homan’s sign and bilateral lower back pain. His back was tender with light palpation rated 8/10.Computed tomography angiography (CTA) of the chest/abdomen/pelvis showed an atretic infrarenal IVC, right common and external iliac vein thrombosis, and left common iliac vein thrombosis to its bifurcation, large thrombosed collaterals in the right retroperitoneum, and left lumbar vein, and azygous/hemizygous vein thrombosis Figures -5. ThereA heparin bolus followed by a drip was administered and the patient was seen by both interventional radiology and vascular surgery. Right lower extremity venogram showed extensive acute occlusive thrombus of the right femoral vein at the level of the femoral head Figure . InterveIVCA or agenesis is often congenital or acquired because of either embryonic dysgenesis or thrombosis during the intrauterine period. During embryogenesis period, the IVC is formed by the fusion of three sets of paired veins . The failure of these veins to fuse into venous structure results in the anomaly of IVC. The presentation of IVC atresia as an extensive deep vein thrombosis with thrombosis or hypertrophy of collateral vessels is a rare clinical form. It is presumed that the collaterals developed before deep vein thrombosis are unable to cope with the increased blood flow, thereby generating venous stasis and recurrent deep vein thrombosis. The presence of thrombus induces an inflammatory response, which in return causes valvular scarring and incompetence, therefore promoting venous reflux and chronic venous hypertension. All of these changes would cause limb swelling, stasis dermatitis, and recurrent DVT . PulmonaEarly intervention is essential to reduce the risk of deep vein thrombosis recurrence and the occurrence of post-thrombotic syndrome. The characteristic of IVC atresia-associated DVT is occurrence before the fourth decade of life, usually male predominance, and extensive or bilateral lower extremities DVT . The DVTThe duration of anticoagulation is debatable. However, in the absence of other risk factors of DVT, a short duration of three to six months is sufficient. In the presence of other risk factors as thrombophilia, chronic immobilization, or malignancy, lifelong anticoagulation is generally indicated ,6. GayerUltrasound and venography are excellent tools in the identification of deep vein thrombosis, but they frequently miss the diagnosis of IVCA. CT or MRI with contrast is more effective in identifying IVC anomalies and is recommended if there is a history of unprovoked deep vein thrombosis in younger patients .Endovascular management with catheter-directed thrombolysis (CDT) is safe and effective in reducing thrombus burden and restoring venous patency. Therefore, decreasing the risk of post-thrombotic syndrome and chronic venous insufficiency. Bush et al. suggested that catheter-directed methods are considered superior to systemic thrombolysis due to the high risk of bleeding . FurtherIn a case report by Dougherty et al., surgical option is an alternative to endovascular therapy in cases of extensive iliofemoral DVT associated with IVC anomalies. Approaches typically involve reconstruction of the absent IVC via placement of bypass grafts, thus permitting a return of venous outflow and resulting in significant symptomatic relief .IVCA can be congenital or acquired due to either embryonic dysgenesis or thrombosis during the intrauterine or perinatal period. Deep vein thrombosis of the IVC veins and femoral veins may be associated with congenital anomalies of the IVC, specifically in young patients with bilateral deep vein thrombosis. A thorough investigation of thrombophilia markers may also be useful to complete the evaluation of these patients. The treatment of choice for IVCA with symptomatic heterozygous factor V Leiden are PCDT, endovascular IVC reconstruction, and long-term anticoagulation.


Nursing home quality has been a matter of long-standing policy interest at the federal and state level, as it concerns the health and well-being of one of our most vulnerable populations. Mor et al. (2004) described the nursing home industry as a ‘two-tiered’ system, with the lower-tier nursing homes operating in a resource-constrained environment given their high proportion of Medicaid residents (85% or higher). Medicaid is the largest payer of nursing homes but its reimbursement rates typically lag Medicare as well as private pay. Lower tier facilities are characterized by lower professional staffing and occupancy rates, and worse quality. Such facilities have a higher proportion of minority residents and are generally located in communities with significant proportions of poor and minority residents, exacerbating the existing disparities in nursing home care. However, there are performance variations among high Medicaid nursing homes, with some facilities performing significantly better than others on both quality and financial performance. What may explain the superior performance of certain nursing homes that are operating in a similarly resource-constrained environment? Factors, such as management resources and environmental resource availability, may be the critically important differentiators. The purpose of this symposium is to examine the organizational/management and community factors that may be associated with high-performance among a similar group of resource-constrained nursing homes. Using survey, secondary, and qualitative data analysis, this symposium will explore the role that culture change, leadership style, human resource management practices, knowledge management, and community factors can have on nursing home performance.


Apolipoprotein E (ApoE) ɛ4 status, has also been described. Finally, the possible explanations for the inconsistent and heterogeneous neuroimaging findings observed in individuals with SCD are discussed, along with future directions. Overall, the literature reveals a preferential vulnerability of AD signature regions in SCD in the context of AD, supporting the notion that individuals with SCD share a similar pattern of brain alterations with patients with mild cognitive impairment (MCI) and dementia due to AD. We conclude that these neuroimaging techniques, particularly multimodal neuroimaging techniques, have great potential for identifying the underlying pathological alterations associated with SCD. More longitudinal studies with larger sample sizes combined with more advanced imaging modeling approaches such as artificial intelligence are still warranted to establish their clinical utility.Subjective cognitive decline (SCD) is regarded as the first clinical manifestation in the Alzheimer’s disease (AD) continuum. Investigating populations with SCD is important for understanding the early pathological mechanisms of AD and identifying SCD-related biomarkers, which are critical for the early detection of AD. With the advent of advanced neuroimaging techniques, such as positron emission tomography (PET) and magnetic resonance imaging (MRI), accumulating evidence has revealed structural and functional brain alterations related to the symptoms of SCD. In this review, we summarize the main imaging features and key findings regarding SCD related to AD, from local and regional data to connectivity-based imaging measures, with the aim of delineating a multimodal imaging signature of SCD due to AD. Additionally, the interaction of SCD with other risk factors for dementia due to AD, such as age and the  The main imaging features and neuroimaging advances in individuals with SCD related to AD are summarized.The symptoms of SCD are associated with specific and distinctive underlying pathological events.A preferential vulnerability of AD-signature regions in individuals with SCD are described.The risk factors for dementia due to AD may interact with SCD and aggregate brain alterations.www.alz.co.uk]. Currently available treatments are moderately beneficial at best for the symptomatic stages of AD ) OR (subjective memory decline[Title/Abstract]) OR (subjective cognitive complaint[Title/Abstract]) OR (subjective cognitive complaints[Title/Abstract]) OR (subjective memory impairment[Title/Abstract]) OR (subjective memory impairments[Title/Abstract]) OR (subjective memory complaint[Title/Abstract]) OR (subjective memory complaints[Title/Abstract]) OR (cognitive complaints[Title/Abstract]) OR (subjective cognitive impairment[Title/Abstract]) OR (subjective cognitive impairments[Title/Abstract])) AND (Alzheimer’s disease) AND (neuroimaging OR PET OR MRI OR EEG OR MEG OR NIRs OR ASL OR DKI OR DSI OR DTI OR fMRI OR sMRI OR QSM)”. The studies were included based on the following inclusion criteria: (1) studies that described neuroimaging changes in individuals with SCD related to AD, (2) participants with SCD exhibited normal performance on standard neuropsychological tests and were free of other medical or psychiatric causes, and (3) original research published in English with the full-text available, regardless of the research settings. The following types of studies were excluded: (1) case reports, conference abstracts, reviews and study design or protocols, (2) studies with an interventional/experimental study design, and (3) studies not related to our topics: i.e., studies that did not use neuroimaging markers and studies focused on SCD that was caused by other conditions , studies focused on MCI or dementia populations, studies focused on other risk factors for impaired cognitive function  and studies focused on other topics not related to our aim. After detailed evaluations, 114 studies were included and reviewed. A detailed description of the article selection process is presented in the flowchart  ɛ4 genotype and the presence of biomarker evidence for AD. Recently, two additional SCD plus features were proposed, including consistent SCD over time and seeking medical help because of SCD [The concept of SCD was first introduced in the early 1980s by Reisberg and colleagues to define an early stage of AD and was initially assessed using the Global Deterioration Scale . In recee of SCD . The fraOnly a few longitudinal studies of people with carefully phenotyped SCD have investigated the rate of progression of SCD to dementia due to AD , 14. Witin vivo [11C-Pittsburgh Compound B (PiB) was the first amyloid PET ligand with high affinity for amyloid [18F-labeled ligands  has facilitated their widespread use due to longer half-lives (~110 min) [The advent of PET amyloid tracers allows the quantification of amyloid deposition in vivo –17. 11C- amyloid . Additio110 min) –21. A me110 min) . Accordi110 min) , 24. Fur110 min) –29. Howe110 min) –33. TherIn clinical patients with dementia due to AD, amyloid deposition exhibits a diffuse pattern that initiates from the prefrontal and posterior parietal regions with the highest vulnerability , 35. IntFurthermore, several studies have focused on the clinical features of SCD, such as specific involved cognitive domains, related concerns, and the confirmation of informants, and explored their relationships with the amyloid burden to increase the predictive power of SCD to the underlying amyloid pathology. For example, Amariglio et al. (2012) revealed a significant correlation between scores of the memory and executive subscales of SCD with the amyloid burden . As showRecently, several studies have consistently suggested that higher amyloid aggregation at baseline indicated a faster rate of decline in various cognition domains , 38 and ApoE ɛ4 genotype and age. Individuals with SCD may present higher allelic frequencies of ApoE ɛ4, and cerebral amyloid levels might be partially predicted by the ApoE ɛ4 level [ApoE ɛ4 carriers with SCD showed higher levels of amyloid accumulation than noncarriers. However, no hypometabolism or atrophy was detected [ApoE genotype, age, and episodic memory [ApoE genotype, age and other potential contributing factors on preclinical AD are complicated and are not completely understood to date. Therefore, additional investigations are needed to clarify the relationship among different risk factors for dementia due to AD.Notably, amyloid deposition in subjects with SCD is also affected by other risk factors for dementia due to AD, such as the ɛ4 level . In anotdetected . Aging idetected  reportedc memory , to furt18F-Flortaucipir [18F-flortaucipir PET and determined that the self-reported memory concern was associated with frontal tau levels, whereas the informant-reported concern was related to parietal tau levels. However, until now, the tau PET studies in individuals with SCD are currently limited. More evidence is needed to further elucidate the association between tau and amyloid pathology and their contribution to SCD and clinical progression.Pathological tau deposition represents another key biomarker of AD , 46. Thetaucipir , allows taucipir , 49. In taucipir . They sc18F-Fluorodeoxyglucose (FDG)-PET has been used to quantify abnormal cerebral glucose metabolism [ApoE ɛ4 [tabolism , 51, 52.tabolism , 54. Thetabolism –57. Howe[ApoE ɛ4 .Moreover, some studies have explored the relationship between regional glucose metabolism and cognitive performance in subjects with SCD. For example, the metabolism in both the left hippocampus and the right amygdala was positively correlated with verbal logical memory immediate recall . FDG-PETBoth cortical and subcortical atrophy develop as AD progresses, making its volumetry one of the most well-established imaging biomarkers of AD . As prefApoE ɛ4 carriers showed more severe atrophy in the left hippocampus [However, during the SCD stage, neuroimaging findings regarding gray matter changes remain mixed. Some studies have observed a decreased hippocampal volume in individuals with SCD both at baseline , 67–74 apocampus  and an apocampus  than nonpocampus . Furtherpocampus –90. In apocampus –94.Interestingly, Peter et al.  used a mUsing brain network modeling methods, a gray matter network can be constructed by calculating the structural covariance between pairs of regions. According to previous studies, gray matter networks of patients with dementia due to AD tend to be more randomly organized with lower clustering coefficients and altered small-world properties –98, suggDiffusion tensor imaging (DTI) has been increasingly applied to investigate microstructural alterations in the WM of patients with a neurodegenerative disease , which mApoE ɛ4 carriers in SCD populations showed lower FA in the splenium of the corpus callosum and the anterior corona radiata [ApoE genotype, K-MMSE recall score and the Seoul Verbal Learning Test. The high-risk group showed more severe microstructural disruptions with reduced FA in the tracts connecting the hippocampus, parahippocampal gyrus, supramarginal gyrus and parts of the frontotemporal lobes [In individuals with SCD, significantly decreased FA and increased MD have been observed in the cerebrum, mainly in the hippocampal body, entorhinal cortex and parahippocampal gyrus, uncinated fasciculi, longitudinal fasciculi and corpus callosum , 109–113 radiata . Anotheral lobes .In contrast to the quantification of local diffusion metrics, other scholars have investigated the topological organization of structural networks underlying SCD with a graph theory analysis. As shown in the study by Shu and colleagues, the SCD connectome exhibited lower global and local efficiency and reduced rich-club and local connections, which were correlated with impaired memory performance in subjects with SCD . AccordiThe relationship between gray matter and WM alterations in subjects with SCD remains largely unknown. Research combining MRI volumetric and DTI measures suggested that individuals with SCD showed a lower entorhinal cortical volume, lower FA and higher MD in the hippocampal body and entorhinal WM . AccordiResting-state fMRI (rs-fMRI) is a noninvasive technique that detects alterations of spontaneous brain activity and interregional functional connectivity (FC) by measuring intrinsic blood oxygen level-dependent (BOLD) low-frequency signal fluctuation. Based on accumulating evidence, the FC of the default mode network (DMN) is selectively disrupted in patients with MCI and dementia due to AD , 130. ThFor subjects with SCD, our group reported a higher amplitude of low-frequency fluctuations (ALFF) of spontaneous brain activity in the left inferior parietal lobule and right middle occipital gyrus and a lower ALFF in the precuneus and cerebellum than in HCs , 135. ThApoE ɛ4 carriers presented a slower longitudinal increase in FC in the frontal lobes than noncarriers [Other studies have focused on the alterations in intrinsic functional networks. Subjects with SCD exhibited higher FC in the retrosplenial cortex and precuneus and lower FC in the frontal-parietal cortex and putative posterior memory system , 137. Ascarriers . OverallTask-based fMRI has been widely used to explore changes in functional activity during different cognitive tasks by examining the changes in BOLD signals. Medial temporal lobe hypoactivation, parietal hyperactivation, and frontal hyperactivation during memory tasks have been reported in patients with MCI and dementia due to AD –144. TasIn one study, subjects with SCD showed increased activation in the middle frontal gyrus, the precuneus and the cingulate gyrus relative to HCs during working memory tasks . HoweverApoE ɛ4 allele [Arterial spin labeling (ASL) MRI is a noninvasive technique for quantifying cerebral perfusion that has been implicated as a useful biomarker of the early stages of AD . Patient4 allele , 161 and4 allele  had an aHowever, fewer ASL-MRI studies of individuals with SCD are available. To the best of our knowledge, only two studies have explored the differences in CBF between individuals with SCD and HCs. According to Hays et al., patients with SCD exhibited lower CBF in the medial orbitofrontal cortex and higher CBF in the right putamen than HCs , while dThe results for the relationship between cognition and CBF are also inconsistent. Hays et al. observed negative association between verbal memory and CBF within the posterior cingulate cortex, middle temporal gyrus, hippocampus, fusiform gyrus and inferior frontal gyrus in patients with SCD , while LThese controversial results may be due to the use of different cohorts and image processing methodologies. Hays et al. used voxelwise statistics among community-dwelling older volunteers, and the other two studies focused on defined ROI regions in the Amsterdam Dementia Cohort. In summary, ASL-MRI has vast potential as a biomarker of SCD, but additional studies using this modality are needed Table .Table 3Electroencephalography (EEG) and magnetoencephalography (MEG) are noninvasive techniques that record the electrical activity and magnetic fields generated by neuronal activity in the brain, respectively. During the last few decades, many studies have investigated the alterations in EEG and/or MEG signals in patients with MCI and dementia due to AD and have reported slowing brain rhythms and abnormal FC in the patients –169.While the advanced stages of AD may be associated with functional disconnection , earlierUsing MEG, researchers have observed a significant alteration in spontaneous alpha activity in elderly participants with SCD, and this alteration was related to a decrease in cognitive performance . An incrOverall, the aforementioned evidence supports the hypothesis that EEG/MEG measures play important roles in detecting early functional brain alterations in individuals with SCD and may serve as early imaging biomarkers of AD initiation Table .Table 4Multimodal neuroimaging techniques combing PET and MRI have been used with increasing frequency to improve our understanding of the pathological interactions underlying SCD due to AD . AbnormaRegarding the relationship between amyloid and functional alterations, several studies have presented diverse results. Chiesa et al. described an association between a greater amyloid load and reduced posterior basal forebrain resting-state functional connectivity (RSFC) in the hippocampus and thalamus . Li et a18F-florbetapir PET) and neurodegeneration status (based on FDG-PET). The results demonstrated that in neurodegeneration-positive subjects, amyloid burden was related to delta power following a U-shaped curve and related to other EEG metrics, such as gamma power, spectral entropy, and complexity, following an inverted U-shaped curve [Multimodal studies involving EEG have indicated that the slowing property detected with EEG was related to white matter lesions (WMLs) and medial temporal atrophy (MTA), but not to the amyloid load , 188. Gaed curve .Tau protein deposition is regarded as another critical pathological biomarker of AD. However, the complicated relationships between amyloid, tau, neurodegenerations and cognitive decline are not clearly understood. Studies using amyloid PET and tau PET have coincidentally suggested that both tau protein and amyloid pathology contributed to the manifestation of SCD , 191. SpIn longitudinal studies using FDG-PET and MRI modalities, the longitudinal reduction in cognitive performance was associated with brain hypometabolism in the precuneus at baseline, but not with gray matter atrophy . SpecifiApoE ɛ4 allele are important factors influencing cognition. However, the distributions of these demographics are highly variable. (c) Methodological differences in the acquisition of parameters and the quantification methods  may also be factors producing some inconsistencies in the results, indicating that the interpretations and comparisons of these findings should be viewed with caution. However, despite the existence of these influencing factors, most studies included in the current review still described some common neuroimaging alterations in individuals with SCD.The inconsistent and heterogeneous neuroimaging findings in SCD may result from several factors: (a) The use of different diagnostic criteria and assessment strategies for SCD may be a factor contributing to the heterogenous findings. Although unified research criteria for SCD have been proposed by SCD-I, it has not been universally used. The evaluation and classification measurements of SCD vary among investigations, including both qualitative methods (SCD/no SCD based on binary questions) and quantitative measures ) (b) Variations in the demographics of the cohorts, both within and across studies, may be another influencing factor. Converging evidence has suggested that demographic characteristics such as age, sex, education level and the presence of the Longitudinal research in this field is still limited. Most of the studies investigating the neuroimaging changes in individuals with SCD often employ a cross-sectional design in which neuroimaging measures are compared between individuals with SCD and HCs. However, this commonly used design does not account for the differences in individual trajectories of brain changes. Longitudinal studies including follow-up scans enable the assessment of individual trajectories of brain changes and the identification of AD pathology in subjects with SCD. Additionally, longitudinal studies facilitate the investigation and validation of causality between pathological markers and emerging neurodegeneration and cognitive decline. Importantly, longitudinal designs allow researchers to explore biomarkers for the early prediction of disease conversion by investigating the subsets of patients with SCD who ultimately progress to dementia due to AD.It is encouraging to learn that multiple international neuroimaging projects investigating dementia due to AD or preclinical AD are collecting data via longitudinal designs. Specifically, the ADNI database, an integral part of a multisite longitudinal study, is collecting multimodal imaging data  and has started adding an SCD group from ADNI-2 . MEMENTODifferent neuroimaging techniques have captured different aspects of the brain abnormalities involved in SCD to help reveal its multimodal signature. However, no single-modality imaging method is currently able to accurately characterize the pathological mechanisms underlying the full spectrum of SCD. Thus, the increasingly utility of multimodal neuroimaging technology provides an opportunity to determine the complicated relationships between amyloid, tau and downstream neurodegenerative pathologies occurring in the AD process. For SCD populations, several studies combining multimodal neuroimaging techniques such as PET and MRI have recently been conducted. However, the complicated relationships between distinct pathological biomarkers, such as amyloid, tau, and macroscale structural and functional brain alterations during the SCD stage, from local to connectivity level changes, still remain largely unexplored. More multimodal imaging studies are urgently needed to understand the interactions between different pathological changes in the early stage of AD.Additionally, newly developed molecular tracers, imaging sequences and ultrahigh field MRI techniques, such as the use of 7-T scanners, will be helpful to detect more subtle alterations in the early stage of the disease and should be applied to further investigate SCD populations.Artificial intelligence, such as machine learning and deep learning, offers a systematic approach to developing sophisticated, automatic, and objective classification frameworks for analyzing high-dimensional data. Additionally, artificial intelligence techniques are able to learn complex and subtle patterns of change across various imaging modalities . Over thIn this review, we have provided a comprehensive summary of the molecular, structural and functional brain alterations of individuals with SCD related to AD investigated at different scales, ranging from regional to large-scale network-based imaging measures.We collected consistent results from the articles included in this review and summarized the shared neuroimaging changes observed in individuals with SCD in the context of AD, as shown in Fig. In conclusion, the pathological alterations underlying the manifestation of SCD are parallel to those underlying MCI and dementia due to AD based on the results obtained using neuroimaging techniques, supporting the notion that SCD represents an early precursor of dementia due to AD. While cognitive function is preserved, early detection of SCD is imperative to ensure that patients will benefit from early intervention and obtain the appropriate treatment in a timely manner. In the future, with additional validation studies of larger samples and longitudinal studies, the combination of multimodal neuroimaging techniques may help identify SCD individuals presenting with early AD pathologies who may be eligible for clinical trials for the early detection and secondary intervention of AD.


In this literature review, the antipathogenic properties and contact-mediated antibacterial and antiviral performance of copper cold spray surfaces are assessed and compared with alternative antimicrobial materials that are able to kill and/or inactivate infectious agents via direct contact. Discussion is also provided concerning the suitability of copper cold spray material consolidations as biocidal and viricidal surfaces that retain long-term functionality as a preventative measure against fomite transmission of pathogenic agents and hospital-acquired infections from contaminated high-touch surfaces. Numerable alternative antimicrobial coatings and surfaces that do not rely upon the oligodynamic action of copper are detailed. Given the ongoing need for recognition of said alternative antimicrobial materials by authoritative agencies, such as the U.S. Environmental Protection Agency, the relevant literature on non-copper-based antipathogenic coatings and surfaces are then described. Furthermore, a wide-ranging take on antipathogenic copper cold spray coatings are provided and consideration is given to the distinctive grain-boundary mediated copper ion diffusion pathways found in optimizable, highly deformed, copper cold spray material consolidations that enable pathogen inactivation on surfaces from direct contact. To conclude this literature review, analysis of how copper cold spray coatings can be employed as a preventative measure against COVID-19 was also presented in light of on-going debates surrounding SARS-CoV-2’s non-primary, but non-negligible, secondary transmission pathway, and also presented in conjunction with the inevitability that future pathogens, which will be responsible for forthcoming global pandemics, may spread even more readily via fomite pathways too. Some have argued that the basic ideas underpinning cold gas-dynamic spray (cold spray) pre-date the conceptualization, research, and formalization that was performed by Papyrin et al. in the late twentieth century ; howCold spray processing parameters vary, from the type of material used to construct the nozzle to the selection of the powder composition and the gas source. Normally, inert gases are used, such as helium or nitrogen. Feedstock particulate systems for cold spray typically maintain a diameter range of approximately 10 μm to 100 μm. Particles reach velocities between 300 m/s and 1200 m/s. A wide range of materials may be cold sprayed, which include composites, copper, aluminum, steel, and titanium, and are selected according to the requirements of a given application. There are a significant number of properties that can influence the high strain rate impact induced and deformation-driven bonding, ranging from the feedstock morphology and powder size distribution to carrier gas type, temperature and pressure, as well as deposition efficiency, applicator design, and nozzle type. These are further compounded by traditional manufacturing factors like traverse speed, step size, etc. Keeping the aforementioned in mind, Fig. As an antimicrobial coating application, cold spray can be deposited onto various substrate materials at various processing temperatures and pressures, thus allowing for exceptionally high versatility in applications. Additionally, because cold spray can be deposited through computer-generated pathways mounted on a robotic arm or as a handheld applicator, generating highly antimicrobial, or functional surfaces on preexisting parts is a highly feasible opportunity for improvement to both new and preexisting parts regardless of geometry. Reemergence of copper as an antimicrobial touch surface application was investigated by Dick et al. at Battelle Columbus Laboratories . Since tFrom an experimentally minded vantage point, Champagne et al. evaluated the antimicrobial capabilities and properties of three uniquely procured copper coatings. Each of the three aforementioned copper coated surfaces were manufactured by way of three thermal spray-based material processing techniques . More spStaphylococcus aureus (MRSA), was selected as the infectious agent of interest for proof-of-concept exploration. Antimicrobial efficacy evaluation was pursued by way of inoculating MRSA on the three copper coated and thermally sprayed surfaces. Thereafter, the inoculated specimens were held for 2 h at room temperature and under standard ambient conditions. Then, the bacterial cells that survived the direct exposure to the copper coated surfaces were cultured in a manner consistent with the EPA protocol of relevance known as “Test Method for Efficacy of Copper Alloy Surfaces as a Sanitizer.” Ultimately, the resultant percent of surviving MRSA after 2 h of exposure time to the three thermal spray copper coatings was consistent with their assertation that differences in biological activity would follow from the differences in microstructures associated with each thermally sprayed surface. While the plasma sprayed surface killed less than 90% of the exposed MRSA after 2 h, the cold sprayed copper killed more than 99.999% of the bacterial agent after the same duration of time .Once the plasma sprayed, arc sprayed, and cold sprayed copper coatings were structurally inspected via microscopy-based methods following successful deposition, Methicillin-resistant Cobetia marina binding to the available surfaces submerged as part of the maritime ships of interest  on it and then touching their own mouth, nose, or possibly their eyes” according to an interpretation distributed by the CDC in May 2020 . Prior tThe environments that house a notable concentration of high-touch surfaces include nursing homes, medical facilities, active public transportation, and schools, and have developed into focal points for the spread and transmission of the SARS-CoV-2 virus during the current COVID-19 pandemic. By way of refurbishing said surfaces within environments that house the greatest concentration of fomite transmission focal points in the most vulnerable and hard-hit geographies with such antiviral copper cold spray coatings, the functionalized material consolidations would contribute to the alleviation and inhibition of SARS-CoV-2 infection. Distinctive copper coating manufacturing processes accomplish variable sterilization rates, even when feedstock materials of the same composition are consumed during antimicrobial surface generation. Copper coatings deposited on a traditional hospital-grade surface via cold spray kill bacteria and inactivate viral pathogens with commendable speed. As a controllable and versatile coating technology, cold spray is especially appropriate for covering hospital equipment and vulnerable touch surfaces found in clinical settings. In fact, the materials science community has also started to advocate for the antipathogenic functionalization of common touch surfaces in public areas through the use of copper in the fight against COVID-19 too –59.


Obstructive sleep apnea (OSA) is a common condition, and if not treated can be a significant risk factor for multiple comorbidities like hypertension (HTN), coronary artery disease (CAD), and congestive heart failure (CHF). The underlying pathophysiology involves coagulation and inflammatory pathways, including an overactive sympathetic nervous system. This ultimately causes hemodynamic changes and subclinical myocardial injuries. We reviewed the published literature about the impact of continuous positive airway pressure (CPAP) when used as a mode of treatment to reduce the OSA effects on cardiomyocytes. We found that the results were mixed, including both ill and good effects. The cardiac markers like N-terminal pro-brain natriuretic peptide (NT-proBNP) and atrial natriuretic peptide (ANP) were reduced, implying the decrease in the incidence of heart failure with CPAP treatment in a few of the studies. They also proved a significant decrease in harmful cardiovascular (CV) outcomes, while others concluded that CPAP therapy might be stressful on the heart, causing an elevation in cardiac troponin T levels. However, the impact on inflammatory markers is still indeterminate and needs more research in future. Obstructive sleep apnea (OSA) occurs when the soft tissue muscles of the oral cavity like tongue and soft palate relax temporarily and fall back causing narrowing of the airway. Untreated OSA was found to be a significant risk factor for many comorbidities like arterial hypertension (HTN), congestive heart failure (CHF), coronary artery disease (CAD), myocardial ischemia (MI), atrial fibrillation (AF), and ventricular tachycardia. Coagulation pathway and inflammatory pathway abnormalities, overactive sympathetic system, vascular endothelial dysfunction, and metabolic dysregulation are most likely the underlying pathophysiological mechanisms involved . OSA leaRecent studies have established a relationship between OSA and the following key biomarkers: a) endothelin-1 (ET-1), a marker of endothelial dysfunction; b) high sensitivity troponin T (hs Trop-T), a marker of myocardial injury; c) high-sensitivity C-reactive protein (hs-CRP), a marker of inflammation; d) cardiac neurohormone N-terminal pro-brain natriuretic peptide (NT-proBNP), a marker of ventricular strain, and e) fibrinogen, a marker of hypercoagulation . SeveralMultiple underlying pathophysiological mechanisms are involved in the development of various CV problems, like systemic or pulmonary HTN, heart failure (HF), and renal disease in OSA patients. A detailed picture illustrating the connections between these pathological processes and the resultant outcome is shown below in Figure Cardiac biomarkersThe impact of CPAP on different cardiac biomarkers is variable. The natriuretic peptides like atrial natriuretic peptide (ANP) and BNP levels are elevated in cardiac failure due to a stretch on the ventricular walls. An observational study done in 2008 by Kita et al. showed a reduction in natriuretic peptide levels with nasal CPAP usage overnight . The resWhen the effect of CPAP was observed for a more extended period, changes in blood pressure and ventricular wall remodeling were noticed. Colish et al. conducted a study on cardiac remodeling by assessing cardiac biomarkers, echocardiography, and cardiac MRI at intervals of three months, six months, and 12 months . It provChang et al. conducted a randomized controlled trial whose results were similar to the observational studies mentioned above . CPAP thEvidence LevelThese studies show that the natriuretic peptides like ANP and BNP are markedly reduced irrespective of the duration of CPAP therapy. Thereby, a decrease in the incidence of HF is evident. However, there was not much effect on the myocardial ischemic biomarker, the highly sensitive troponin T (hs trop-T), which even increased at times. This, however, might be related to the cardiac stress that is associated with CPAP usage.Cardiovascular outcomesIncreased myocardial oxygen consumption and decreased oxygen supply in OSA are the main reasons for the nocturnal ischemia. Peled et al. found that these ischemic events could be minimized by a combination of CPAP treatment and medical therapy to control heart rate and elevated blood pressure. In particular, they noticed significantly ameliorated nocturnal ST depression time with CPAP usage . In an oAnother study by Kasai et al. highlighted the prognosis of HF in OSA patients treated with CPAP . They coNocturnal blood pressure fluctuations (NBPF) are frequently seen in patients with CVD and OSA, which is, in turn, associated with the mean value of nocturnal BP and the arterial stiffness. Picard et al. did research and stated that CPAP treatment decreased the frequency of NBPFs, the mean value of the nocturnal BPs, and the arterial stiffness after six months of CPAP therapy . It alsoThe overall incidence of CV deaths in sleep apnea patients reduced significantly with CPAP prescription regardless of the degree of apnea. Many meta-analyses showed an association between CPAP usage and a decrease in composite CV events, all-cause deaths, and CV deaths that were particularly demonstrated only in observational studies and not in randomized trials . AccordiThe outcome of CPAP usage resulting in a reduction in apneic events  is more dependent on the compliance, the time duration, and the effective way of device application. Four multicenter RCTs with 3780 patients reviewed meta-analysis conducted by Abuzaid et al. in 2017 proved that CPAP decreased the incidence of MACE only in a particular subgroup, sleep apnea cardiovascular endpoints (SAVE) study, accounting for 65% of the meta-analysis subjects' sample who were wearing it for > four hours. The study also stated that the average CPAP usage was not sufficient to translate into MACE benefits . HoweverAn absolute and relative increase in left ventricular ejection fraction (LVEF), improvement in daytime left ventricular (LV) systolic function in HF patients, in association with a decrease in LV end-systolic dimension, daytime SBP, and heart rate was detected in patients associated with sleep apnea . The lat2), though the underlying mechanism is not clear [In 2010, a traditional review found that CPAP administration was beneficial in terms of improvements in LVEF, blood pressure, heart rate, sympathetic activity, and sleepiness scores in hospitalization and mortality. According to Canadian Continuous Positive Airway Pressure for Patients with Central Sleep Apnea and Heart Failure trial, a physician needs to know whether the apnea is due to OSA or CSA, before prescribing CPAP, as CPAP is not that useful in CSA as in OSA . Later oot clear .OSA is considered to have an impact on vascular endothelial design and hence is attributed as a sole, additional, or even synergistic risk factor for CVD along with multiple genetic and physical characteristics in both population- and clinic-based studies. Celen et al., by conducting a traditional review, found that CPAP reduced daytime sleepiness, improved quality of life, and in the prognosis of CVD in clinic-based cohorts only . HoweverEvidence LevelAccording to our review, all observational studies showed the beneficial side of the CPAP usage in terms of cardiovascular function like improvement in heart failure, hypertension (HTN), post-CABG patients, and CV deaths, while in clinical trials, the usefulness of CPAP was detected only when the patients used it for at least four hours a day for at least one year.Inflammatory markersThe inflammatory marker, hs CRP, is a serum biomarker of CV injury. A study conducted by Zhao et al. in the year 2011 in Chinese patients with CAD on medications found that hs CRP is independently related to OSA, which shows an association between inflammation and OSA. This elevated hs CRP can be reduced with CPAP management . Randomized Intervention with CPAP in Coronary Artery Disease and Sleep Apnea (RICCADSA) trial experimented by Thunström et al. to prove the CPAP effects on inflammatory markers because of the association between non-sleepy OSA and vascular inflammation in CAD patients is evident . The stuEvidence LevelTo date, hs CRP is considered a better marker for both inflammation and atherosclerosis together . In our LimitationsWe didn't include animal studies to find the CPAP effects on heart cells. We excluded other language studies except for English. We also couldn't observe whether CPAP is beneficial in pediatric and geriatric groups.In this review article, we explored both positive and negative effects of CPAP on the CV system. The impact of CPAP therapy on cardiomyocytes is reflected in the form of changes in cardiac biomarkers like ANP, NT-proBNP (reduced), and highly sensitive troponin C  in OSA patients associated with CVD when compared to patients with OSA alone. While considering the CV outcomes, the results varied based on the type of study conducted. Most of the studies showed that CPAP had positive consequences in terms of improvement in CV events, whereas according to some RCTs and reviews, the results were mostly linked to proper compliance to the CPAP therapy. However, the evidence showing benefits of CPAP usage on inflammatory markers like hs CRP and IL 6 (which serve as a connection between inflammation and atherosclerosis) is inconclusive. Further research is needed to explore the use of CPAP as a sole treatment to reduce the ill effects of sleep apnea on cardiomyocytes.