Several anatomical variations concerning the median nerve have surfaced in the medical literature. Among them, bifid median nerve or median nerve bifurcation with or without persistent median artery has been widely reported. Sporadic case reports describe median nerve trifurcation (trifid median nerve) as well. In the present report, we describe carpal tunnel syndrome manifestations in association with trifid median nerve unveiled incidentally under high-frequency musculoskeletal ultrasonogram in a lactating mother-a first in the medical literature. The median nerve is one of the most important branches of the brachial plexus and supplies the wrist and two-third radial aspect of the volar hand. Its sensory supply reaches the hand going over the flexor retinaculum, whereas motor division passes underneath the retinaculum, except in some anatomical variations . More thA 30-year-old woman on postnatal care presented with the complaint of pain, tingling, numbness sensation according to the distribution of the left median nerve. The complaints were more while using hands, including caring for her baby and performing other usual daily chores. Sometimes the pain ascended retrograde in the left forearm, though she denied any radiating neck pain. Because of the nocturnal rise of the symptoms, the patient had disturbed quality of sleep. We examined the patient’s hand and wrist. Positive Tinel’s at the carpal tunnel, Phalen’s and reverse Phalen’s maneuvers at wrist favored a CTS diagnosis. There were no thenar and hypothenar muscles wasting. Her thyroid status was normal. She was non-diabetic and had no inflammatory joint disorders either.Considering the above information, further scrutiny of the carpal tunnel under MSUS was planned. Oval-shaped, ovary-like median nerve morphology was found distorted, and the nerve was seen split into three divided hypoechoic segments, encircled within a hyperechoic sheath Figures , 1B. Dia2/minute for 15 minutes). At her second visit, symptoms were found improved by approximately 50%. She was also advised how to adopt side-lying and foot-ball hold position while participating in baby care.The condition was treated with diclofenac potassium (50 mg twice daily for three weeks) and the local application of ultrasound therapy over the flexor retinaculum for two weeks  and nerve conduction study (NCS) is useful in delineating CTS and adjacent nerve anomalies ,8. SurgiIn the present study, high-frequency MSUS depicted three variably-sized hypoechoic median nerve masses encircled within a hyperechoic sheath. There was no persistent median artery among them. Sizes of the bifurcated nerves are mostly similar; however, their sizes could vary, and the same could occur for trifurcated median nerve as well. In their published works, Yalcin et al. and Rayegani et al. described similar ultrasonographic cross-sectional areas (CSA) for the trifurcated nerve portions at the carpal tunnel ,8. HowevTrifid median nerve has already been described in limited cases. Alongside some above mentioned clinical features, the present study further differs from the previous cases based on the breastfeeding status. Pregnancy and breast-feeding are associated with increased CTS prevalence ,12. The Carpal tunnel syndrome in breastfeeding women can be treated using the following interventions - oral anti-inflammatory drugs, vitamin-B combination, diuretics, intralesional steroid injection, splinting, local ultrasound and laser therapy, however, sometimes, surgical exploration of the carpal tunnel is required to release the compressed median nerve . Here weTo sum up, trifurcation of the median nerve is a rare clinical scenario. As Lanz classification appears inappropriate in accommodating trifid median nerve, revising it or launching a new criterion to classify median nerve anomaly seems rational. To the best of our knowledge, this report is unique in describing carpal tunnel syndrome in association with the trifid median nerve in a lactating mother. When planning the treatment of carpal tunnel syndrome, the possibility of a trifid median nerve in the compromised carpal tunnel should be kept in mind. Since a single case report does not make everything crystal-clear about the disorder, extensive research on various aspects of the trifid median nerve is warranted.


Crop yield improvement is necessary to keep pace with increasing demand for food. Due to climatic variability, the incidence of drought stress at crop growth stages is becoming a major hindering factor to yield improvement. New techniques are required to increase drought tolerance along with improved yield. Genetic modification for increasing drought tolerance is highly desirable, and genetic engineering for drought tolerance requires the expression of certain stress-related genes. Genes have been identified which confer drought tolerance and improve plant growth and survival in transgenic wheat. However, less research has been conducted for the development of transgenic wheat as compared to rice, maize, and other staple food. Furthermore, enhanced tolerance to drought without any yield penalty is a major task of genetic engineering. In this review, we have focused on the progress in the development of transgenic wheat cultivars for improving drought tolerance and discussed the physiological mechanisms and testing of their tolerance in response to inserted genes under control or field conditions. Triticum aestivum L.) is one of the most important cereal and staple food crops worldwide, mainly grown in semiarid and arid regions of the world where water scarcity is causing severe yield losses [−1 to 5 t ha−1 by 2050 to feed a population of 9 billion [Bread wheat  and Zea mays (maize) for drought tolerance have been developed and approved. However, despite continuous research, less progress has been made for the development of transgenic wheat as compared to other staple crops like rice and maize which might be ascribed to the complex genetic characteristics of wheat [Drought tolerance is a complex quantitative polygenic trait controlled by a large number of genes and thus, it is difficult to understand the molecular and physiological mechanisms ,12. Untiof wheat .Although transgenic plants have a potential to transform agriculture, limited progress has been achieved, particularly for wheat where no drought-tolerant transgenic wheat has been approved for commercialization . The firHaHB4) from Helianthus annuus (sunflower), which belongs to homeodomain-leucine zipper family (HD-Zip I), and had increased water use efficiency and yield. Transgenic wheat carrying a GmDREB1 gene from soybean, under a ubiquitin promoter, showed drought tolerance [The task of the successful generation of transgenic plants is not only limited to the success in the transformation process but also to properly incorporate the stress tolerance. The proper understanding of physiological effects of the inserted gene and evaluation of transgenic plants under stress are major challenges. After controlling and inserting ‘single-action’’ genes, the regulatory mechanism of transcription factors has emerged as a new tool for controlling the expression of many stress-responsive genes. González et al.  reportedolerance . One maiolerance . The othThis review focuses mainly on the recent studies of genes involved in physiological or biochemical processes which have been used successfully in the genetic engineering of wheat for improvement of drought tolerance (summarized in Table 1). Furthermore, we will discuss recent successes and limitations in the application of genetic manipulation to increase drought tolerance in wheat.Numerous genes have been isolated from various plants and inserted in transgenic wheat to induce stress resistance. These genes could be classified into two groups. The first group is genes involved in cellular protection including osmoprotectants, membrane stabilization, detoxification, and transport proteins. The genes in the second group are the transcription factors and signaling molecules .These osmoprotectants are the favorite targets for genetic engineering and many crops are genetically engineered using osmoprotectants, like glycine betaine, mannitol, and trehalose to increase tolerance by protecting important macromolecules. The higher accumulation of these compounds by transferring genes in transgenic wheat plays a critical role in improving drought tolerance . Higher Solanum tuberosum L.) [Nicotiana tabacum) [1-pyrroline-5-carboxylate synthase) enzyme, which then reduces to proline. P5CS is a rate-limiting enzyme for the synthesis of proline by feedback inhibition of P5CS [Proline is a well-known proteogenic amino acid which acts as a compatible osmoprotectant and accumulates under osmotic stress to protect cellular structure and function ,23. Proltabacum) . In plan of P5CS .Vigna aconitifolia under stress-inducible AIPC promotor. Transgenic wheat plants were exposed to 14 days of water withholding at the booting stage. Transgenic plants showed 50% intact cellular membrane as compared to wild type with 13% intact membrane. The enhanced tolerance to water deficit was mainly due to improved antioxidants also manifested with less MDA contents, rather than the enhanced osmotic adjustment. Pavei et al. [2 generation containing the p5cs gene, and transgenic plants produced 1.85 times more proline after 8 days of water stress content than non-transgenic showing the overexpression of the p5cs gene. However, MDA contents were not decreased in transgenic plants which indicated that despite higher proline accumulation, cell membrane protection against oxidative stress was not increased.Vendruscolo et al.  used thei et al.  evaluatebetaA) involved in the synthesis of glycine betaine, have been inserted into transgenic plants [Glycine betaine is a quaternary ammonium compound and is known to have a protective role against drought stress by maintaining osmotic balance and protecting quaternary structures of proteins . Variousc plants ,31,32. Tc plants ,34. TranAtriplex hortensis showed higher betaine aldehyde dehydrogenase activity [6 transgenic wheat line overexpressing the BADH gene cloned from Atriplex hortensis under maize ubiquitin promoter through the microprojectile bombardment method. Transgenic and wild type (Shi 4185) were exposed to osmotic stress at −1.88 MPa using 30% PEG and results indicated that transgenic plants overexpressing glycine betaine led to increased photosynthesis by improving water status and antioxidant activity. In the second study, T6 lines of transgenic wheat plants were exposed to drought (78–82% relative water content) by controlling irrigation [betA gene-encoding choline dehydrogenase under maize ubiquitin promoter [The wheat plants naturally accumulate glycine betaine, but the in-vivo level is too low to maintain the osmotic balance under drought stress ,33. Tranactivity . Wang etactivity  generaterigation . Transgepromoter . TransgemtlD gene from Escherichia coli in tobacco [Oryza indica) [Arabidopsis thaliana) [Arachis hypogaea L.) [mtlD gene transformed from Escherichia coli caused the accumulation of mannitol in transgenic wheat [Mannitol is sugar-alcohol, which serves as a major carbon source and has a role in osmoregulation as a coenzyme regulator and scavenging of reactive oxygen species. Mannitol is widely distributed in various plant species . Transge tobacco ,38, rice indica) , arabidohaliana)  and peangaea L.)  demonstrgaea L.) ,42. Wheaic wheat . Moderatic wheat . Transgeic wheat .S) are important bacterial genes for bacterial acclimatization to low temperature and drought stress. CSPS genes conferred resistance to drought stress and improved grain yield in maize under drought conditions [Escherichia coli. Transgenic wheat lines with SeCspA showed enhanced tolerance with lower water loss, less wilting and MDA content, and higher proline, chlorophyll content, 1000-grain weight, and grain yield compared to non-transgenic under drought stress. Transgenic lines with SeCspB showed no such improvement under field condition. Seven-day-old seedlings were exposed to severe water deficit and the recovery rate of SeCspA transgenic plant after re-watering was significantly higher than the non-transgenic plants [Bacterial cold shock proteins (CSPnditions . Yu et anditions  (2017) cc plants .HVA1 gene in rice [OsLEA3-1 in rice [HVA1 in spring wheat [Late embryogenesis-abundant (LEA) proteins are hydrophilic and are induced by drought, salt, and ABA. LEA acts as a molecular chaperone protein by stabilizing the protein or membrane structure. HVA1 is an ABA-inducible LEA protein which is naturally accumulated in the aleurone layer of barley under seed desiccation . Transge in rice  OsLEA3-1 in rice , and HVAng wheat  enhancedHVA1 gene, which is a group-3 LEA protein, indicated the potential of the HVA1 gene to enhance the tolerance to water deficit stress [HVA1 gene transformation in transgenic wheat and its constitutive expression much improved the drought tolerance in terms of higher dry mass accumulation, WUE and higher cell integrity under moderate water deficit conditions in greenhouse tests [HVA1 transgenic wheat using T4 progeny of six transgenic lines and two new lines. Substantial variability was found for transgenic lines and coincided with the expression rate of HVA1 transgene. Line 111/1 showed higher yield and biomass than the wild type, and in sixth season, the yield of new transgenic lines (765 and 1201) increased more than in line 111/1 and wild type. Higher relative water content was observed in lines with higher expression of the HVA1 gene which shows the potential of the HVA1 gene to confer drought tolerance.Transgenic wheat over-expressing t stress ,49. The se tests . After t2O2 contents were lower under 10% PEG.Transporters genes play an important role in restoring ionic homeostasis under stress. Ferritins are iron-storage proteins which sequester and release iron when needed. Ferritins are highly conserved in plants with two genes in hexaploid wheat on chromosomes 4 and 5 . Previou4 enzymes genes is also a promising approach to increasing the yield and photosynthesis rate of C3 plants like wheat. Transgenic wheat plants over-expressing C4 enzymes, PEPC (phosphoenolpyruvate carboxylase) and PPDK (pyruvate orthophosphate dikinase), showed a significant positive effect on photosynthetic traits and yield [Transforming Cnd yield . Later, nd yield . TransgePlants induce the expression of various transcription factors to cope with environmental stresses. Then the transcription factors up or down-regulate the expression of series of genes by binding with the enhancer or promoter region of the gene with DNA-binding domains ,55,56. STaDREB1 is a DREB2-type transcription factor induced by drought and other abiotic stresses [TdDRF1, has been isolated from durum wheat and is characterized to be involved in drought tolerance [Dehydration-responsive element binding (DREB) transcription factors have been reported to enhance drought tolerance in transgenic wheat ,63. In wstresses . Likewisolerance .DREB1A gene were produced at CIMMYT and were tested in small pots under greenhouse [DREB1A gene of Arabidopsis thaliana was transferred into bread wheat under the control of the stress-inducible rd29A promoter. Transgenic wheat plants expressing the DREB1A gene demonstrated substantial resistance to water stress as compared to wild type under greenhouse conditions, as manifested by delayed wilting and leaf bleaching after withholding water. On the other hand, the non-transgenic plants were dyed after 15 days of holding water [AtDREB1A transgenic plant is achieved by increasing the relative water content, chlorophyll, sugar, and proline contents as compared to non-transgenic plants [Wheat transgenic plants with the eenhouse . DREB1A ng water . The higc plants .GmDREB gene of soybean into wheat by bombardment. Transgenic wheat plants using ubiquitin and rd29A promoters showed normal growth and higher drought resistance than the wild type. Furthermore, some transgenic seeds germinate at 18% PEG6000 solution where all seeds of wild type could not even germinate. Pierre et al. [DREB1A gene as described by Pellegrineschi et al. [DREB1A gene increased the survival rate and water use efficiency. Therefore, it might be possibly assumed that high-yielding transgenic wheat lines could be achieved by adequate screening and transformation protocols.Shiqing et al.  transfore et al.  conductei et al. . ResultsGmDREB1 transgenic wheat line using deep sequencing and bioinformatic techniques. They found that 23 miRNAs were found differentially expressed in transgenic wheat seeds. The variations between transgenic and non-transgenic wheat lines were higher than which was induced by transgene.Jiang et al.  investigThe WRKY proteins form one of the largest families of transcription factors in plants, characterized by their WRKY domain of about 60 amino acids. WRKY acts as a repressor or activator and regulate various plant growth processes as well as abiotic and biotic stress responses . VariousTaWKRY genes were detected and the expression of all the quantified TaWRKY transcripts was found to be up-regulated in the roots of drought-tolerant wheat under drought. Gao et al. [TaWRKY2 gene contributes to drought tolerance as indicated by lesser water loss and higher survival rate as compared to wild type and also of spring wheat. In addition, the transgenic TaWRKY2 wheat had a higher yield and higher chlorophyll, proline, and sugar contents [Okay et al.  investigo et al.  cloned tcontents .HDG11, a transcription factor belongs to the HDZip IV TF subfamily, was found to induce drought tolerance by increasing the expression of numerous genes responsive to drought, including genes involved in calcium signaling and ABA synthesis pathway [AtHDG11 gene were studied after 30 days of water stress conditions [AtHDG11 not only improved the physiological traits but also increased the yield and exhibited lower water loss rate and stomatal density, while accumulating more proline contents. The activities of antioxidative enzymes, net photosynthesis rate, water use efficiency, and grain yield were higher in transgenic wheat than non-transgenic after drought stress. pathway ,72. Trannditions . TransgeTaSHN1 promoter conferred drought tolerance in transgenic wheat without any yield loss under controlled growth conditions. The overexpression of the TaSHN1 gene in transgenic wheat plants enhanced drought tolerance by changing cuticle composition, effecting cuticle biosynthetic genes and decreasing the leaf stomatal density as compared to non-transgenic plants [Cuticle protects plant from various abiotic and biotic stresses and from water loss. Cuticle biosynthesis depends on various metabolic activities which are regulated by several TFs from different families . SHINE1/c plants .TaNAC69) in wheat. The expression of TaNAC69 genes was highly upregulated in the leaf and root of wheat under drought stress, however, the expression of TaNAC69 gene in roots under normal conditions indicated the involvement of the TaNAC69 gene in root cellular activities [TaNAC69 in transgenic wheat lines induced the enhanced expression of several stress-related genes. Transgenic lines produced more root biomass under PEG-induced dehydration stress [NAC constitutes one of the largest families of transcription factors and is characterized by a highly-conserved DNA binding domain at the N-terminus (NAC domain). Several members of the NAC family have been identified in many plant species and are known to be involved in the regulation of plant response under abiotic and biotic stresses by constitutive expression ,76. Manytivities . Later, tivities  identifitivities . The conn stress .The bZIP transcription factors, characterized by a highly conserved bZIP domain, are composed of the leucine zipper and amino acids. bZIP transcription factors are involved in ABA signaling and plant response to various stresses such as drought. Its overexpression increased tolerance to drought stress . SeveralArabidopsis thaliana to wheat. Overexpression of AtOTS1 in bread wheat improved the drought tolerance of transgenic wheat. Transgenic wheat showed improved growth and delayed senescence under drought by increasing photosynthesis and chlorophyll content.Post-translational modification of small ubiquitin-like modifiers (SUMOylation) is an important mechanism and regulates plant growth and development under stress conditions ,83. SUMOTaPEPKR2) is a highly conserved serine-threonine protein kinase gene and is reported to be induced by heat and drought. Transgenic wheat lines transformed with the TaPEPKR2 gene exhibited enhanced heat and dehydration stress tolerance and higher total root lengths in the presence of 10% PEG than wild type [Protein kinases regulate key aspects of cellular function, including responses to external signals . Phosphoild type .2+ sensor proteins that under unfavorable conditions and drought stress interact with target proteins to transduce signals. CBLs proteins interact with CBL-interacting protein kinase (CIPKs) [TaCIPK genes were overexpressed in wheat under drought, and TaCIPK23 was most responsive. Transgenic wheat over-expressing TaCIPK23 genes showed a higher survival rate under drought stress with a higher accumulation of osmoprotectants, and the expression of drought and ABA-responsive genes was increased.Calcineurin B-like (CBLs) proteins are Ca (CIPKs) . Cui et  (CIPKs)  reportedNF-Y) gene family is involved in various regulatory functions for plant development and performance under stress [Nuclear factor Y  transcription factors into wheat, the plants showed improved resistance to drought but also exhibited undesirable phenotypic characteristics such as reduced biomass and yield ,106.In many previous studies, molecular biologists are screening transgenic plants in small pots under severe water stress applied for few hours or days and injury or survival-related plant responses were induced under the conditions of severe stress, which will be different from the response for a long-term slowly-induced water deficit stress. However, under natural conditions, water deficit stress advances slowly in a gradual manner with the drying of soil and plants under these conditions adjusting the morphological and physiological traits accordingly, like the accumulation of osmolytes to maintain cell hydration . Thus, iMost of the studies which reported the yield increase of transgenic plants were conducted in the greenhouse-controlled conditions  and the Accurate phenotyping is most crucial for drought tolerance and should be selected under suboptimal field conditions in order to draw correct assumptions about the role of the discovered genes towards drought tolerance and their utilization in plant breeding. The selection of phenotypic traits for water use efficiency, osmotic adjustment, root architecture, stomatal conductance, carbohydrates remobilization, chlorophyll contents, and traits related to stay green and delayed leaf senescence will be useful for the improvement of yield under water stress .Furthermore, there are some significant issues related to the cascading effect of the regulatory gene on different genes pathways, such as increased competition due to introgression of a transgene into wild, and the impact of regulatory genes on the environment and human health, which need to be properly addressed .Genetic modification is a promising approach which gives us an insight into the regulatory mechanism by a genetic change of a single or few genes. Recently, some progress has been made by transgenic approaches in identifying the key regulators of drought tolerance in wheat. Transgenic wheat plants with inserted genes such as structural and protected genes of mannitol, proline, glycine betaine, and LEA protein and regulatory genes of NAC and DREB transcription factors are being used for drought tolerance. The first drought-tolerant genetically-modified wheat was developed by the Argentine company, but needs approval for commercial release. After the approval for commercial release, Argentina will be the first country to release genetically-modified wheat engineered for drought tolerance .It is of importance that the tolerance to a specific stress such as water stress be considered with the tolerance to other stresses. Wheat has a complex hexaploid allopolyploidy genome structure. Therefore, future breeding and genetic transformation efforts require the complete information of functional genomics and identification of the functional and structural role of genes involved in tolerance and determining higher grain yield. Some potential genes have been discovered which have not yet been tested in wheat and could be targeted to improve drought tolerance and yield. These potential genes are responsible for allocating sucrose during seed development, recovering from drought stress at the vegetative stage, and signaling genes involved in plant growth regulations. Research is being undergone in Mexico by the International Maize and Wheat Improvement Centre in which genetically-modified wheat inserted with these genes will be studied, and the yield will be determined under drought. Furthermore, genetic variations in wheat genotypes for sucrose allocation will be focused. Hopefully, the new developed drought-tolerant varieties will soon be developed and deployed through exchanging knowledge between research institutes and industries. Some modern and advanced molecular techniques like CRISPR/Cas9 and RNA interference are emerging as new end-products-based regulators in stress tolerance. These approaches could provide a more favorable potential base for future wheat-breeding programs by effective collaboration with traditional breeders. By collaboration and successful introgression of these genetic techniques, the outcome could be translated from laboratory tools to fields.


Tau is a microtubule-associated protein that mainly localizes to the axon to stabilize axonal microtubule structure and neuronal connectivity. Tau pathology is one of the most common proteinopathies that associates with age-dependent neurodegenerative diseases including Alzheimer’s disease (AD), and various Parkinsonism. Tau protein undergoes a plethora of intra-molecular modifications and some altered forms promote the production of toxic oligomeric tau and paired helical filaments, and through which further assemble into neurofibrillary tangles, also known as tauopathy. In this review, we will discuss the recent advances of the tauopathy research, primarily focusing on its association with the early axonal manifestation of axonal transport defect, axonal mitochondrial stress, autophagic vesicle accumulation and the proceeding of axon destruction, and the pathogenic Tau spreading across the synapse. Two alternative strategies either by targeting tau protein itself or by improving the age-related physiological decline are currently racing to find the hopeful treatment for tauopathy. Undoubtedly, more studies are needed to combat this devastating condition that has already affected millions of people in our aging population. One may or may not develop tauopathy lesion even when his/her family members have Alzheimer’s disease or Parkinsonism– sounds like good news because most tauopathy cases are sporadic . However14 nodes. In a micro-scaled connectome, cells in the network undergo amazing morphological changes during neuronal cell differentiation by forming thousands of synapse and multiple dendrites, and these structures are deemed to be dynamic throughout the lifetime [The emergence of an animal brain is the ingenuity of numerous neurons wiring together to form networks that relay and process external and internal stimuli. Our brain comprises an estimated 10~ 100 billions of neurons, and each neuron has hundreds to thousands of synapses that connect to others. In a complex, macro-scaled neuronal network of cortico-cortical pathways, Drs. Olaf Sporns and Patric Hagmann proposed the term “connectome” to conceptualize the comprehensive map of structural connections emerging from the ideas that can be traced back to neuronal connectionism in the early twentieth Century, including studies by Santiago Ramón y Cajal on the microscopic structure of brains , 9. The lifetime . Any matlifetime . It is tlifetime , 14.Here we review what is known about the potential “trans-synaptic Tau spreading hypothesis” in many devastating neurological conditions, especially in age-related disorders such as AD and PD, of both are prevalent with connectomic pathologies  thus refTau was firstly discovered via co-purification of proteins that associate with microtubule from the brain lysate, by Mark Kirschner and colleagues , 26. HumThe role of Tau has extended from stabilizing axonal microtubule to organizing actin microfilament in the synapses , 35. TheSeveral Tau loss-of-function studies in animal models have provided some insights on its role in neurons. The knock-out of tau in mice could lead to defective axonal transport of amyloid precursor protein (APP), intraneuronal iron accumulation, and neuronal loss in the substantia nigra . MoreoveTau is one of the most common proteins involved in different neurodegenerative diseases, and nowadays we use tauopathy to call neurological conditions with the pathogenic involvement of tau aggregates . It is eMAPT gene. Thus, how the normal Tau proteins become dysfunctional and self-assemble into Tau pathology is a mystery. These modifications of Tau are believed to be the culprit of Tau pathogenesis and have been the central area of Tau research for years [Phosphorylation/dephosphorylation2+/ calmodulin-dependent protein kinase II could modify the provisional phosphorylation sites near or in the microtubule-binding motif. These modifications often detach Tau protein from microtubules by which may cause toxicity. Phosphorylation of tau by a subtype of tyrosine protein kinase, including Src family kinases such as FYN [Phosphorylation of Tau protein is always a complicated issue in physiological and pathological states. Phosphorylation and dephosphorylation are the dominant modifications of physiological Tau and may alter its association with microtubules and likely other mechanisms. The 2N4R Tau composes 85 putative phosphorylation sites , in which 17 Thr-Pro (T/P) or Ser-Pro (S/P) motifs are abnormally hyperphosphorylated in the AD and other tauopathy conditions . These mh as FYN . FYN-medh as FYN . Howeverh as FYN . Moreoveh as FYN .Like many kinase-phosphatase substrates, Tau can be phosphorylated by kinases, and their phosphorylation can be reversed by dephosphorylation via phosphatases. Tau protein phosphatases have been identifed like PP2A, PP1, PP2B, PP2C, and PP5 . NotablyTruncationTau protein could be cleaved by caspases at multiple sites including two highly conserved aspartate residues at 314 and 421 (Asp314 and Asp421) . The truAcetylation/deacetylationKXGS preserved in all four repeats. Enzymes like p300 acetyltransferase and NAD+-dependent sirtuin of which functions as deacetylase could act on Tau [The other layer of Tau protein modification is acetylation and deacetylation . Tau hast on Tau . One piot on Tau . Becauset on Tau . Paradoxt on Tau , indicatPatients who suffer from tauopathies rarely bearing mutated or years . The posor years . In thisor years . To dateor years , 58. Furor years . The folThe mammalian brain needs much more energy compared to the rest of the body. When the supply is low, balancing energy expenditure in locals creates a challenge for neurons . Thus, r2O2 and other free radicals, forming a vicious circle to damage macromolecules, including Tau [A cell bargain with its residential mitochondria for proper energy production. As mitochondria generate ATP, they also generate byproducts of reactive oxygen species (ROS) such as superoxide, hydroxyl radical, and hydrogen peroxide . Undoubtding Tau , 86. Tauding Tau –89. ExteAnother plausible pathogenic mechanism linking Tau and mitochondria appears to associate with DNA damage in nuclear and mitochondria. For post-mitotic neurons, although neurons usually would not replicate their nuclear DNA, mitochondrial DNA, however, is continuously replicated . BecauseChristian DeDuve and his colleagues discovered that cells could digest their cytoplasm by lysosomes in states of starvation or stress, and termed lysosomal degradation processes in general “autophagy”  in his seminal work around 1960 . NeuronsAs the autophagy-lysosome pathway has several distinguishable marks, its links to tauopathies have been investigated. Emerging reports have indicated a massive accumulation of autophagic vacuoles and lysosomes in the brain sections from patients with Tauopathies, suggesting a defect of the autophagosome-lysosome pathway that contributes to Tau pathology. Massive autophagic defect rather than too much autophagy induction is associate with axonal and dendritic dystrophy where their compartment integrity was lost , 101. ThUnderstanding the temporal and spatial dynamics of autophagosome formation in the association with pathological Tau accumulation in the dystrophic neurons would be an essential investigation. Furthermore, as the functions of many Atg proteins have been discovered, perhaps the genetic and biochemical approaches on dissecting the link between the induction Atg genes and Tau modifications could address this intertwined problem with a straight answer .C. elegans identified exophers could act as a large vacuole to removing the dysfunctional mitochondria and lysosomes from neurons expressing a neurotoxic, aggregable variant of huntingtin [Additionally, exosomes and exophers are two alternative pathways for the quality control in cells. It has been shown that Tau pathology could spread via the trans-synaptic connections and several potential mechanisms have been proposed, including unconventional protein secretion and exosome-mediated spreading. Several studies using biochemical and ultrastructure anatomical analyses supported that the inter-neuronal Tau propagation might be operated via exosomes from presynaptic neurons, which also hijack the endosomal pathway to penetrate receiving neurons , 107. Thntingtin . It willTauopathy in human is believed to last several decades in prodromal phase with NFT development with no significant clinical symptoms . Axon paThe axonal connectivity of neurons in a mature animal brain is mostly stable in macroscale. However, we do know that neurons can rewire their connections through pruning and regeneration . How neuwww.healthline.com/health/brain-disorders). Functional magnetic resonance imaging (MRI) (www.fmridc.org) and positron emission tomography (PET) in vivo brain imaging could detect functional connectivity imaging and Tauopathy using PHF tau ligands but the longitudinal analysis of changes across the brain associated with age and sex, is not yet common [The diagnose of different neurological disorders rely on patients’ functional disability with the assumption about that the distinct brain lesion could be explained to their anatomical manifestation from medical images . This WldS gene encodes a chimera of Ube4b and nicotinamide mononucleotide adenylyltransferase (Nmnat1); and its expression can suppress axon destruction in neurodegenerative animal models and axotomy [More than 150 years ago, Waller observed that after severing the peripheral axons in frogs, the part of injured axon rapidly degenerate beginning via distal to proximal axon trajectory toward soma. This degenerative pattern is now named Wallerian degeneration . Recent  axotomy . Axon se axotomy , but whywww.alzforum.org/alzbiomarker) [The most significant risk factor for AD and PD is age. It is a mysterious why Tau protein becomes mishehaving that let the aged neurons entering the paths to lure Tau become toxic seed and spread. The cruel and destructive tau seeds propagate and mishehaving breed with normal tau with puzzles of how they sweep through anatomic connectomicsh. Regarding Tau protein deposition, large-scale examinations of normal, pre-symptomatic, and diseased brains revealed that brain associated with tauopathy could develop over several decades, begins Braak I, and progresses to Braak VI stages , 140. Asomarker) , the strhttps://clinicaltrials.gov/ct2/home). These are all anti-Tau vaccines that aim to boost immunogenicity to prevent the seeding of tau aggregation and the potential spreading. The first immunotherapy strategy developed by Axon Neuroscience using AADvac1 vaccine is currently under phase III human trials. This anti-Tau vaccine comprises a synthetic peptide from amino acids 294 to 305 of tau (KDNIKHVPGGGS), which might prevent the residues 306–378 of tau proteins to adapt to beta/beta-helix structure of protofilaments [As of 2017, there are nine Tau-based intervention agents in the pipeline of clinical trials  [+) [+ repletion may benefit DNA repair and decelerate neuron aging process [Although AD and PD are considered as diseases prevalent in the elderly, the initiation of neuron pathology associated with tauopathy in the AD, PD, and other tauopathy-associated neurodegenerative diseases starts early before clinical symptoms are evident (ymptoms) , 142. Duymptoms) –146. Theymptoms) . As an eoms) [+) . NAD+ re process , 150. Th


A 70-year-old male with a medical history significant for long-standing ischemic cardiomyopathy (ICM) and heart failure with reduced ejection fraction (HFrEF) was admitted to the hospital with shortness of breath (SOB) five days after an acute heart failure (HF) exacerbation. He had non-radiating chest pressure now at rest, but without evidence of an acute coronary syndrome (ACS). Diagnostic work-up on readmission included a transthoracic echocardiogram (TTE), which revealed worsening left ventricular (LV) systolic dysfunction with new wall motion abnormalities and an incidental echo density in the LV apex, suggestive of an LV thrombus. These findings were unseen on imaging 20 months prior. The patient was initiated on warfarin to be maintained for three months, and discharged in stable condition after optimization of his anginal symptoms. Cardiac catheterization was not attempted secondary to the patient’s chronic kidney disease (CKD). The incidental finding of an LV thrombus occurred despite compliance with guideline-directed medical therapy of HFrEF and ICM, including adjunctive use of clopidogrel. With the poor survival associated with thromboembolism, the prevention, risk stratification and appropriate therapeutic approach to LV thrombus are poorly delineated in patients with HFrEF in sinus rhythm. Currently, the screening guidelines for the identification of LV thrombus in patients with HFrEF are also unknown. Given mixed evidence regarding prophylactic anticoagulation, we present this case of an incidental LV thrombus found during an episode of acute decompensated HF in the setting of long-standing ICM to emphasize the need to suspect LV thrombus formation after such presentations with closer follow-up for prompt detection and timely treatment. A left ventricular (LV) thrombus is a complication of severe LV systolic dysfunction, most notably secondary to anterior myocardial infarction (MI), chronic heart failure (CHF) and dilated cardiomyopathy -2. The pA 70-year-old Caucasian male with a medical history significant for long-standing ICM with HFrEF (EF = 40% w/ grade I diastolic dysfunction), chronic kidney disease (CKD) stage III B, and hypertension presented to the emergency room (ER) with complaints of acute onset non-radiating exertional chest pressure, orthopnea, and shortness of breath (SOB). Eight months prior, the patient had presented with similar symptoms and was treated medically for an acute exacerbation of his HF (New York Heart Association Class III). Physical examination revealed 2+ bilateral pitting pedal edema and diffuse crackles on lung auscultation. Review of outpatient medications revealed optimized HFrEF guideline-directed medical therapy and the patient endorsed compliance. Initial workup was significant for notable elevations in N-terminal-pro hormone B-type natriuretic peptide (NT-proBNP) (to >4000 pg/mL) and low suspicion of the acute coronary syndrome (ACS) from unchanged electrocardiogram (ECG) findings Figure  and stabHowever, the patient returned to the ER five days after initial discharge with complaints of SOB and similar non-radiating chest pressure now present at rest. He was admitted for observation given persistent chest pain in the setting of significant cardiac history. Diagnostic workup included ECG, which was significant for new T-wave changes in the inferior leads concerning for possible ischemia Figure  and tranThe presence of LV thrombus secondary to severe LV systolic dysfunction (<35%) has been reported at a rate of around 20%, with ICM alone found to be an independent predictor of thrombus formation and thromboembolism . Using tCurrently, the screening guidelines for identification of LV thrombus in patients with HFrEF are unknown. After AMI, it has been suggested that TTE should be performed in patients at high risk for apical LV thrombus (i.e. anterior MI or delayed reperfusion) within 24 hours of admission and consideration of follow up imaging within one to three months . Unlike In the case described, the patient had long-standing ICM of nearly 13 years with associated HFrEF that had been both optimized by revision of his three-vessel coronary artery bypass (CABG) five years prior and medical management. Additionally, the patient’s last TTE, 20 months prior to his presentation, failed to show significant changes in pump function and major wall motion abnormalities since his revision. It is likely that his HFrEF, perhaps in relation to worsening ICM, became refractory to optimized medical management, noted by his initial presentation of acute decompensated HF eight months prior to identifying his LV thrombus. Considering worsening ICM, the patient’s advanced CKD prohibited cardiac catheterization to characterize this further. In this case, repeated cardiac imaging would have provided temporal information regarding the thrombus formation in the last 20 months. Given that ICM is an independent risk factor for LV thrombus formation, in addition to severe LV systolic dysfunction alone with sinus rhythm, it may be that acute decompensated HF, particularly refractory HF requires closer follow-up that is guided temporally. After compensation of the patient’s exacerbation occurring eight months prior, cardiac imaging would not only have been helpful to identify an LV thrombus, it would have assessed worsening and permanent wall motion abnormalities  associated with increased risk for its formation. In the patient’s subsequent course described, these were found with the incidental identification of the LV thrombus. While the patient was scheduled for outpatient follow-up for echocardiography after the first admission detailed, the detection of his LV thrombus would remain incidental to the concern of worsening ventricular function. Additionally, only a 42% utilization rate was noted by Goyfman et al. with follow-up echocardiogram performed during an index admission for acute decompensated HF in the setting of medication noncompliance where such risk is higher . IrrespeWith the poor survival associated with thromboembolism, the prevention, risk stratification and appropriate therapeutic approach to LV thrombus are poorly delineated in patients with HFrEF in sinus rhythm. We present a case of an incidental LV thrombus found after acute decompensated HF in the setting of long-standing ICM and HFrEF to emphasize the need to consider LV thrombus formation in such patients with close follow-up. Likewise, without evidence for prophylactic anticoagulation, identifying patients at highest risk of LV thrombus formation will refine guidelines for cardiac imaging to increase the prompt detection and treatment of these patients to thereby prevent fatal thromboembolism.


To evaluate the prognostic effects of combining serum circulating tumor cells (CTCs) and squamous cell carcinoma antigen (SCC-Ag) levels on patients with locally advanced cervical cancer treated with radiotherapy.Ninety-nine patients with locally advanced cervical cancer ([FIGO] stage IIB-IVA) undergoing radiotherapy (RT) or concurrent chemoradiotherapy (CCRT) were identified. The association between serum CTC level and clinicopathological parameters was examined. Univariate and multivariate survival analyses were performed by using Cox’s proportional hazards regression model.Elevated CTC and SCC-Ag levels were significantly associated with poor disease-free survival (DFS). Multivariate analysis suggest that serum CTC level, FIGO stage and serum SCC-Ag level were independent prognostic factors for two-year DFS. When CTC and SCC-Ag levels were combined into a new risk model to predict disease progression of cervical cancer patients, it performed a significantly better predictive efficiency compared with either biomarker alone.Serum CTC and SCC-Ag levels are potentially useful biomarkers for prediction of prognosis in locally advanced cervical cancer patients and their combination significantly improves predictive ability for survival in locally advanced cervical cancer patients. According to a recently published study by the GLOBOCAN on the research of cancer, cervical cancer is the fourth most common cancer in women, with approximately 266,000 cancer-related deaths worldwide in 2012. UnfortuSquamous cell carcinoma antigen (SCC-Ag) is the most widely used and reliable tumor marker for the diagnosis, monitorCirculating tumor cells (CTCs) are rare tumor cells that are shed from primary or metastatic tumors detected in peripheral blood. CTC hasWe retrospectively reviewed 99 consecutive patients with locally advanced cervical cancer ([FIGO] stage IIB-IVA) undergoing radiotherapy (RT) or concurrent chemoradiotherapy (CCRT) from November 2012 to December 2014 at the Affiliated Cancer Hospital & Institute of Guangzhou Medical University, China. This study was reviewed and approved by the institutional review board and ethics committee of Affiliated Cancer Hospital & Institute of Guangzhou Medical University. All participants gave their written informed consent.The pre-treatment evaluations included a complete patient history, physical examinations, haematology and biochemistry profiles, SCC-Ag, CTC, colposcopy, chest X-ray, abdominal sonography, electrocardiogram, magnetic resonance imaging (MRI), computed tomographies (CTs), and whole-body bone scan. All the patients were treated with external beam radiotherapy (EBRT) and brachytherapy. The EBRT dose was 45~50 Gy delivered in 25 fractions  by using a conventional four-field box technique. The radiation field included the primary tumor, uterus, pelvic lymph node and the paracervical, parametrial, and uterosacral regions. High-dose rate intracavitary brachytherapy was delivered two fractions per week with a fraction dose of 5.0 Gy at point A for 4~6 fractions. A month after the completion of RT or CCRT, all patients were given pathological examination and pelvic MRI.The regimens for CCRT consisted of intravenous infusion of weekly cisplatin or cisplatin combined with docetaxel administered every 3 weeks during radiotherapy.The first patient follow-up was administered at one month after RT or CCRT completion, then every 3~6 months for the first two years, and every 6–12 months thereafter. The follow-up intervals can be assessed more frequently for patients suspected of having recurrent or metastatic diseases.Peripheral blood samples were collected via venipuncture before radiotherapy and processed within 24 hours after collection. To avoid bias, all blood samples collection, enrichment, and result reading were blindly performed by different personal. The strategy of enrichment of cervical cancer CTCs was essentially similar to the one that was previously published . In brieSerum SCC-Ag levels were measured by using microparticle enrymeimmunoassay (MEIA) with a commercially available kit . The normal upper limit for SCC-Ag was 1.5 ng/mL.The association between pretherapeutic serum CTC level and clinicopathological parameters were performed by the chi-square test. Receiver operative characteristic (ROC) curve was used to determine the optimal cutoff value of tumor markers for survival. According to the cutoff value, the cervical cancer patients were divided into two groups, CTC negative group and CTC positive group. Disease-free survival (DFS) was defined as the time from the date of definite diagnosis to the date of disease progression  or censored at the date of last follow-up. Survival times of patients still alive or dead as a result of other causes than cancer were censored with the last follow-up date. DFS was calculated by the Kaplan–Meier method. The differences of survival were compared with the log-rank test. Univariate and multivariate analysis were performed using Cox’s proportional hazards regression model with a forward stepwise procedure . Analyses were performed using the statistical software package SPSS 20.0  and Graph Pad Prism for windows, version 6 . A two-sided P-value less than 0.05 was considered statistically significant.The study included a total of 99 cervical cancer patients with FIGO stage IIB-IVA. The clinicopathological characteristics of the study cohort were shown in The pretreatment serum CTC level was associated with SCC-Ag. No association between CTC and other clinicopathological characteristics was found .In univariate survival analysis, elevated CTC level, was strongly associated with poorer DFS of cervical cancer patients with HR of 3.354  . The twoFor elevated CTC and SCC-Ag levels were strong predictors of DFS, we hypothesize that combination of these 2 biomarkers would improve their predictive efficiency for survival. Then, the new combined risk model performed significantly better than CTC or SCC-Ag level alone . TherefoAlthough FIGO stage is the most important clinical prognostic indicators for cervical cancer patients, many patients with the same FIGO stage have different treatment outcomes due to tumor heterogeneity, suggesting that the FIGO stage system urgently needs to be improved by additional prognostic factors such as tumor biomarkers for recurrence and metastasis. To the best of our knowledge, this is the first study investigating the role of CTC alone or in combination with SCC as independent prognostic factors for disease progression in locally advanced cervical cancer patients treated with radiotherapy. In the present study, our results demonstrated that CTC and SCC-Ag individually or in combination were associated with DFS of locally advanced cervical cancer patients. In addition, the predictive efficiency could be significantly improved when CTC and SCC-Ag were combined into a new risk model to predict disease progression of cervical cancer patients compared with either biomarker alone, indicating that the combination of these 2 biomarkers might help to improve the prognostic stratification and guide the individual treatment for cervical cancer patients in the future.CTCs are identified as tumor cells shed from the primary solid tumor into blood circulation. CellSearch is the only CTC detection technique that has been approved for clinical use by the Food and Drug Administration. However, CellSearch has a limit sensitivity and specificity due to its dependence on epithelial cell adhesion molecule (EpCAM) enrichment technique. Brigitte et al. reported that the positive rate of CTCs detected by the Cellsearch system was only 21.5% in 2026 patients with early breast cancer before adjuvant chemotherapy . In thisBayarri et al. found that the detection rate of CTCs in 56 patients with stage I-IIIA non-small cell lung cancer (NSCLC) was 51.8% by immunocytochemical and related with the disease free survival for NSCLC patients , 21–23. Moreover, we also observed that CTC, SCC-Ag and FIGO stage were significant independent prognostic factors for DFS of locally advanced cervical cancer patients. Elevated serum CTC and SCC-Ag level predicted poorer survival for cervical cancer patients. Our results were in line with the results from several previous studies , 24, 25.Serum SCC-Ag levels were demonstrated to be associated with the FIGO stage, 26, 27,However, the molecular mechanism by which the combination of both biomarkers improves the prognostic stratification for cervical cancer patients is still unclear. It is probably that CTC and SCC promote the progression of cervical cancer through taking part in the tumor signaling pathways or influencing the tumor biological behaviors. Epithelial–mesenchymal transition (EMT) is a complex process that the epithelial cell loses differentiation and increases motility via rearrangements of cellular contact junctions and eventually the loss of cell adhesion. EMT might involve the formation of CTC by increasing the ability of the tumor cell to migrate and effecting the cancer aggressiveness. TherefoAs a retrospective study, our study was limited by biases such as lack of random assignment, and patient’s incomplete data acquisition. Therefore, larger trials with longer follow-up times are promptly needed to further testify whether detection of serum CTC and SCC-Ag levels could improve the prognostic stratification and guide the individual treatment for cervical cancer patients.In conclusion, our study reveals that elevated CTC and SCC-Ag levels individually or in combination are significantly associated with poorer DFS of locally advanced cervical cancer patients, indicating that they are potentially useful biomarkers for prediction of prognosis in cervical cancer patients. Further studies are required to reveal the molecular mechanism by which the combination of both biomarkers improves the prognostic stratification for cervical cancer patients.All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. There was no disagreements among all participants included in the study.S1 Table(DOCX)Click here for additional data file.


The third-generation sequencing technology, PacBio, has shown an ability to sequence the HIV virus amplicons in their full length. Thelong read of PaBio offers a distinct advantage to comprehensively understand the virus evolution complexity at quasispecies level (i.e.maintaining linkage information of variants) comparing to the short reads from Illumina shotgun sequencing. However, due to the highnoisenature of the PacBio reads, it is still a challenge to build accurate contigs at high sensitivity. Most of previously developed NGSassembly tools work with the assumption that the input reads are fairly accurate, which is largely true for the data derived from Sanger orIllumina technologies. When applying these tools on PacBio high-noise reads, they are largely driven by noise rather than true signaleventually leading to poor results in most cases. In this study, we propose the de novo assembly procedure, which comprises a positivefocusedstrategy, and linkage-frequency noise reduction so that it is more suitable for PacBio high-noise reads. We further tested theunique de novo assembly procedure on HIV PacBio benchmark data and clinical samples, which accurately assembled dominant and minorpopulations of HIV quasispecies as expected. The improved de novo assembly procedure shows potential ability to promote PacBiotechnology in the field of HIV drug-resistance clinical detection, as well as in broad HIV phylogenetic studies. HIV strains are frequently mutated from one HIV generation to thenext, resulted in high genetic diversity of the HIV populations(named "quasispecies") in a given infected host over a time period, 2. PartEven though the next generation sequencing (NGS) technology ofIllumina shortgun sequencing offers improved variant detectionability (~1% detection limit) over the traditional Sanger-basedsequencing method (~20% detection limit) , 5, bothIn this report, we describe an improved de novo assemblyprocedure to accurately construct HIV quasispecies with highsensitivity. The PacBio read fasta file is the only required inputwithout the need of reference sequence and other prior knowledgeof the sequences. The procedure was successfully applied not onlyon HIV benchmark datasets, but also on real-life HIV relapsepatient samples, leading to the early detection of the dynamic ofHIV drug resistance strains.The HIV benchmark datasets and clinical patient data used in thisreport were adopted from a previously published paper . InsummThe quality of the CCS reads is typically associated with certainparameters of sequencing process . We seleTo evaluate each CCR read, it is compared to an artificial consensusreference sequence(s) derived from the total input PacBio CCRreads. The consensus reference serves as real-time temporarystandard for the given input dataset. The majority-rule basedprocedure  was usedAfter building the consensus reference, each of the CCS reads wascompared to it using the alignment program of BWA bwasw ,which wAll possible paired combinations of the variant candidates fromabove step were formed. The actual co-occurrence frequencies ofthe pairs were surveyed by examining each of the CCR reads. Thevariant pairs with the actual co-occurrence frequency significantlybeyond expected random co-occurrence frequency (Frequency ofvariant 1 x Frequency of variant 2) were determined by the G-test(see formula below), and selected in the final tag pool . Inaddii Oi · ln (Oi / Ei)G = 2 ∑where, Oi is the observed count and Ei is the expected count underthe null hypothesis. In order assess the efficacy of the G test anddetermine the best cutoff value of the G statistic, performance datawere assessed on the benchmark data set .Based on the final tag pool from above step, each CCR read have amutation profile to represent its genetic character. The CCR readswere partitioned into groups based on the similarities of theirmutation profiles. The number of groups is completely driven bythe data itself ranging from 1 to n.Each of the PacBio read groups from above step represents aunique HIV quansispecies. The final contigs were built for each ofthe group using a previously reported clustering procedure .A Perl script was developed to automate above steps of theproposed de novo assembly . The onlA clear phenomenon is that the noises in PacBio reads occurrandomly . Thus, fThe tag-based partition procedure  for builThe PacBio HIV benchmark datasets mimic the situation of HIVgenetic diversity by admixing two highly close and known HIVstrains in different ratios (i.e. 90:10 and 99:1 respectively) . ThePacThe real-life HIV patient samples can be more complicated than thebenchmark data and therefore more challenging than assemblingartificial benchmark data. To further examine the ability of our denovo assembly procedure, two HIV clinical samples from the samepatients at two time points (i.e. before and after anti-HIV treatmentrelapse) had been sequenced using PacBio . As descEven though Sanger sequencing and Illumina sequencing had beendone on the two samples , there rAfter de novo assembly was applied on the PacBio sequencing of thetwo samples, the results showed that the patient at time point 1 contained not only dominant WT HIV strains but also minor HIVdrug resistant strain at 0.6% level, which later could not beidentified by Sanger and Illumina sequencing [Most of previously developed NGS assembly tools were based onthe assumption that the input reads are fairly accurate , 13,whi


CFTR) gene disrupt the capacity of the encoded protein to function as a channel to transport chloride ions and water across cell membranes. The consequences are deleterious, system-wide, and immensely variable, even among patients with the same CFTR genotype. This underscores the need to characterize the mechanisms contributing to CF pathophysiology. Gene replacement and gene editing therapies have been pursued intensively and are expected to provide a one-time treatment for CF. However, gene replacement therapy is limited by the lack of efficient vectors to deliver functional copies of CFTR to cells without immunological complications, while gene editing technologies such as CRISPR/Cas9 are still in their infancy, mainly useful in somatic cells and limited by off-target insertions. Small molecule treatments targeted at potentiating or correcting CFTR have shown clinical benefits, but they are limited to a few CFTR mutations and insufficient to overcome challenges related to clinical heterogeneity. Transcriptome profiling approaches have emerged as robust tools capable of characterizing phenotypic variability and revealing novel molecular targets with therapeutic potential for CF. We summarize current insights gained through transcriptome profiling approaches in CF studies and recent advances in molecular therapeutics.In cystic fibrosis (CF), mutations in the cystic fibrosis transmembrane conductance regulator ( CFTR) gene .Small molecule pharmacological agents developed to target basic CFTR defects have already yielded remarkable results in clinical trials . These aAs both transport of chloride ions and delivery of CFTR protein to the cell surface are equally important to relieve the symptoms of CF, CFTR combination therapies using lumacaftor/ivacaftor or tezacaftor/ivacaftor have emerged effective agents for treating patients with Class 2 . AmplifiVDR) gene which encodes the nuclear hormone receptor for vitamin D3 [Beyond CFTR modulators, several other small molecule agents targeting other CF-associated genes have already completed phase 4 in clinical trials. For example, previous studies showing that increased levels of Matrix metallopeptidase (MMP-9) is associated with more severe lung disease in CF prompted the development of doxycycline, an antibiotic that is also a potent inhibitor for MMP-9, as a CF therapeutic . In additamin D3  Table 3VDR gene GHR), interferon-γ receptor 1 (IFNGR1), interferon-γ receptor 2 (IFNGR2), and insulin receptor (INSR)  . Althouggnatures . Thus, tAs shown in Expression profiling of non-coding RNAs (ncRNAs) is emerging as an approach for identifying new therapeutic targets for CF, based on the crucial role these molecules play as master regulators of gene expression and biological processes . AlthougBriefly, miRNAs are short single-stranded small ncRNA species (20–25 nucleotides in length) that modulate the expression of their target genes by base-pairing with their complementary sequence. The altered expression of several miRNAs has been reported in a wide range of human diseases including cancers ,56 and cCFTR expression [P. aeruginosa, investigators identified a unique lncRNA profile characterizing CF and potentially relevant to the impaired immune response seen in patients [Similar to miRNAs, lncRNAs can act as activators or repressors of gene expression. LncRNAs are large (>200 nucleotides in length) ncRNA species that localize to the nucleus or cytoplasm, with a capacity to interact with DNA, RNA, and protein . The regpression . Althougpression . More repatients . In addipatients .CFTR [As the expression of ncRNAs can be modulated in vitro or in vivo to mediate the expression of their target gene , includiCFTR , the ideAlternative splicing is an important biological mechanism through which most mammalian genes generate distinct transcript isoforms that can have diverse functions in different cell-types or disease states ,71. MammAlthough transcriptome profiling holds promise for revolutionizing our understanding of the molecular complexities of CF and its phenotypes in any cell type, barriers to this approach include the lack of useful model systems and cellular heterogeneity. These challenges limit the capacity of these advanced technologies to identify new therapeutic opportunities in CF.CFTR gene in 1989, the first mouse models were developed [CFTR mutations identified so far that can result in phenotypic differences [The availability of well-characterized model systems for transcriptome profiling has been instrumental in understanding the pathogenesis of many diseases and developing effective therapies . Shortlyeveloped ,77. Theseveloped . The CFTeveloped ,80. Mucheveloped . Howeverferences , there iOne human model system that can be used effectively to distinguish disease phenotypes at transcriptome level is the human PBMCs-based model. This system reflects host immune cell responses to external stimuli that can be measured quantitatively at mRNA level using transcriptome profiling approaches. Human PBMCs stimulated with plasma or serum from patients followed by transcriptome profiling have provided new insights into diseases ,82. ReceAlthough transcriptome profiling approaches have fueled many important discoveries in CF , most stNew computational algorithms and transcriptome profiling at single-cell resolution have emerged as novel approaches to tackle challenges due to bulk sampling. Several computational methods capable of delineating cellular heterogeneity based on gene expression datasets generated from bulk transcriptome profiling have been developed ,85,86. HCFTR gene result in aberrant expression of genes encoding molecules relevant to several altered biological pathways in CF, prominently signal transduction and immune pathways. Although much of this knowledge seems to have been gained by studying airway epithelial cells, few studies have analyzed blood cells. Together, these studies indicate impaired immune responses is a dominant feature of CF. With data from GTEx confirming that CFTR is abundantly expressed in many unexplored tissues and organs, future studies focusing on such targets will elucidate molecular mechanisms underlying how dysfunctional CFTR results in a multisystem CF disease. Beyond the identification of dysregulated genes in CF cells, identification of CF-specific isoforms from multiple-isoform genes may reveal novel molecular targets for specific therapy. Current knowledge of dysregulated genes in CF transcriptomes are based on analyzing bulk cells. Recent computational algorithms and novel molecular methods such as scRNA-Seq will allow researchers to decipher cellular heterogeneity in gene transcription signatures. Taking advantage of transcriptome profiling will open new horizons for better and specific therapies for CF.In just a few years, transcriptome profiling has expanded our understanding of CF pathophysiology. We have learned from the past studies that mutations in


With the development of ankle arthroscope techniques and procedures, the number of arthroscopic modified Broström procedures (MBPs) is increasing. All-inside arthroscopic MBP was developed recently, with good to excellent results. However, several complications have been reported in patients after arthroscopic MBP. This case report describes a rare complication of arthroscopic MBP.A 34-year-old woman presented with severe pain in her right ankle and underwent arthroscopic MBP for lateral ankle instability. About 6 months postoperatively, she presented with severe pain on the lateral aspect of the right ankle, especially while walking.In physical examinations, there was marked swelling around the ankle and focal tenderness in the posterolateral malleolar area. Ankle ultrasonography showed a diffuse low-echoic mass-like lesion at the distal fibula between the fibular tip and peroneus tendon. T1-weighted sagittal magnetic resonance imaging images showed an irregularly shaped mass-like lesion with a heterogeneous signal near the distal fibula posteriorly where the anchor protruded.The suture anchor in the posterior distal fibula area, which had irritated the peroneus tendon, was removed with debridement of the granulomatous lesion.At the 3-month follow-up, the patient was almost asymptomatic and had a nearly full range of motion. No complications or recurrent symptoms were noted at the 1-year follow-up.Three-dimensional computed tomography studies of the appropriate fibular depth and position of suture anchors are needed to standardize the procedure and reduce complications. Surgery is indicated for those patients in whom nonoperative attempts fail.,6Ankle sprains are common sports injuries and may sometimes result in chronic lateral ankle instability.; Gould modified this technique in 1980 by reinforcing the inferior extensor retinaculum, and Karlsson proposed reattaching the ATFL to the fibula at its anatomical origin through drill holes.,9 The main advantages of this anatomic technique are the simplicity of the procedure, possibility of restoring the physiological joint anatomy and kinematics, and preservation of subtalar joint mobility.,10 After 50 years, the open modified Broström anatomic repair technique is widely accepted as the reference standard for lateral ankle stabilization.,11In 1966, Broström proposed an anatomic procedure to repair the anterior talofibular ligament (ATFL) using its remnants–15 Arthroscopic MBP is technically straightforward, and reduces the recovery time by limiting surgical dissection of the tissues about the ankle joint, while providing comparable ankle stability to open procedures.,15–17With developments in ankle arthroscope techniques and procedures, the number of arthroscopic-modified Broström procedures (MBPs) is increasing. The all-inside arthroscopic MBP was developed recently and yields good to excellent results.,13,14,18However, several complications have been reported in patients after arthroscopic MBP, including sural nerve neuritis, superficial peroneal nerve neuritis, portal site irritation, prominent asymptomatic suture knots, and knot pain.We present a rare case of peroneal tendon irritation caused by the suture anchor after an arthroscopic Broström procedure.2This case report was approved by the Institutional Review Board (IRB) of Soonchunhyang University Hospital (IRB No. 2019-05-021). The patient consented to publication of this report and the accompanying images.2  presented with severe pain in her right ankle. She had no underlying disease. She had a history of lateral malleolus fracture of the right ankle 6 years earlier and underwent internal fixation with a plate. The internal device was removed 1 year after the fracture and she had no residual pain or other symptoms.A 34-year-old woman with a body mass index of 30.85 kg/mShe had no complaints with her right ankle until an acute ankle sprain 16 months before visiting our hospital. Subsequently, she complained of pain and instability of her right ankle joint. At least once a week, the ankle felt like it had given way while walking. Conservative treatment including medication, physical treatment, and exercise treatment was tried for 4 months, but the pain and sensed instability persisted. With a diagnosis of chronic ankle instability, arthroscopic MBP was performed on her ankle elsewhere 1 year before visiting our clinic. A short-leg cast was applied for 1 month after that surgery, after which rehabilitation was started. Five weeks postoperatively, weight-bearing walking was permitted and she started ordinary activities. She had no ankle pain or discomfort after the arthroscopic MBP. Six months postoperatively, she presented to our clinic with severe pain on the lateral aspect of the right ankle, particularly during motion. Physical examination showed marked swelling around the ankle and focal tenderness in the posterolateral malleolus area. The anterior drawer test was negative and the talar tilt angle was 3.2° on a varus stress view radiograph, which was within the normal range  after placement of a posterior anti-glide plate for fibular malleolar fractures.Some studies have reported peroneal tendon complications after application of a plate for lateral malleolar fractures.Similar to the plate for lateral malleolus fractures, when undergoing an arthroscopic MBP using suture anchors, a suture anchor that penetrates distal fibula can rarely cause peroneal tendinopathy. There is also a possibility of injuring the peroneal tendon with the drill while reaming for suture anchors.,22Many other conditions can cause pain or discomfort similar to peroneal tendinopathy, including lateral ankle ligament sprains, lateral talar process fractures, ankle capsular impingement syndrome, distal tibiofibular syndesmotic ligament injury, lateral osteochondral lesions of the talus, subtalar joint pathology, os trigonum syndrome, sural neuropathy, and anterior process fractures of the calcaneus.Therefore, a careful examination is needed for an accurate diagnosis. If there is swelling, tenderness, or pain along the peroneal tendon, and if the pain becomes worse with the pain provocation test, or when the peroneal muscle power decreases, peroneal tendinopathy should be suspected.,19,23,24 In our case, the anchor was inserted past the far cortex of the fibula and the muscle portion of the peroneus tendon was stimulated because the suture anchor was not inserted perpendicular to the fibula. We believe that the location and length of the suture anchor inserted are important for preventing peroneal tendinopathy when doing arthroscopic MBP using a suture anchor.The drill hole for suture anchors is typically directed from anterior to posterior, perpendicular to the anterior surface of the fibula, and parallel to the plantar plane and plane of the lateral gutter to reproduce the native insertion of the ATFL.4Many arthroscopic MBP techniques have been introduced, but the proper position and location of the suture anchor according to the shape of the distal fibula has not been established. Further radiographic studies analyzing the appropriate depth and position of suture anchors using 3-dimensional computed tomography are needed to standardize the procedure and reduce complications.The authors thank the Soonchunhyang University Research Fund for support.Conceptualization: Young Koo Lee.Project administration: Sung Hun Won.Resources: Hyun Kwon Kim.Software: Chang Hyun Kim.Supervision: Hong Seop Lee, Aeli Ryu, Woo Jong Kim.Writing – original draft: Whi Je Cho, Woo Jong Kim.Writing – review and editing: Woo Jong Kim.Woo Jong Kim orcid: 0000-0002-4579-1008.


The present perspective paper addresses and discusses whether cognitive dysfunction in bipolar disorder qualifies as a diagnostic intermediate phenotype using the Robin and Guze criteria of diagnostic validity. The paper reviews current data within (1) delineation of the clinical intermediate phenotype, (2) associations of the intermediate phenotype with para-clinical data such as brain imaging and blood-based data, (3) associations to family history / genetics, (4) characteristics during long-term follow-up, and (5) treatment effects on cognition. In this way, the paper identifies knowledge gaps and suggests recommendations for future research within each of the five areas. Based on the current state of knowledge, we conclude that cognitive dysfunction does not qualify as a diagnostic intermediate phenotype or endophenotype for bipolar disorder, although promising new evidence points to emotion and reward processing abnormalities as possible putative endophenotypes. Cognitive dysfunction in bipolar disorder is a core illness symptom that has received intensive research interest over the past decade because of its negative impact on socio-occupational outcome, quality of life and illness prognosis –3. HowevThis area concerns whether cognitive dysfunction in bipolar disorder in remission is circumscribed clinically as a separate diagnostic intermediate phenotype of bipolar disorder and whether such an intermediate phenotype differs from similar intermediate phenotypes within related disorders such as schizophrenia and unipolar disorder.Meta-analyses have consistently shown disturbances in executive function, verbal learning and memory, visual memory and attention in bipolar disorder compared with healthy control individuals –10. CognOn the other hand, cognitive deviances are not specific for bipolar disorder. Cognitive impairment is also prevalent in schizophrenia  and unipEmotion dysregulation may be another cognitive feature of bipolar disorder that persists into periods of remission. Such deficits in “hot”  cognition are closely linked to emotional disturbances  and diffEmerging evidence points to partial persistence of such hot cognition dysfunction during remission in unipolar disorder, particularly within negative affect processing,  and the It is unknown whether shared manifestations of cognitive dysfunction across diagnostic categories also reflect shared neurobiological mechanisms or whether the sources of impairment differ. A recent study investigated the associations between general cognitive deficits  and functional network integrity measures including global and local efficiency of the whole brain, cingulo-opercular network (CON), frontoparietal network, and auditory network . Patienthypo-activity in schizophrenia and bipolar disorder while the findings in unipolar disorder are more variable. In particular, we found in a systematic review of >100 neuroimaging studies across bipolar disorder and unipolar disorder consistent evidence for abnormal (predominantly hypo-) activity in dorsal and lateral PFC cognitive control regions during performance on working memory, executive skills, memory encoding, and sustained attention . Notably, the direction of this dorsal PFC activity depended on patients' performance levels. Dorsal PFC hypo-activity is consistently linked to impaired task performance; that is reduced cognitive capacity. In contrast, dorsal PFC hyper-activity is generally accompanied by normal performance levels and thus seems to reflect reduced cortical efficiency; that is, a need to recruit more neural resources to maintain normal performance. These associations are likely to explain the more consistent evidence for dorsal PFC hypo-activity in the generally more severely cognitively impaired patients groups .Another common neural underpinning of cognitive deficits across bipolar disorder, unipolar disorder, and schizophrenia is aberrant task-related activity in the dorsal prefrontal cortex (PFC), although findings regarding the direction of the aberrant activity vary between studies with most evidence for Another consistent finding in the review was reduced deactivation of the default mode network (DMN) and limbic structures during active task performance across bipolar disorder and unipolar disorder (ibid). This suggests that cognitive impairments across mood disorders are exacerbated by a failure to suppress task-irrelevant neural activity associated with emotional reactivity, self-focus and rumination (ibid).Emerging neuroimaging evidence points to deficits in emotion dysregulation being a prominent feature of bipolar disorder, while unipolar disorder seems to be more consistently associated with negative processing biases . EmotionPeripheral inflammation might be related to cognitive deficits in schizophrenia and bipolar disorder. Single studies suggest the role of C-reactive protein (CRP), interleukin (IL)-1 receptor antagonist, IL-6, and tumor necrosis factor-α (TNF-α) with its receptors in the development of cognitive impairment in bipolar disorder as summarized in reviews , 34. DueA recent meta-analysis of cognitive functions in first-degree relatives of probands with bipolar disorder and schizophrenia showed that probands with schizophrenia displayed cognitive deficits in all domains (d = 0.20–0.58) whereas probands with bipolar disorder underperformed healthy controls in processing speed, verbal fluency and speed based executive function tests . It was In terms of neurocognitive-genetic investigations, catechol-O-methyltransferase (COMT) and brain-derived neurotrophic factor (BDNF) are the two most studied candidate genes especially in patients with schizophrenia . WhereasCognitive deficits in bipolar disorder in remission seem to persist over time or even progress supporting the view that these deficits qualify for an intermediary phenotype. Using a 5 years longitudinal cohort, 91 individuals with bipolar disorder and 17 healthy controls were administered a battery of neuropsychological tests that captured four main areas of executive functioning that were found to persist over time .Based on cross-sectional studies, cognitive deficits seem to deteriorate during late stages of the disorder . In contRegarding cognitive functioning in unipolar disorder, some cross-sectional studies suggest that cognitive function in the euthymic phase is associated with the duration or number of prior episodes [–54, for all subsequent studies have confirmed that unipolar disorder  and psychological treatments (cognitive remediation and cognitive training) on cognition in bipolar disorder identified 19 studies of which 13 were RCTs and six were open-label or non-randomized studies . The effIt is clear from the present summary of studies on cognition in bipolar disorder that at the current state of knowledge cognition in bipolar disorder does not qualify as a diagnostic intermediate phenotype using the Robin and Guze criteria of diagnostic validity  or the lIt is further evident from the present summary of studies on cognition in bipolar disorder that a number of research initiatives are needed within all five of the Robin and Guze criteria.1. Research is needed integrating “hot” and “cold” cognition in bipolar disorder. Few if any studies have investigated how emotion dysregulation  interact with cold cognition. As recently emphasized, cognitive biases, reward processing and motivation, rumination, and mood stability may play significant roles in the manner in which attention, appraisal, and response processes are deployed in mood disorders .2. Emotion dysregulation (hot cognition) should be investigated across mood disorders and schizophrenia. Emotion dysregulation has emerged as a new research area that may characterize mood disorders, and potentially specifically bipolar disorder, rather than schizophrenia. Although these speculations are clinically plausible, emotion dysregulation has not been systematically investigated across mood disorders and schizophrenia.3. Structural and functional neuroimaging data on cognitive features (“cold” and “hot”) should be integrated across mood disorders. Such multimodal neuroimaging studies aiming to identify structure-function relationships in neural circuitry have previously been suggested in relation to bipolar disorder in general . As high4. Neurogenetics should be integrated into research in cognitive disturbances in patients with mood disorders and schizophrenia and in their first degree relatives.5. Research in cognitive enhancement treatments. We have previously suggested implementation of a ‘neurocircuitry-based’ biomarker model to evaluate neural target engagement in cognitive enhancement . We suggMore evidence is needed confirming whether cognitive deficits comprise a diagnostic intermediate phenotype in bipolar disorder. The long-term perspective is that cognitive deficits may aid diagnostic accuracy and represent a key treatment target in bipolar disorder.LK developed the idea and drafted the first version of the paper. KM revised the paper and both authors accepted the final version of the paper.LK has received consultancy fees from Sunovion in the past 3 years. KM has received consultancy fees from Lundbeck and Allergan in the past 3 years.