The coordination of axial thorax and pelvis rotations during gait has been shown to be affected by several pathologies. This has been interpreted as an indication of increased apparent axial trunk stiffness, but arm swing may also affect these rotations. The objectives of this study were to assess the effect of trunk stiffness and arm swing on the relative timing (‘coordination’) between thorax and pelvis rotations, and to assess if apparent trunk stiffness can be inferred from thorax-pelvis kinematics. A forward dynamic model was constructed to estimate apparent trunk stiffness from observed thorax and pelvis rotations and arm swing moment around the longitudinal axis of the trunk of 30 subjects. The effect of independent manipulations of trunk stiffness and arm swing moment on thorax-pelvis coordination and gain of axial thorax-pelvis rotations were assessed using the same forward dynamic model. A linear regression model was constructed to evaluate whether forward dynamic model-based estimates of axial trunk stiffness could be inferred directly from thorax-pelvis rotations. The forward dynamic model revealed that axial trunk stiffness and arm swing moment have opposite effects on axial thorax-pelvis coordination. Apparent axial trunk stiffness could not be predicted from observed thorax-pelvis rotations. The relative phase between these segment rotations can vary from plus to minus 180 degrees. A value of plus or minus 180 degrees corresponds to perfect out-of-phase rotation and a value of 0 degrees corresponds to perfect in-phase rotation2. If timing of thorax rotations is expressed relative to the pelvis , negative values indicate that thorax rotations lag pelvis rotations, and positive values indicate that thorax rotations lead those of the pelvis. In healthy individuals, thorax-pelvis relative phase is around minus 20 degrees in slow walking (1 km/h). The lag of thorax phase increases with gait speed resulting in a thorax-pelvis relative phase of minus 150 degrees in fast walking (5.4 km/h)1. This relative timing of thorax and pelvis rotations, henceforward ‘axial thorax-pelvis coordination’ can be affected by several pathologies; for example, the shift from in-phase towards out-of-phase coordination was found to be smaller in patients with Parkinson’s disease2, stroke3, pregnancy related pelvic-girdle pain4 and low-back pain1 with a 20 to 30 degree more in phase thorax-pelvis coordination at higher gait speeds. This has been interpreted as indicative of an increased axial trunk stiffness in such pathologies6.At low gait speed, thorax and pelvis demonstrate synchronous axial rotations  in the same direction, i.e., in-phase rotation. When speeding up, this pattern gradually changes towards rotations in opposite directions, i.e., out-of-phase rotation7 that, combined with forces from passive structures, generate the net trunk moment. During gait, this moment shows a close to linear relationship with the angle between thorax and pelvis6, as in a torsion spring that pulls thorax and pelvis towards a neutral relative orientation. Consequently, the mechanical behaviour of the trunk around the vertical axis during gait can be parameterized as an apparent axial stiffness9.Axial trunk stiffness, in this context, is a parameterization of the relationship between axial rotations of thorax and pelvis and axial trunk moments. Trunk muscles show components of phasic and tonic activity during the gait cycle10, arm swing amplitude may affect thorax-pelvis kinematics14, via shoulder reaction forces acting on the thorax. These forces result in a moment around the longitudinal axis of the trunk6, henceforward ‘arm swing moment’. An increased arm swing moment would pull the timing of thorax rotations towards arm swing timing, that is, out of phase with axial pelvis rotations. At given arm swing frequency, accelerations of the arms must increase with increasing arm swing amplitude and hence the arm swing moment will increase as well. The axial accelerations of the thorax are driven by the arm swing moment and by the internal trunk moment, which act in opposite directions, limiting axial thorax rotations6. With increasing arm swing amplitudes during gait, internal axial trunk moment also increase15.In addition to apparent axial trunk stiffness9. However, the fact that trunk stiffness is modulated with gait speed, provides no conclusive evidence that this modulation causes concomitant modifications in thorax-pelvis coordination, because changes in, e.g., step length and/or frequency may influence intersegmental coordination as well16. In one study, trunk stiffness of healthy subjects was increased with an orthopaedic brace on the trunk. This resulted in more in-phase thorax-pelvis rotations during gait compared to a condition without the brace10. However, this was mainly the result of changes in pelvis timing, whereas changes in thorax-pelvis relative phase in patients are mainly the result of changes in thorax timing16. The effect of arm swing was evaluated in a study in which one arm of healthy subjects was constrained. This clearly resulted in more in-phase axial thorax-pelvis coordination at higher gait speeds compared to the normal arm swing condition. However, the timing and amplitude of the kinematics of the unconstrained arm were affected as well12, which may have influenced axial thorax-pelvis coordination.Some insight into the effect of axial trunk stiffness and arm swing on thorax-pelvis rotations in gait of healthy subjects can be obtained from previous studies. Two studies that estimated apparent axial trunk stiffness in healthy subjects’ gait reported that stiffness changes as a function of gait speed2 and patients with low-back pain demonstrated lower stride-to-stride variability of axial rotations between thorax and pelvis17. Although these less variable coordination patterns could be the result of an increased apparent axial trunk stiffness, they might also be the result of modulation of timing and amplitude of muscle activation to reduce stride-to-stride variability of thorax-pelvis kinematics. External perturbations did not reveal increased apparent axial trunk stiffness in low-back pain patients, who demonstrated more in-phase thorax-pelvis coordination than healthy controls18. Arm swing amplitude was found to be lower in gait of patients with Parkinson’s disease13 and unilaterally in stroke patients14, but arm swing amplitude was found to be unaffected in low-back pain patients with lumbar disc herniation, who did demonstrate more in phase axial thorax-pelvis coordination compared to healthy controls19.Indications of increased axial trunk stiffness and decreased arm swing amplitude have been observed in some of the pathologies in which axial thorax-pelvis coordination is known to be affected during gait. The relative phase of thorax and pelvis was found to be less variable in gait of patients with Parkinson’s diseaseAlthough the aforementioned studies provide some insight into the association between apparent axial trunk stiffness, arm swing and axial thorax-pelvis coordination in healthy subjects and patients, the causality remains elusive. A forward dynamic model could be used to demonstrate how axial trunk stiffness and arm swing moment modulate thorax-pelvis coordination during gait. The first objective of this study, therefore, was to assess the effect of axial trunk stiffness and arm swing moment on axial thorax-pelvis coordination using a forward dynamic model. The second objective was to evaluate the common variance between apparent axial trunk stiffness and arm swing moment. The third objective of this study was to assess whether apparent axial trunk stiffness can be inferred from thorax-pelvis kinematics. We hypothesized that increased axial trunk stiffness and reduced arm swing moment would result in more in-phase rotations of thorax and pelvis. Regarding the second objective, given the associations of both axial trunk stiffness and arm swing moment with gait speed, we hypothesized that a moderate to high positive correlation is present between these two variables, which would confound inferences on axial trunk stiffness from thorax-pelvis kinematics. Given the second hypothesis, estimation of axial trunk stiffness from thorax-pelvis kinematics would be prone to error. Hence, we hypothesized that the predictive value of thorax-pelvis kinematics to estimate axial trunk stiffness would be limited.20. Normalized internal trunk moment, normalized arm swing moment and normalized apparent axial trunk stiffness and damping were corrected for subject height and weight.In this study, experimental data of 30 subjects were used. To reduce between subject variability caused by differences in anatomy some outcomes were normalized® Release 2018a using Simscape™ in the Simulink® environment . All code and data accompanying this manuscript can be found via the data availability statement. The thorax and pelvis were modelled as two rigid segments with one joint between them, L5S1, which allowed only axial rotation. The model aimed to ‘predict’ a time series of axial thorax rotations based on observed time series of axial pelvis rotations, arm swing moment in terms of time series of the moment caused by shoulder reaction forces around the longitudinal axis of the trunk through L5S1, thorax inertia and estimated axial trunk stiffness and damping. Axial trunk stiffness and damping coefficients were estimated using an optimization procedure that minimized the root mean square error (RMSE) of the observed thorax rotations vs the modelled thorax rotations using a Nelder-Mead minimization procedure, that searches for a local minimum in a two-dimensional space using a triangular simplex21. Initial stiffness was set to 100 Nm/rad and initial damping was set to 1 Nms/rad. The termination tolerance for the dependent variable, i.e., the RMSE of thorax rotations, and both independent variables, i.e., stiffness and damping, was set to 10−4. Figure We constructed a model of the trunk in MATLAB18. In this study 15 healthy subjects and 15 patients with low-back pain were included. Low-back pain patients had to have experienced low-back pain in the three months prior to inclusion and have a minimum current 100 mm Visual Analogue Score (VAS) for low-back pain intensity of 20 mm at the time of inclusion. An overview of subject characteristics is presented in Table Data that were used as input for the model were obtained from a previously published study1.The protocol of the previous study was approved by the Medical Ethical Committee of the VU Medical Centre, Amsterdam, The Netherlands (NL 37399.029.12) and was in accordance with the Declaration of Helsinki. An informed consent was obtained from all participants. In the study, fifteen healthy subjects and fifteen subjects with chronic low-back pain walked at a speed of 4 (km/h) on a treadmill for two minutes. This speed is high enough for possible differences in thorax-pelvis coordination between patients and controls to become clearly visible, and not too high for most patients to keep up with the treadmill24. The inertia of the thorax was estimated from body mass and the circumference and length of the segment8. The forward dynamic model was run for each individual, resulting in thirty predicted axial trunk stiffness and damping coefficients and thirty predicted time series of thorax rotations.Whole-body kinematics were captured at a rate of 100 (samples/s). Axial pelvis rotations were registered and shoulder reaction forces were calculated using top-down inverse dynamicsR2, of the observed vs modelled thorax rotations.For each subject, the goodness of fit of the optimized model prediction was determined in terms of common variance, i.e., 6. Here, stiffness was estimated as the slope of the regression line between the internal axial trunk moment, and axial trunk angle. Trunk moment was calculated using the same principles as used to calculate the shoulder reaction forces24. We calculated the % common variance and root mean square error between the stiffness estimates obtained with both methods.To evaluate whether the stiffness values obtained through the optimization procedure were plausible, we estimated stiffness using inverse dynamics as wellThe focus of the current study was not to compare the subject groups with and without chronic low-back pain, but to evaluate effects of axial trunk stiffness and arm swing amplitude on axial thorax-pelvis coordination in both groups. Therefore, after checking for group differences in apparent axial trunk stiffness and damping, magnitude of shoulder reaction forces and thorax-pelvis coordination  with independent sample t-tests, the data of both groups were pooled.After estimating the apparent axial trunk stiffness and damping of each subject with the corresponding modelled time series of thorax rotations, the effects of axial trunk stiffness and arm swing moment on axial thorax-pelvis coordination were assessed. To this aim, simulations were run after multiplication of either apparent trunk stiffness or the experimental arm swing moments by factors of 0.5, 0.75, 1.25 and 1.5., assuming that the obtained time series of axial thorax rotations would reflect the effects of decreased or increased axial trunk stiffness or arm swing moment.The effects of these manipulations on thorax-pelvis coordination were quantified by calculating the phase and gain of the frequency response function from pelvis to thorax rotations at the stride frequency. The stride frequency was determined as the local peak in the power spectrum of the pelvis rotations closest to 1 (Hz). A gain of one reflects equal amplitudes of pelvis and thorax rotations and higher gains correspond to a larger thorax rotation amplitude for a given pelvis rotation amplitude. No statistics were performed on these outcomes, because the multiplication factors were chosen arbitrarily and the level of significance between the different quantities of axial trunk stiffness and arm swing moment depends on the multiplication factors.The % common variance between the normalized forward dynamic model-based estimates of apparent trunk stiffness and normalized observed arm swing moment was calculated to assess whether arm swing amplitude confounds the association between axial thorax-pelvis coordination and apparent axial trunk stiffness.A linear regression model was constructed to assess whether observed thorax-pelvis coordination can be used to predict normalized forward dynamic model-based estimates of apparent axial trunk stiffness. We tested whether the dependent and independent variables were normally distributed using a Kolmogorov-Smirnov test. Multicollinearity between the independent variables was evaluated by calculating the correlation coefficient. Linearity of the relation between the variables was visually checked using scatter plots. Subsequently, we constructed a linear regression model with thorax-pelvis relative phase and gain and an interaction term as independent variables and apparent axial trunk stiffness as dependent variable. Thorax-pelvis relative phase and gain of each of the thirty subjects were estimated from the observed kinematics. The goodness of fit of the regression models was evaluated by calculating the % common variance between the axial trunk stiffness predicted by the regression model and that returned by the forward dynamic model.A typical example of observed versus modelled axial thorax rotations of one subject is presented in Fig. A typical example of the simulated effects of axial trunk stiffness and arm swing moment on thorax-pelvis coordination in one subject is presented in Fig. The average modelled effects of axial trunk stiffness and arm swing moment on axial thorax-pelvis coordination are presented in Fig. Observed arm swing moments and forward dynamic model-based estimates of apparent axial trunk stiffness had a common variance of 22% (p = 0.008), indicating that effects of arm swing moment on axial trunk stiffness on axial thorax-pelvis relative phase and gain is small, albeit significant.Normalized stiffness and axial thorax-pelvis relative phase and gain were normally distributed and no collinearity was present. We found no indication for a non-linear relationship between these the dependent and independent variables in the scatterplots. Axial thorax-pelvis relative phase did not contribute significantly to the prediction of apparent axial trunk stiffness (p = 0.99) nor did gain (p = 0.32), or the interaction between phase and gain (p = 0.65).3, and a lower gain  explain this lack of predictability of trunk stiffness from thorax-pelvis kinematics. However, we found only a low common variance between these outcomes. Hence, it appears that in healthy subjects and patients with low-back pain, between subject variance in thorax-pelvis coordination is mainly caused by other factors than apparent axial trunk stiffness and arm swing moment.4. However, to the best of our knowledge, the gain between these segments was not reported in these studies. An increased range of motion of axial pelvis rotations has been reported in patients with lumbar disc herniation19, pregnancy related pelvic-girdle pain4, and in a subgroup of chronic low-back pain patients with relatively in-phase thorax-pelvis coordination18. In these studies, thorax range of motion was not found to be significantly different between groups. Higher pelvis range of motion combined with an equal thorax range of motion would imply a lower transfer from axial pelvis rotations to the thorax. Such combined alterations in phase and gain would be in line with increased apparent axial trunk stiffness and/or decreased arm swing amplitude in these patients according to the present study. In the study of Huang et al.19, no significant differences between patients and controls were reported for arm swing amplitude. This may imply an increased axial stiffness in patients with lumbar disc herniation, but alternative strategies that may alter thorax-pelvis coordination cannot be excluded.In previous studies on several pathologies, the relative phase of axial thorax-pelvis rotations during gait was found to be affected14. Although these variables are related15 and we found a high common variance, the relationship is not perfect. Other factors, such as the acceleration and velocity profiles of arm swing could affect arm swing moment as well.There are some limitations of this study that need to be addressed. First, the axial trunk moment was modelled as if provided by a linear passive spring/damper-system. This was motivated by previous studies in healthy subjects that showed a linear relation between axial trunk angles and moments during gait and, in the present study, resulted in a good fit for thorax rotations in both healthy subjects and patients with low-back pain. However, it is possible that this linear relationship does not exist in patients with altered thorax-pelvis coordination, when they alter timing of trunk muscle activation. In this case their behaviour cannot be modelled as a simple passive system. Studies that estimate trunk moment angle relationships in these patients should be performed to determine if patient data fit the model approach used here, and if such a model is to be used for further comparison of trunk coordination between healthy subjects and patients with altered axial thorax-pelvis coordination. A second limitation is that we evaluated the effect of arm swing moment on thorax-pelvis coordination as a means to assess the effect of increased or decreased arm swing amplitude as observed in some pathologies in which arm swing amplitude is affected19. Possibly, pelvis range of motion could influence thorax-pelvis relative phase. Alterations in pelvis motion might be caused by altered movement patterns of the lower extremities25, and this could cause a change in timing of thorax rotations, but new research is needed to specifically investigate these relationships.The focus of this study was on the direction of the effect of simulated altered arm swing moment and axial trunk stiffness on predicted thorax-pelvis coordination using a forward dynamic model. The same observed pelvis rotation time series were used within subjects to simulate these effects. We did not assess any possible effect of altered arm swing moment or axial trunk stiffness on pelvis kinematics. The silent assumption that pelvis kinematics would be unaffected is probably unrealistic, but we assume that this had no effect on our hypotheses. Moreover, we did not study the effect of pelvis kinematics on thorax-pelvis coordination. In multiple studies, increased range of motion of axial pelvis rotations was found in combination with more in-phase thorax-pelvis rotationWe conclude that both apparent axial trunk stiffness and arm swing moment clearly affect relative phase and gain of axial thorax-pelvis rotations. The forward dynamic model predicted that increased axial trunk stiffness and decreased arm swing moment result in more in-phase thorax-pelvis rotation, as reported in several patient groups, and a decreased gain. Apparent axial trunk stiffness could not be predicted from axial thorax-pelvis coordination.Supplementary Figure


Besides analgesic effects, chronic use of opioid can also cause tolerance, dependence, and even addiction. Effective treatment of opioid addiction remains a big challenge today. Studies on addictive effects of opioids focus on striatum, a main component in the brain responsible for drug dependence and addiction. Some transcription regulators have been associated with opioid addiction, but relationship between analgesic effects of opioids and dependence behaviors mediated by them at the molecular level has not been thoroughly investigated. In this paper, we developed a new computational strategy that identifies novel targets and potential therapeutic molecular compounds for opioid dependence and addiction. We employed several statistical and machine learning techniques and identified differentially expressed genes over time which were associated with dependence-related behaviors after exposure to either morphine or heroin, as well as potential transcription regulators that regulate these genes, using time course gene expression data from mouse striatum. Moreover, our findings revealed that some of these dependence-associated genes and transcription regulators are known to play key roles in opioid-mediated analgesia and tolerance, suggesting that an intricate relationship between opioid-induce pain-related pathways and dependence may develop at an early stage during opioid exposure. Finally, we determined small compounds that can potentially target the dependence-associated genes and transcription regulators. These compounds may facilitate development of effective therapy for opioid dependence and addiction. We also built a database ( Opioids such as morphine have long been used as mainstay therapy for treating different types of chronic severe pains such as cancer pain, noncancer-related pain, and neuropathic pain . As a reDespite that opioids have beneficial analgesic effects of alleviating acute and chronic pain, chronic opioid use can lead to adverse side effects including tolerance, hyperalgesia, withdrawal reactions, and even dependence , 4, 5. IStudies on effects of opioids to relieve pain mainly focus on brain regions such as periaqueductal gray, rostral ventromedial medulla, and dorsal root ganglia , while iDespite that different drugs of abuse often elicit similar behavioral responses in animals and humans, molecular mechanisms underlying addiction induced by different drugs can be distinctly different . OpioidsDespite all these efforts, however, much remains to be known about molecular connections between the genes and pathways activated by opioids in the pain-related processes and those involved in opioid dependence and addiction. Elucidating such connections can not only shed light on the mechanisms which contribute to the opioid epidemic, but may also allow people to identify better candidate targets for therapeutic interventions to prevent opioid dependence and addiction during pain management.In order to treat opioid addiction, opioid antagonists such as naltrexone have been used to treat opioid addiction for several decades. However, they have shown limited efficacy in relapse prevention , 19. Rechttp://daportals.org. Our findings can facilitate identification of novel candidate gene targets as well as potential therapeutic interventions for treating opioid dependence and addiction.In this work, we developed a new computational strategy for identification of novel genome-wide targets and potential therapeutic treatments for opioid dependence. In particular, this strategy involves first detecting genes and pathways induced by either morphine or heroin which are associated with dependence, then identification of small compounds which can target the dependence-associated genes responsive to the opioids. We analyzed a data set generated from a previous study by Piechota et al , in whick-means clustering, we identified 6 expression patterns among genes induced by each opioid  and cation transmembrane transport (M phase) were upregulated by heroin, whereas genes involved in regulation of neuron death were downregulated (IE phase) . These rAlso, we noticed that genes involved in cell morphogenesis involved in neuron differentiation, positive regulation of axonogenesis, and regulation of synapse organization were upregulated among IE and L phases after heroin exposure. These results are supported by the previous evidence that drugs of abuse can induce changes in structural plasticity in animals during chronic exposure .Our results also showed that heroin induced genes participating in other key biological processes involved in pain-related pathways, e.g., genes involved in protein autophosphorylation are upregulated in the IE phase. Since protein phosphorylation is known to play key roles in desensitization and implicated in opioid-induced hyperalgesia , our resIn order to find out whether DEGs induced by either morphine or heroin are associated with various harmful effects linked to drugs of abuse, we conducted the association analysis between expression levels of morphine- or heroin-induced DEGs and twelve DA-related harmful effects including dependence, physical dependence, psychological dependence, pleasure, physical harm, social harm, health care cost, and conditioned place preference   Tables. Next, we investigated whether the dependence-associated DEGs induced by either morphine or heroin were involved in the pain-related neuroimmune pathways mediated by opioids. As shown in Tables In order to find out whether the dependence-associated DEGs induced by each opioid were co-regulated by any TFs or epigenetic factors, we performed the TF and epigenetic factor binding site enrichment test using the ENCODE ChIP-Seq significance tool . Our anaMore than half of the TFs we detected regulating dependence-associated DEGs after morphine exposure are previously known to play important roles in drug dependence and addiction. For example, we found that MEF2A upregulated four DEGs which were associated with physical dependence in the M phase, while that MEF2C upregulated one DEG associated with dependence in the IE phase after morphine exposure, agreeing with the evidence that MEF2 is crucial in inducing behavioral changes after exposure to drugs of abuse .Our results also showed a few novel TFs activated by morphine. In order to quantify the magnitude of the effects the detected transcription regulators on the dependence-related behaviors induced by the opioids, we developed a scoring metric, called dependence score, based on the total fold changes of the dependence-associated DEGs co-regulated by each regulator  of the detected transcription regulators after morphine exposure were epigenetic factors . LiteratDEGs upregulated by EGR1 and CREB1 were associated with psychological dependence in the IE phase after administration of heroin, consistent with the fact that both EGR1 and CREB are key TFs which regulate genes involved in dependence-related behavioral responses during exposure of opioids as well as other drugs of abuse , 7. MoreWe found that E2F6 (which showed the highest dependence score in morphine) also had the highest dependence score of 6.52, potentially regulating four DEGs associated with psychological dependence after exposure to heroin.Similar to morphine, more than 40% of the detected transcription regulators were epigenetic factors after heroin exposure . All theTaken together, our results suggest that distinct transcriptional regulatory mechanisms are responsive to exposure of morphine and heroin in mouse striatum, and that epigenetic regulation plays major roles after exposure to both opioids. Further investigation is needed to elucidate the roles of the novel TFs  with high dependence scores after exposure of either morphine or heroin.To facilitate development of therapeutic interventions for treating morphine or heroin dependence, we developed a strategy which allowed us to identify small compounds that can target the opioid-induced dependence-associated DEGs and their potential transcription regulators  and morphine in humans and mice , 55, it gh doses , heroin gh doses  and thusAmong detected transcription regulators that potentially regulate the dependence-associated DEGs, MEF2A induced by morphine as well as EGR1 and CREB1 by heroin are known to play crucial roles in drug addiction. We also found that more than 40% of the detected transcription regulators are epigenetic factors after both morphine and heroin exposure, including HDAC8 and HDAC6 activated by morphine, which supports the previous notion that epigenetic factors are important for addiction. Furthermore, using the dependence score, a metric we developed for measuring the extent the detected transcription regulators affect the dependence-associated DEGs, we found that E2F6 has the highest dependence scores after exposure of both morphine and heroin.In summary, our work here intent to elucidate molecular connections between the analgesic and tolerance-related pain pathways and harmful side effects of opioid use during pain treatment. Despite the general belief that morphine is safe for managing patients with pain, our results suggest that morphine may induce tolerance to analgesia and dependence on the drug in the patients in the very early stage, which may increase the possibility of the same patients to abuse heroin thereafter, since heroin may further induce acute analgesic effects as suggested by our results. Moreover, because heroin can cause both structural and behavioral changes among patients, abusing heroin after morphine may lead to more potent dependence on the drugs among the patients.Furthermore, we found several small compounds which could potentially target some of the dependence-associated DEGs and the detected transcription regulators induced by the opioids. In particular, we identified Securinine and Meclofenoxate which could target E2F6 in humans after exposure to morphine and heroin, respectively. These compounds can facilitate future development of effective therapeutic interventions which can target the adverse side effects of morphine and heroin, while preserving their analgesic effects.We also compared the approach and findings from this work with those from the previous study by Piechota et al.  from whiThe limitations of our work include the following. The gene expression microarray data we analyzed spanned only 8 hours after administration of morphine and heroin, which limited our ability to discover chronic effects of the drugs. In the future study, we intend to employ the same strategy to investigate long-term effects of morphine and heroin, and to compare them with the acute effects we discovered in this work. Also, our results in this work were generated based on analyzing a single gene expression profiling data set, further biological validation of some of the genes differentially induced over time in mouse striatum by morphine and heroin should be conducted to verify our findings here. Despite these limitations, we found that our results agree well with the previously known evidence about drug abuse and addiction, suggesting our findings are valid and worth further in-depth investigation. Moreover, our work provides insight into the molecular connections between the opioid-induced pain-related pathways and the adverse harmful effects associated with morphine and heroin. Understanding such connections may facilitate development of effective therapies which allow people to target dependence-associated genes and transcription regulators at an early stage of opioid use while preserving analgesic effects of opioids.The gene expression microarray data set we analyzed in this work was obtained from the NCBI Gene Expression Omnibus (GEO) database under the accession number [GEO:GSE15774]. This data set was generated from a previous work described in , in whicT relative to the control time point satisfied: 1) adjusted p-value < 0.05, and 2) fold change ≥ 1.2.In order to identify genes differentially expressed over time in mouse striatum after administration of either morphine or heroin, we employed a local regression smoothing technique  to estimK clusters where K is pre-assigned. To determine an optimal number of the clusters for the DEGs, we employed the average silhouette width (ASW) as described in . Let Gj denote a vector of expression values of gene G corresponding to drugs D at time point j; Gj is a DEG induced by either morphine or heroin at time point j, but the gene is not required to be differentially induced by the other drugs at the same time point. The expression values of gene G for the drugs including cocaine, methamphetamine, ethanol, and nicotine were estimated for each drug by using the same local regression smoothing techniques as described above for morphine and heroin. Finally, we calculated the correlation between Gj and Si using both the Pearson correlation and a quadratic polynomial regression; if the resulting p-value from any of the methods was less than 0.05, Gj was considered as significantly associated with Si.Our association analysis aimed to determine whether morphine- and heroin-induced DEGs were associated with any harmful effects of drugs of abuse. The scores which assessed the magnitudes of the twelve harmful effects of various drugs of abuse were taken from Nutt et. al.  and can To identify potential transcription and epigenetic factors that regulate dependence-associated DEGs responsive to each opioid in mouse striatum, we employed the ENCODE ChIP-Seq significance tool  to identR activated in a certain phase P, we assume that R regulates a number N of morphine or heroin-induced DEGs associated with a dependence-related harmful effect  within phase P. As shown in Figs R in phase P was then defined as iFC represents the maximum absolute fold change of the expression values of a DEG Gi within phase P, relative to that of the control time point, and Gi is regulated by R. The higher the dependence score, the more impact the transcription regulator R can have on dependence.Furthermore, to facilitate ranking the significantly enriched TFs and epigenetic factors in terms of their impact on dependence, we developed a scoring metric called the ‘dependence score’ as follows. For each transcription regulator R if the DEGs it regulates were also associated with other harmful effects of drugs  were used to obtain the DEGs induced by small compounds in cells. In BaseSpace, most of the raw gene expression datasets involving perturbations by small compounds were obtained from the Gene Expression Omnibus (GEO) database (http://www.ncbi.nlm.nih.gov/geo/). Only genes with the p-values < 0.05 and absolute fold changes >1.2 were considered as DEGs induced by small compounds. To identify top compounds that have gene expression profiles most correlated with the dependence-associated DEG or the transcription regulators induced by morphine or heroin, we searched the gene expression profiles of small compounds stored in BaseSpace through BaseSpace integrated Pharmaco Atlas search. Then, the correlation between the DEGs induced by small compounds and the opioid-induced DEGs or transcription regulators was calculated as described below.First, a commercial Illumina BaseSpace (former Nextbio™) software   to represent its fold change. For each transcription regulator, we used its dependence score to represent its fold change value.The correlation between the DEGs induced by each small compound and the opioid-induced dependence-associated DEGs or transcription regulators was calculated using the BaseSpace software. This software provided a modified form of the rank-based enrichment statistics to compare the two sets of the DEGs , 65. BasS1 FigFour genes were regulated by both heroin and buspirone, but in opposite directions.(TIF)Click here for additional data file.S1 Table(A) Significantly enriched GO terms induced by morphine. (B) Significantly enriched KEGG pathways induced by morphine.(XLSX)Click here for additional data file.S2 Table(A) Significantly enriched GO terms induced by heroin. (B) Significantly enriched KEGG pathways induced by heroin.(XLSX)Click here for additional data file.S3 Table(XLSX)Click here for additional data file.S4 Table(XLSX)Click here for additional data file.S5 Table(XLSX)Click here for additional data file.S6 Table(DOCX)Click here for additional data file.S7 Table(DOCX)Click here for additional data file.S8 Table(DOCX)Click here for additional data file.S9 Table(A) Small compounds negatively correlated with dependence-associated DEGs induced by morphine. (B) Small compounds negatively correlated with the transcription regulators induced by morphine.(XLSX)Click here for additional data file.S10 Table(A) Small compounds negatively correlated with dependence-associated DEGs induced by heroin. (B) Small compounds negatively correlated with the transcription regulators induced by heroin.(XLSX)Click here for additional data file.S11 Table(XLSX)Click here for additional data file.


Schizophrenia is a psychiatric disorder with a worldwide prevalence of ∼1%. The high heritability and reduced fertility among schizophrenia patients have raised an evolutionary paradox: why has negative selection not eliminated schizophrenia associated alleles during evolution? To address this question, we examined evolutionary markers, known as modern-human-specific (MD) sites and archaic-human-specific sites, using existing genome-wide association study (GWAS) data from 34,241 individuals with schizophrenia and 45,604 healthy controls included in the Psychiatric Genomics Consortium (PGC). By testing the distribution of schizophrenia single nucleotide polymorphisms (SNPs) with risk and protective effects in the human-specific sites, we observed a negative selection of risk alleles for schizophrenia in modern humans relative to archaic humans . Such findings indicate that risk alleles of schizophrenia have been gradually removed from the modern human genome due to negative selection pressure. This novel evidence contributes to our understanding of the genetic origins of schizophrenia. However, recent GWAS findings by The development of evolutionary genomic tools and the emergence of a critical mass of GWAS data have provided the opportunity to empirically examine the “schizophrenia paradox” and uncover evolutionary mechanisms underpinning the pathogenesis of schizophrenia. To assist in reconciling the current evidence to date, additional evolutionary genomic markers i.e., modern-human-specific (MD) sites and archaic-human-specific (AD) sites have recently become available . These g1, which consisted of 34,241 cases and 45,604 controls.Summary statistics of GWAS SNPs were obtained from the PGC schizophrenia study2.Minor allele frequency (MAF) information from the 1000 Genomes Project in European (pop_id = 16652) populations were downloaded from the dbSNP149 database3. We have extracted information  for SNPs within modern-human (MD-SNPs), and archaic-human (AD-SNPs) specific sites. Although most of these sites were fixed in modern humans and did not have alternative alleles, 91,752 MD-SNPs (28.5%) and 66,952 AD-SNPs (31.0%) were identified in the PGC schizophrenia GWAS following cross-table querying using NCBI identifiers (rsID) or chromosome coordinates as keys. It was these polymorphic sites that were used in the subsequent analyses -based SNP pruning process because statistical tests, as described below, assume independence of the studied data. The pruning process was conducted by PLINK software in a 1 Mb window in which any pair of SNPs with F-scores) within each association p-value decile bin  were calculated as the difference between the observed proportion and the expected proportion:To control the potential bias caused by MAF, only SNPs with a MAF < 0.1 were included in the enrichment analysis. The MAF of <0.1 was selected because variants in human-specific sites occur at this frequency or below. Fold change scores  was applied separately to the bipolar, autism and major depressive disorder GWAS data. The chromosome coordinates for genome build 38 (hg38) and build 18 (hg18) were aligned with the coordinates for genome build hg19 by the LiftOver software, along with corresponding conversion references56.To determine if our results observed in schizophrenia could also be observed in other psychiatric disorders, we obtained PGC GWAS summary resultsp-value across all bins = 0.66) or AD-SNPs  among all GWAS SNPs.As shown in p-value = 3.9 × 10−15) was found within the decile bin containing SNPs with the smallest p-value in the PGC schizophrenia GWAS . One explanation for this observation is background selection. Background selection is based on the notion that negative selection could decrease the frequency of a deleterious allele, along with the removal of linked variation within the same LD block. Based on background selection, the elimination of schizophrenia risk alleles may not be the result of their intrinsically deleterious effects, but the negative selection of causal alleles.Our findings show that since the modern human lineage split from Neanderthals and Denisovans, risk alleles for schizophrenia but not for other psychiatric disorders, have been progressively eliminated from the modern human genome. Interestingly, the tendency toward eliminating risk and retaining protective alleles has been identified in not only nominally associated SNPs, but also SNPs that currently have not been associated with schizophrenia  and the relatively recent operationalization of schizophrenia, pose a significant challenge in evaluating changes in the incidence of schizophrenia from an evolutionary perspective. However, an epidemiological study has suggested the incidence of schizophrenia is declining .Our framework could be strengthened or refined by answers to several outstanding questions. First, when did the “turning point” occur? We have speculated the occurrence of this event to have taken place 100,000 – 150,000 years ago but more precise estimates would allow for more sophisticated evolutionary models to be created. Second, how many schizophrenia common risk alleles were present at the turning point? Our framework assumes the number of schizophrenia risk alleles or polygenic burden was greater among our human ancestors but the extent of this additional burden is unknown. Third, what is the rate at which common risk alleles have been eliminated and to what extent have other evolutionary mechanisms such as balancing selection or sexual selection counteracted the rate of allele elimination? Our proposed framework assumes removal of risk alleles has occurred in a static, linear fashion since the turning point. However, to confirm this assumption, DNA from more distant ancestors will be required. Finally, can a single evolutionary framework explain the genetic origin of schizophrenia? Our analysis and framework assume that schizophrenia is a unitary disorder. However, it is widely accepted that schizophrenia represents a clustering of various symptoms rather than a unitary disorder and any comprehensive framework is likely to require a combination of models. As such, our analyses would have ideally been performed on more homogenous populations that shared similar symptoms. Unfortunately, most public schizophrenia GWAS datasets are limited in the amount of symptom level data available, prohibiting these types of analyses. Nevertheless, our findings suggest that risk alleles for schizophrenia have been progressively eliminated from the modern human genome, regardless of the presumed symptom heterogeneity within our sample. Future investigations of schizophrenia GWAS data with high quality phenotyping is warranted.p-value thresholds. Novel evolutionary markers encompassing more schizophrenia SNPs are therefore required to further investigate SNPs with genome-wide significance. Second, insertion-deletion (indels) variants were not included in our analysis due to the low number available in our dataset. Indels play regulatory roles in brain functions, thus future studies should explore their contribution to the genetic origins of schizophrenia. Third, our findings rely on genome information of several archaic humans, but the psychiatric status of the Neanderthal or Denisovan individuals remains unknown. If any of them were affected by psychosis, our findings could be biased. Finally, other evolutionary models, such as the sexual selection and balancing selection model (Despite the novelty and strength of our study, we acknowledge several limitations. Due to the limited number of associated SNPs, the study did not examine the enrichment and substitution of schizophrenia susceptibility under strict on model , have beIn sum, we have performed a novel evolutionary analysis using schizophrenia and other psychiatric disorder GWAS data and comparative genome results in modern and archaic humans. Our study, for the first time, provides experimental evidence supporting the role of negative selection in eliminating risk alleles for schizophrenia but not other psychiatric disorders from the modern human genome. Based on these theoretical and biological findings, we have proposed a novel evolutionary framework to stimulate further research on the evolutionary paradox and genetic origin of schizophrenia.CL conceived and designed the study, performed bioinformatics and statistical analyses. CB and CL interpreted the main findings. CB, IE, and CP supervised the work.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.


Randomized controlled trials targeting maternal dietary and physical activity behaviors during pregnancy have generally failed to accomplish reductions in the prevalence of adverse maternal and neonatal outcomes. Interventions carried out during pregnancy could thus be missing the mark in maximizing intervention health benefit.pre-pregnancy and early pregnancy dietary behavior as reported at inclusion into the Norwegian Fit for Delivery (NFFD) trial was associated with maternal and neonatal outcomes irrespective of subsequent randomization assignment.To investigate whether pre-pregnancy diet score) and dietary behavior at inclusion (early pregnancy diet score), respectively. The diet scores ranged from 0 to 10, with higher score reflecting healthier dietary behavior. Associations between diet scores and maternal and neonatal health outcomes were estimated in multivariate logistic regression models.The study is a post-hoc observational analysis of data from a randomized controlled lifestyle intervention. We constructed two diet scores from participant responses to a 43-item questionnaire that addressed dietary behavior in retrospect  , preterm delivery , and birthweight ≥ 4,000 g . A one-point increase in early pregnancy diet score was associated with lower odds of excessive GWG , preterm delivery , and preeclampsia .A total of 591 women were eligible for analysis. A one-point increase in pre-pregnancy diet and with preeclampsia to early pregnancy diet.Higher diet score either pre-pregnancy or in early pregnancy was protectively associated with excessive GWG and preterm delivery, whereas the protective association with high birthweight was confined to Both pre-pregnancy and early pregnancy dietary behavior was associated with important maternal and neonatal health outcomes in the NFFD dataset. Excessive gestational weight gain (GWG) has been identified as a potentially modifiable risk factor for adverse pregnancy outcomes based on consistent findings from several observational studies . In the These seemingly contradictory findings from observational versus experimental studies could possibly be reconciled by taking into account the time window represented by the dietary data. The abovementioned observational studies information on maternal diet was collected during pregnancy. High correlations have previously been demonstrated between presently reported diet and diet reported several years ahead in the general population . Dietarybefore inclusion, assessed both pre-pregnancy and in early pregnancy, was associated with aspects of maternal and neonatal health irrespective of subsequent randomization assignment.In the NFFD study, participants responded to questions about diet and dietary behavior both at the time of inclusion around week 15 of pregnancy and, in retrospect, to identical questions covering the period before getting pregnant. This left us with the opportunity to investigate both pre-pregnancy and early pregnancy dietary behavior in relation to subsequent maternal and neonatal outcomes and compare the respective effect sizes. The aim of this observational post-hoc analysis was thus to investigate whether NFFD participants’ dietary behavior The present paper is a post-hoc analysis carried out among pregnant women participating in the NFFD study . We treaThe NFFD study is a population-based lifestyle RCT carried out among nulliparous pregnant women in Southern Norway between 2009 and 2013 . The main aim of the study was to facilitate optimal GWG through dietary advice and twice-weekly supervised exercise lessons, and thereby reducing the number of infants with high birthweight. The study protocol and the effectiveness of the intervention on various outcomes have been published previously –21.2, were 20 weeks pregnant or less at inclusion, carrying a single fetus, literate in Norwegian or English, and had provided written consent (n = 303) or intervention group (n = 303), respectively. Twelve women were later withdrawn from the study because of miscarriage (n = 6), twin pregnancy (n = 2), and relocation outside study area (n = 4). One woman was excluded from participation in the trial due to very low BMI after being mistakenly included, and two women withdrew from the trial without giving permission to use data. A total of 591 participants were thus included in intention-to-treat analyses in the main study and were also eligible for the observational analyses in the present study.Women were eligible for participation if they were 18 years or older, nulliparous, had pre-pregnancy body mass index (BMI) ≥19 kg/mThe diet intervention aimed at facilitating optimal GWG and otherwise promoting a healthy pregnancy through simple diet rules aimed at heightening participant reflection on dietary behavior (see below). We based the intervention components on 10 dietary recommendations developed specifically for the study. The rationale for the 10 recommendations has been published previously .The 10 dietary recommendations in the NFFD trial are the following :Eat regular mealsDrink water when thirstyEat vegetables with dinner every dayIn-between meals – choose fruits and vegetablesEat sweets and snacks only when you really appreciate itChoose small portion sizes of unhealthy foodsLimit your intake of added sugarLimit your intake of saltDo not eat beyond satietyRead nutritional labelsWomen randomized to the intervention group received an illustrated booklet describing the dietary recommendations and their simplified rationale shortly after randomization. The recommendations were reinforced and tailored to the individual in two telephone sessions with a trained advisor, scheduled approximately 4–6 weeks apart. The intervention also comprised access to supervised exercise classes twice weekly, including strength training and cardiovascular exercise at moderate intensity. Women in the control group received routine pregnancy care but answered the same questionnaires and received the same medical follow-up as intervention participants, including extra ultrasound investigations and blood tests. The present paper addresses pre-intervention dietary behavior in relation to maternal and neonatal health outcomes.pre-pregnancy and an early pregnancy diet score, respectively. The scores were designed to reflect participant degree of compliance with the 10 dietary recommendations prior to inclusion into the study. Both diet scores were built from 10 subscales, each subscale referring to a corresponding dietary behavior. The subscales were built from participants’ responses to the baseline questionnaire that included a 43-item questionnaire with food frequency questions (FFQ) and questions about aspects of dietary behavior. All 43 questions addressed pre-pregnancy diet in retrospect, and present diet at the time of inclusion (e.g. ‘how often did you drink water before you became pregnant?’ and ‘how often do you drink water now?’). The questionnaire only covered selected aspects of diet and dietary behavior, mainly the dietary aspects that were targeted in the NFFD intervention 44% or more of drinking events being water having vegetables with dinner ≥5 times/weekchoosing fruits or vegetables for in-between meal snacks ≥3 times/week never eating sweets and snacks without appreciationbuying small portion size of one or more unhealthy food items consuming sugar-rich food items once a day or lessconsuming fast-foods, snacks, or other salty food less than dailyeating beyond satiety less than once a weekreading nutrition labels on foods sometimes or often.A detailed description of the construction of the diet score and its test–retest reliability has been published previously .Outcomes in the present study were excessive and inadequate GWG, preeclampsia, preterm delivery, GDM, and various measures of birthweight. Birth records and hospital charts were reviewed in retrospect to validate information on maternal and neonatal outcomes 2) was calculated based on self-reported pre-pregnancy weight (kg) and measured height (m). Participants were also weighed on admission to the delivery ward. If admission weight was not available, the last weight in the prenatal record was recorded with its corresponding date. Total weight gain was calculated for women who delivered at ≥37 gestational-weeks with measured weight available within 2 weeks of admission . Height was measured with a stadiometer . Pre-pregnancy BMI kg/m was calcParticipants underwent a glucose tolerance test in gestational week 30, with measurement of fasting serum glucose after overnight fasting, and postprandial level 2 h after intake of 75 g of glucose. Glucose levels ≥7.8 mmol/l at 2 h were classified as elevated, based on 2006 WHO criteria . The diaPreeclampsia was diagnosed based on guidelines adopted by the Norwegian Federation of Obstetricians and Gynecologists; an increase in blood pressure to at least ≥140 systolic or 90 mm Hg diastolic after 20th gestational week combined with proteinuria (protein excretion of at least 0.3 g/24 h or ≥1+ on dip-stick), both measured at least twice  and low birthweight  , and relInformation on maternal age, education, marital status, occupation, income, smoking, pre-pregnancy weight and early pregnancy physical activity level was collected from the baseline questionnaire completed upon inclusion. BMI was calculated from self-reported pre-pregnancy weight and height measured with a stadiometer at inclusion . Physical activity level was assessed with the International Physical Activity Questionnaire short form (IPAQ-SF) , 28 thatp-value of ≤ 0.05 was considered significant. Maternal age, weight, height, and BMI are presented with mean and standard deviation (SD). Sociodemographic variables are presented with number and proportions (%). We calculated mean diet score for each category of the sociodemographic variables to visualize covariance between pre-pregnancy and early pregnancy diet scores and potential confounders.Statistical analyses were performed with SPSS for IBM statistical software package version 24.0 . A two-sided We compared dietary intake across diet score categories and presented this information with median and interquartile range (IQR) as Supplementary Table 2. Prevalence of maternal and neonatal outcomes were similarly compared across low, medium and high diet score categories and tested for trend across categories with the Mantel-Haenszel statistics .pre-pregnancy and early pregnancy diet scores as main exposure in separate tables. In the multivariate models, we included the following potential confounders: maternal age at inclusion (continuous), marital status , pre-pregnancy BMI (continuous), educational attainment , household income , and randomization assignment (control/intervention). In the early pregnancy analyses, we additionally included current smoking (yes/no). A total of 110 participants had missing information on early pregnancy physical activity level. We therefore fit a third early pregnancy model that included early pregnancy physical activity level  along with the other potential confounders.We estimated crude and adjusted odds ratios (OR) and 95% confidence intervals (CI) for all outcomes with the continuous Given the randomized controlled design, and the fact that the intervention group improved diet and physical activity behaviors compared to the control group between randomization and delivery , we perfWritten informed consent was obtained from all participants before inclusion into the study. The study was approved by the Norwegian Regional Committee for Medical Research Ethics South East C (REK reference 2009/429). The authors assert that all procedures contributing to this work comply with the ethical standards of the Norwegian Regional Committee for Medical Research Ethics and with the Helsinki Declaration of 1975, as revised in 2008. The NFFD trial has the Clinical Trials registration: clinicaltrial.gov NCT0100168.2 (SD 3.9). Mean pre-pregnancy and early pregnancy diet score across categories of the sociodemographic variables are presented in p < 0.001) and a negative correlation with smoking status (p < 0.05). Pre-pregnancy diet score was positively correlated with early pregnancy physical activity level (p = 0.029). Neither age, pre-pregnancy BMI, marital status, income nor occupation was significantly associated with the diet scores. A comparison of the dietary characteristics associated with low, medium, and high diet scores in both pre-pregnancy and in early pregnancy are presented in Supplementary Table 2. Higher diet score implied more frequent consumption of main meals, fruits, vegetables, and water, and less frequent consumption of sweetened beverages, sweets, and snacks. There was considerable correlation between the continuous pre-pregnancy and early pregnancy diet scores .Descriptive information about the 591 participants is presented in pre-pregnancy and early pregnancy diet scores, respectively, are presented in pre-pregnancy diet score categories, but concurrent higher prevalence of SGA with higher diet scores. For the early pregnancy diet score, we observed significant trends toward lower prevalence of preterm delivery and macrosomia with higher diet score, and a concurrent higher prevalence of SGA.Differences in prevalence of maternal and child outcomes with low, medium, and high pre-pregnancy and early pregnancy diet scores and odds of excessive GWG in crude and adjusted models (Mean GWG was 15.0 kg (SD 6.0). The overall prevalence of excessive and inadequate GWG was 48.6 and 20.9%, respectively, leaving 30.5% with optimal GWG. There were significant inverse associations between a one-point increase in d models  and 4 bupre-pregnancy (13.9%) or in early pregnancy (12.5%)  NFFD participants were diagnosed with GDM. The highest prevalence of GDM was observed among women in the medium diet score category, whether assessed  (12.5%) . There wanalyses  and 4.A total of 25/582 participants (4.3%) developed preeclampsia, with 15/582 (2.6%) classified as severe cases. Early pregnancy diet score was protectively associated with preeclampsia risk in model 3 when adjusted for pre-pregnancy physical activity level in addition to other potential confounders . The samearly pregnancy diet score had the highest prevalence of preterm delivery (12.5%), while women with high diet score pre-pregnancy had the lowest prevalence (2.6%)  delivered preterm. Women with low e (2.6%) . There we (2.6%)  and 4. Tpre-pregnancy and early pregnancy diet score were inversely associated with birthweight above 4 kg in crude models, but the association was attenuated and no longer significant in the adjusted models  newborns had birthweight ≥4,000 g at term, and 7/557 (1.3%) had birthweight ≥4,500 g. A total of 18/591 (3.0%) were classified as LGA. Both the d models  and 4. Tty level . There wpre-pregnancy and early pregnancy models confined to the control group to assess the associations in a non-intervention setting. This made no substantial difference in the direction or magnitude of the estimates although some of the associations were no longer significant because of the smaller sample (Supplementary Tables 3a and 3b).There was no formal interaction between randomization assignment and the diet scores. We nevertheless reran all pre-pregnancy and early pregnancy dietary behavior. Lower odds of high birthweight were only observed with increasing pre-pregnancy diet score, whereas lower odds of preeclampsia were only observed with increasing early pregnancy diet score. No association between the two diet scores and GDM was observed in this sample.In this study, we investigated whether and how degree of maternal compliance with a set of predefined dietary behaviors assessed both pre-pregnancy and in early pregnancy was associated with maternal and neonatal outcomes in the NFFD dataset. For the outcomes excessive GWG and preterm delivery, respectively, we found protective associations of similar magnitude with To our knowledge, no other study has investigated both pre-pregnancy and early pregnancy dietary behavior in the same individuals in relation to subsequent maternal and neonatal outcomes. Having done so, allows for speculation regarding sensitive periods for the role of diet and dietary behaviors in the prevention of adverse pregnancy outcomes. Our findings suggest a protective influence of healthier pre-pregnancy dietary behavior on GWG, preterm delivery, and newborn macrosomia, but possibly also an independent protective influence of early pregnancy dietary behavior on preeclampsia risk. Although aspects of dietary behavior changed from pre-pregnancy to early pregnancy among NFFD participants , 31, theThe protective associations observed between pre-pregnancy and early pregnancy dietary behavior and excessive GWG support the relevance of targeting the chosen dietary behaviors for optimizing GWG. A recent observational study from Greece reported that higher adherence to the Mediterranean diet prior to pregnancy was associated with decreased risk for deviation from the maternal recommended GWG .pre-pregnancy had similar prevalence of excessive GWG as women in the intervention group (41.6% vs. 42.8%) (NFFD women with high diet score . 42.8%) . Given tpre-pregnancy and early pregnancy diet scores and subsequent preterm delivery. Our findings are in agreement with previous observations of protective associations between healthy dietary patterns during pregnancy and subsequent preterm delivery   . The NFFr score) . Given tpre-pregnancy diet score and preeclampsia in the present study. A significant protective association was, however, observed between early pregnancy dietary behavior when the model was adjusted for physical activity level   .pre-pregnancy and early pregnancy diet score highlights that there is also a risky side of presumably healthy dietary behaviors, and that energy balance–related behaviors might compromise fetal fuel availability if taken too far. There was however no significant association between the diet scores and odds of SGA in multivariate analyses, indicating that other maternal characteristics associated with the diet scores might explain the increased prevalence of SGA in the unadjusted analysis in p = 0.679)  could be more conscious about their diet than women with lower risk, and therefore more likely to be categorized in the medium (or high) diet score category. A pre-pregnancy ‘Meats, snacks, and sweets’ pattern was associated with higher GDM risk, and a ‘Mediterranean-style’ pattern with lower risk after adjustment for socioeconomic, reproductive, and lifestyle factors in the Australian Longitudinal Study on Women’;s Health . Large pThere are several strengths to the present study. The participation rate in the trial was high. All women provided dietary data upon inclusion in early pregnancy, and in retrospect, the same dietary data pertaining to the period before getting pregnant. Birth records and hospital charts were reviewed for all participants to confirm data on maternal weight gain and maternal and neonatal outcomes.Only nulliparous women were included in the study. Nulliparity is associated with higher risk of pregnancy complications compared to multiparous pregnancies . Thus, hSufficient variation in diet is necessary to detect true diet–disease associations in epidemiological studies . RandomiThere are, however, also limitations that warrant discussion. Causality cannot be inferred from observational data. We adjusted for randomization assignment in all models and reran all models confined to the control group to avoid bias introduced by the intervention. There could, however, still be residual or unmeasured confounding from participating in a lifestyle intervention trial. The diet scores are likely to capture level of health consciousness in general, which could imply that variation in personal traits not captured by the sociodemographic variables could positively or negatively confound the associations.pre-pregnancy diet score in general. If random, misreporting would tend to bias the estimates toward null association. Misreporting or measurement error in the other covariates could not only lead to biased estimates but would also tend to bias estimates toward null association. We therefore assume that our estimates are conservative.The NFFD diet score and subscales have shown acceptable test–retest reproducibility  but haveThe NFFD diet score represents a crude operationalization of dietary behavior and equal weight is given to each dietary behavior regardless of their potential individual impact on the various outcomes. We did not investigate individual dietary behaviors in relation to the outcomes as our aim was to evaluate this constellation of dietary behaviors. It has previously been documented that single behaviors have less power as predictors of complex outcomes such as preterm delivery .The NFFD diet score was primarily constructed to evaluate post-intervention effect of the diet intervention and reflected degree of adherence to the 10 dietary recommendations that were forwarded to the intervention group in the trial . It coulThe women participating in the NFFD study were predominantly white, European, highly educated, and nulliparous, and therefore not fully representative of the pregnant background population. This self-selection may have affected outcome prevalence but is less likely to have influenced diet-outcome associations .early pregnancy diet score. Based on these findings, we speculate that the previously observed relationship between diet reported during pregnancy and pregnancy complications such as preterm delivery in observational studies could be a representation of a relationship that at least partly exists between maternal pre-pregnancy dietary behavior and the neonatal outcomes in question.There are numerous reasons why pregnant women should be encouraged to achieve and maintain a healthy and nutritious diet during pregnancy. The relevance of pre-pregnancy diet for maternal and offspring antenatal and long-term health should, however, be explored as a means to securing maximum benefit of public health interventions. Our findings suggest that NFFD participants’ pre-pregnancy compliance with the dietary behaviors targeted in the NFFD trial was beneficially associated with risk of pregnancy and neonatal outcomes such as excessive GWG, preterm delivery, and newborn macrosomia. We did not observe substantial differences between associations with early pregnancy as opposed to pre-pregnancy dietary behavior, except for the lower odds of preeclampsia that was only observed with increasing Prospectively collected high-quality dietary data from various time-points before conception and during pregnancy with the possibility of linkage to birth registry data would help identify important windows of opportunity for a healthy pregnancy and a nutritionally sound start to life. RCTs evaluating diet interventions before conception will need to be undertaken to establish causality.Click here for additional data file.


MT) through signaling to the nucleus. Mitochondrial damage or danger associated molecular patterns (DAMPs) provide a link between mitochondria, inflammation and inflammatory disease processes. Additionally, a new class of peptides generated by the mitochondria affords protection against age-related diseases in mammals. In this short review, we highlight the role of mitochondrial signaling and regulation of cellular activities through the mitochondrial UPRMT that signals to the nucleus to affect homeostatic responses, DAMPs, and mitochondrial derived peptides.Mitochondria are established essential regulators of cellular function and metabolism. Mitochondria regulate redox homeostasis, maintain energy (ATP) production through oxidative phosphorylation, buffer calcium levels, and control cell death through apoptosis. In addition to these critical cell functions, recent evidence supports a signaling role for mitochondria. For example, studies over the past few years have established that peptides released from the mitochondria mediate stress responses such as the mitochondrial unfolded protein response (UPR This response is initiated by the accumulation of unfolded proteins in the mitochondria resulting in the induction of UPRMT components , and mitochondrial derived peptides (MDPs) .Mitochondria are essential double membrane cellular organelles that provide the energy to the cell through oxidative phosphorylation. Mitochondria also play a key role in cellular function and homeostasis through adenosine triphosphate (ATP) production, calcium homeostasis, apoptosis signaling, and fatty acid oxidation. In addition, mitochondria modulate redox signaling through the production of reactive oxygen species (ROS). While the role of mitochondrial ROS signaling in modulation of cellular processes has been established, recently several studies have highlighted additional signaling roles for mitochondria that are not initiated by ROS. The idea that mitochondria can regulate cellular metabolism through mitochondrial derived signaling was first described in yeast. Using mitochondrial DNA depleted l stress . Higher mponents . In addiMT signaling pathway was first elucidated in C. elegans. Mitochondrial stress generated from misfolded proteins was shown to activate the adenosine triphosphate (ATP)-dependent mitochondrial protease, ClpP, to cleave misfolded proteins  and hsp-10  depleted mammalian cells. The mammalian transcription factors, CHOP and C/EBPβ were implicated as putative transcription factors for this pathway based on conserved regulatory element in promoters of the UPRMT related genes  mutant Cos-7 cells under proteotoxic stress  .In recent years, studies have shown that mitochondria can modulate inflammation and the immune response through the release of signaling factors known as Mito-DAMPs . Under ps (NFPs)   plays a toxic role. eATP is upregulated in diabetic nephropathy , hyperteN-Formyl peptides are a class of peptides that are produced by bacterial cells and mitochondria suggesting their involvement in host defense against bacterial infection and the clearance of damaged cells. NFPs have a high affinity binding site for FPR, NFP  in the mitochondrial genome. MDPs regulate a wide range of cellular signaling pathways and have an implicated role in aging. In this section, we review known MDPs and their role in cellular activities.Humanin was the first discovered MDP using a functional expression screen for peptides that could suppress neuronal cell death induced by Aβ . HumaninHumanin elicits cytoprotection inter- and intracellular via anti-apoptotic effects and binding to two plasma membrane receptors. Humanin interacts via binding with IGFBP-3, Bax, and tBid . In cellDue to the universal cytoprotective activities of humanin, it has been proposed to have therapeutic potential to enhance human healthspan. In fact, humanin has been linked to aging. Humanin levels significantly decline with age in humans and rodent models . OffspriMOTS-c is a 16-amino-acid peptide encoded by 12S rRNA sORF in the mtDNA that has been proposed to play a role in regulation of metabolism . The MOTMicroarray analysis in two different mammalian cell culture lines demonstrated that MOTS-c regulates global gene expression specifically affecting metabolic and inflammatory related genes . The altStudies have shown that MOTS-c can protect against a number of pathologies. MOTS-c treated mice have reduced body weight, food intake, and blood glucose. MOTS-c promotes insulin sensitivity and protects from high-fat diet induced insulin resistance and obesity in mice . SpecifiAnalyses of the mitochondrial genome from an exceptionally long-lived Japanese population suggest a role for MOTS-c in human longevity . Mitochoin silico prediction analyses of sORFs identified six novel peptides named small humanin-like peptides (SHLPs) 1–6 (An LPs) 1–6 . The exiCell viability and apoptosis studies revealed that SHLPs 2 and 3 promotes cell viability and protection against cellular apoptosis in NIT-1 and 22Rv1, mouse beta and human prostate cancer cells, respectively . One metSimilar to humanin and MOTS-c, SHLP 2 circulating levels decline with age making it a potential therapeutic target for age-related diseases . In factMT, was demonstrated in C. elegans and more recently studies have demonstrated that mitochondrial stress restricted to neuronal tissue induced the UPRMT in a heterologous tissue, the intestine. These findings suggest that there is not only intracellular signaling resulting in UPRMT activation, but that there is also signaling between/among tissues resulting in UPRMT activation. This is a novel concept that has important implications for extending our understanding of the role of mitochondria in cellular function and resistance to stress. Mitochondrial peptides have also been shown to regulate cytoprotective activities and mitochondrial stress responses in mammals. For example, a recently discovered MDP, humanin, is released during mitochondrial dysfunction resulting in an increase of cytoprotective activities and providing protection against a range of pathologies. Since the discovery of humanin, MOTS-C and a class of six other mitochondrial derived peptides (SHLPs) have been identified. Similar to humanin, these peptides have shown to afford cytoprotection but not much is known. Future work will likely continue to demonstrate exciting new signaling and regulatory functions for the mitochondria.Since the initial finding of mitochondrial nuclear signaling in yeast, our understanding of the potential for mitochondrial to act in a cell signaling capacity has expanded significantly. A similar mitochondrial-nuclear signaling pathway, the UPRSH, KS, and HVR wrote the text. KS prepared the figures.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.


Circadian rhythms orchestrate crucial physiological functions and behavioral aspects around a day in almost all living forms. The circadian clock is a time tracking system that permits organisms to predict and anticipate periodic environmental fluctuations. The circadian system is hierarchically organized, and a master pacemaker located in the brain synchronizes subsidiary clocks in the rest of the organism. Adequate synchrony between central and peripheral clocks ensures fitness and potentiates a healthy state. Conversely, disruption of circadian rhythmicity is associated with metabolic diseases, psychiatric disorders, or cancer, amongst other pathologies. Remarkably, the molecular machinery directing circadian rhythms consists of an intricate network of feedback loops in transcription and translation which impose 24-h cycles in gene expression across all tissues. Interestingly, the molecular clock collaborates with multitude of epigenetic remodelers to fine tune transcriptional rhythms in a tissue-specific manner. Very exciting research demonstrate that three-dimensional properties of the genome have a regulatory role on circadian transcriptional rhythmicity, from bacteria to mammals. Unexpectedly, highly dynamic long-range chromatin interactions have been revealed during the circadian cycle in mammalian cells, where thousands of regulatory elements physically interact with promoter regions every 24 h. Molecular mechanisms directing circadian dynamics on chromatin folding are emerging, and the coordinated action between the core clock and epigenetic remodelers appears to be essential for these movements. These evidences reveal a critical epigenetic regulatory layer for circadian rhythms and pave the way to uncover molecular mechanisms triggering pathological states associated to circadian misalignment. Circadian rhythms are apparent in most living organisms, as persistent 24-h cycles in physiology, behavior, or even metabolism. They have evolved to adapt and anticipate daily environmental fluctuations, temporally segregating biological functions to specific hours along the day. For example, in humans, sleep/wake cycles are under circadian control, and they fluctuate in coherence with feeding/fasting periods. As a result, metabolic fluxes show rhythmic regulation in most tissues, allowing the organisms to efficiently couple food intake with adequate energy use . MoreoveClassic and novel genetic and molecular biology approaches shed light on the gears of circadian rhythms at the cellular level . RemarkaIn mammals, the circadian clock is a time tracking system that allows the organism to anticipate and adapt to environmental changes. This system is organized as a hierarchy of oscillators, coordinated by a central pacemaker located in suprachiasmatic nucleus (SCN) of the hypothalamus. The SCN is composed of about 20,000 neurons with unique network properties that confer the entire nucleus a remarkable synchrony in its electrical properties, showing autonomous circadian cycles in the action-potential firing from these pacemaker neurons . RemarkaPeriod (Per1-3) and Cryptochromes (Cry1-2) genes, which when translated, dimerize together and with members of the casein kinase 1 family  and conform the Period repressive complexes . In. In61]. Dbp gene . AdditioPER2 and CLOCK during the circadian cycle serve as a predictor of their transcriptional activity [ASH1L  is dynamically coupled inside a circadian interactome with additional rhythmically expressed and cell-type-specific genes  and HNF6 (hepatocyte nuclear factor 6) in the liver, which in turn can mediate tissue-specific looping, thereby shaping a particular circadian transcriptome for each tissue or cell type , 96. ThiFasn (fatty acid synthase), Acaca (acetyl-CoA carboxylase 1), Acox1 (acyl-CoA oxidase 1), or Aldh3a2  [An important question remains whether enhancer-promoter interactions could be the trigger of distinct genetic programs of gene expression in response to environmental challenges . Recent mber A2) . In thismber A2) –102.+, is generally diminished [The dynamic interplay between spatial organization of the genome and the circadian gene expression program is emerging. Up-and-coming research highlights a remarkable plasticity on chromatin states and genome dynamics during the circadian cycle, and epigenetic transitions appear to be at the core of transcriptional reprogramming triggered by environmental cues. Components of the molecular clock, including BMAL1 and REVERBα, emerge as important regulators of dynamic interactions in the three-dimensional genome during the circadian cycle. However, the role of the circadian machinery in defining functional regulatory elements in response to environmental challenges remains to be understood. Growing our understanding on these mechanisms will remarkably benefit from recent technological advances on molecular imaging of live cells . For examinished . Hence, All these findings provide an exciting scenario to investigate circadian regulation of pathological states and constitute starting points to uncover precise molecular links that couple the circadian clock with metabolic control, epigenetic regulation, and environmentally triggered phenotypes Fig. b. For ex


In patients who have undergone resection for rectal cancer after neoadjuvant radiotherapy, loop ileostomy is commonly performed with few serious complications. In rare cases, if this irradiated small bowel is strictured, reversal of the affected ileostomy can have dire consequences. We present a case of a 62-year-old male with recurrent intestinal obstruction after closure of his loop ileostomy.  RC is a 62-year-old male who initially presented with rectal cancer and underwent neoadjuvant chemoradiation prior to a laparoscopic low anterior resection with diverting loop ileostomy. He underwent elective reversal of his ileostomy and developed persistent postoperative obstruction. He underwent resection of the prior reversal site with normal-appearing dilated proximal bowel loops and collapsed distal bowel loops. He again developed an obstructive picture and underwent resection of the prior anastomosis with creation of an ileocolic anastomosis, after which he recovered well postoperatively.  In patients who receive radiation adjuvant therapy for colon cancer, radiation-induced stricture should be considered as a cause of small bowel obstruction postoperative. In the setting of a longstanding ileostomy, evaluation of a defunctionalized distal ileum may be necessary to evaluate potential obstruction from radiation changes. Radiation enteropathy is a functional disorder of the intestine that occurs during or after a course of radiotherapy to the abdomen, pelvis, and rectum . It is eRC is a 62-year-old male who initially presented with a T3N2M0 midrectal cancer and underwent neoadjuvant chemoradiation four weeks prior to a laparoscopic low anterior resection with diverting loop ileostomy. He completed adjuvant chemotherapy and returned for an elective reversal of his ileostomy nine months postoperative. His preoperative workup included a colonoscopy which revealed exclusion colitis for which he was treated. He also underwent a gastrografin enema and computed tomography (CT) imaging of his abdomen and pelvis with no evidence of recurrence, obstruction, or distant metastases. On CT imaging, the proximal ileum appeared normal, but the distal ileum was not imaged. After his reversal, his postoperative course was complicated by persistent small bowel obstruction, for which he was managed conservatively for two weeks. He subsequently underwent a CT abdomen and pelvis, which was highly suspicious for anastomotic stricture.On postoperative day 14, the patient underwent a diagnostic laparoscopy showing multiple adhesions around the previous reversal site with normal-appearing dilated proximal and collapsed distal small bowel. There was no localized stricture in the defunctionalized distal ileum. He underwent a resection of the prior reversal site and creation of a new side-to-side primary anastomosis. Despite creation of new anastomosis, his small bowel obstruction continued for additional two weeks. CT imaging and small bowel series were obtained, both modalities showing a narrowing of the ileum distal to the previous anastomosis Figures . On hospRadiation-induced small bowel injury has been reported with an incidence of 0.8-17%, but true incidence is difficult to determine with underrepresentation in the literature , 4. RadiIn patients who receive radiation adjuvant therapy for colon cancer, radiation-induced changes should be considered as a cause of small bowel obstruction postoperative. Complete radiologic workup before diverting ileostomy reversal is necessary to evaluate distal bowel patency for reanastomosis but may miss potential radiation-induced pathology. In the setting of a longstanding ileostomy, evaluation of the patency of the defunctionalized distal ileum may be necessary to evaluate potential obstruction from radiation changes. These patients can be successfully treated with resection of the affected segment and reanastomosis.


Computerized tomography (CT)-guided blue dye localization has been widely discussed for preoperative localization of pulmonary nodules. However, few studies have investigated this technique for intra-abdominal lesions. Although preoperative localization is not commonly required in laparotomy, it may assume importance with advancements in the field of laparoscopic surgery.Herein, we report the cases of 2 patients diagnosed with colon cancer who underwent hemicolectomy with extended lymphadenectomy and subsequent chemotherapy.Follow-up CT scans showed newly developed metastatic lymphadenopathy and peritoneal tumor implants.Considering the difficulty in identification of and access to the target lesions during laparoscopic surgery, preoperative CT-guided blue dye localization was performed in both cases.All the target lesions were identified by the dye marker and removed successfully. The pathologic results revealed adenocarcinoma.We established the following strategy for preoperative CT-guided dye localization of intra-abdominal lesions:Intra-abdominal lesions that are hard to identify due to their size or morphology, and difficult to approach due to their location or surrounding structures, maybe the candidates for this procedure, especially in cases of laparoscopic surgery.Operators should adjust their localization planning based on the surgery method, cutting path, and location of port sites. The target dye marker should be clearly visible in the presumed intra-operative field of view.A second dye marker should be made to ensure surgical success when the target dye marker is obscured by the surrounding structures in the presumed intra-operative field of view. However, in cases where identification of a lesion is challenging or the target location is difficult to access, especially during laparoscopic surgery, preoperative localization may play an important role in ensuring surgical success. Herein, we report the cases of 2 patients who underwent CT-guided blue dye localization for metastatic lymphadenopathy and peritoneal tumor implants because of colon cancer before laparoscopic surgery. We discuss the advantages and disadvantages of using this technique in these 2 cases, which may help operators develop improved strategies for localization planning.Computerized tomography (CT)-guided blue dye localization is a well-developed technique and is already being used in many clinical cases. It has been widely discussed for preoperative localization for wedge resection of pulmonary nodules.22.1A 49-year-old woman diagnosed with ileocecal valve adenocarcinoma in October 2015 underwent right hemicolectomy with extended lymphadenectomy and subsequent chemotherapy. Pathologic analysis revealed American Joint Committee on Cancer (AJCC) 7th stage pT4aN2bM0. After 17 months of regular follow-up, CT imaging showed newly developed right internal iliac lymphadenopathy with a short axis diameter measuring up to 13 mm ,In Case 1, preoperative blue dye localization was performed because of difficulty in accessing the target lesion due to the overlying psoas muscle. Although the procedure was successful, the surgeon did not identify the lesion via the laparoscopic ports at the beginning of the surgery because the dye marker was mostly obscured underneath the muscle. To avoid this, precise surgical planning (including cutting path and port site locations) and the presumed intra-operative field of view should be put into consideration when the operator determines the exact extent of the dye marker. Furthermore, a second dye marker is required when the target dye marker is obscured by the surrounding structures. In this case, the second dye marker should have been made at the ventral surface of the psoas muscle so that the surgeon could have noticed the to-be-cut level of the target lesion at first sight (Fig. In Case 2, preoperative assessment revealed multiple target sites with surrounding adhesion. Hence, blue dye localization for the smallest tumor implant was performed because of the surgical complexity. Although the target tumor nodule itself was not difficult to access, preoperative localization shortened the duration of laparoscopic surgery and resulted in a favorable outcome by facilitating identification of the subtle lesion.,3,5,6Technically, CT-guided blue dye localization is a safe and efficient procedure with a high success rate. Before the procedure, a detailed history taking should be performed to know whether the patient has had specific allergies, severe claustrophobia, or severe coagulopathy. When performing intra-abdominal localization, a safe path for puncture should be established to avoid hollow organs and large vessels. Patients should change their posture, take oral diluted iodine contrast medium, or receive intravenous iodine contrast medium injection to avoid non-target puncture, if necessary. According to published literature on the localization of pulmonary nodules and our experiences with the localization of both pulmonary and intra-abdominal lesions, 0.3 to 0.5 mL of pure blue dye is adequate for a lesion measuring <10 mm. In addition, wire causes pleural or peritoneal irritation, whereas dye localization has no such disadvantages.Kleedehn et al retrospectively reviewed 107 cases of lung nodules subjected to wire or blue dye localization, and no significant differences between these 2 localization methods were observed in terms of the success rate and complications. Although wire dislodgement occurred in 13% of the cases, no influence on the surgical outcome was noted.In our facility, patients undergo the surgery within 3 hours after completion of wire localization in case of dislodgement. On the other hand, according to our experience, the injected dye marker may last up to 24 hours in vivo and still offer the surgeon precise identification of the target lesion. Therefore, dye localization offers greater flexibility with respect to scheduling of CT examination rooms and operating rooms.–11 Montgomery et al reported that among 2392 patients who underwent sentinel lymph node mapping for breast cancer, the incidence of allergy to isosulfan blue dye and hypotensive reactions was 1.6% and 0.5%, respectively.Some studies have shown that blue dye causes allergies.We have established the following strategy for preoperative CT-guided dye localization of intra-abdominal lesionsIntra-abdominal lesions that are hard to identify due to their size or morphology, and difficult to approach due to their location or surrounding structures, maybe the candidates for this procedure, especially during laparoscopic surgery.Operators should modify their localization planning based on the surgical method, cutting path, and location of port sites. The target dye marker should be clearly visible in the presumed intra-operative field of view.A second dye marker should be made to ensure surgical success when the target dye marker is obscured by the surrounding structures in the presumed intra-operative field of view.In summary, this article highlights the clinical importance of preoperative CT-guided dye localization for select cases during laparoscopic surgery. Further experience is needed to advance the protocol for patient selection and improve the strategies for localization planning.Data curation: Bi Li Yang.Project administration: Bi Li Yang.Supervision: Chin Chu Wu.Writing – original draft: Bi Li Yang.Writing – review and editing: Bi Li Yang, Kuo Chang Chen, Chin Chu Wu.


Patient reported history of comorbid illness may be the only information available to the treatment team during an acute injury admission. Nevertheless, acute injury, particularly traumatic brain injury (TBI) which affects cognition, may decrease the patient’s ability to accurately report medical history. Thus, the objective of this study was to evaluate the accuracy of patient-reported comorbid illness burden compared to the patient’s Medicare administrative claims. Records of older adults treated for TBI at an urban level 1 trauma center 2006-2010 were linked to their Medicare administrative. Comorbidities were recorded in Medicare claims based on ICD9 codes and were reported in the trauma registry (TR) based on patient medical history recorded by a physician or nurse. Prevalence of each of the following comorbidities was calculated using information from the TR and claims: Alzheimer’s disease and related dementias, chronic kidney disease, COPD, heart failure, diabetes, depression, stroke, and hypertension. Sensitivity of each patient-reported comorbidity was calculated using Medicare claims as the gold standard. We identified patient factors associated with accurate self-report using logistic regression. Among 408 older adults with TBI that linked to their Medicare claims, prevalence of each comorbidity was higher in Medicare claims compared to the TR, except for hypertension. Sensitivity for detecting these comorbidities using the TR ranged from 2% to 68%, with the highest sensitivity observed for hypertension. Older age and race were predictors of less accurate reported medical history. Reconciling self-reported patient history of these comorbidities with those reported in claims can better inform decisions regarding treatment.