Anomalous patterns of brain gyrification have been reported in major psychiatric disorders, presumably reflecting their neurodevelopmental pathology. However, previous reports presented conflicting results of patients having hyper-, hypo-, or normal gyrification patterns and lacking in transdiagnostic consideration. In this article, we systematically review previous magnetic resonance imaging studies of brain gyrification in schizophrenia, bipolar disorder, major depressive disorder, and autism spectrum disorder at varying illness stages, highlighting the gyral pattern trajectory for each disorder. Patients with each psychiatric disorder may exhibit deviated primary gyri formation under neurodevelopmental genetic control in their fetal life and infancy, and then exhibit higher-order gyral changes due to mechanical stress from active brain changes  thereafter, representing diversely altered pattern trajectories from those of healthy controls. Based on the patterns of local connectivity and changes in neurodevelopmental gene expression in major psychiatric disorders, we propose an overarching model that spans the diagnoses to explain how deviated gyral pattern trajectories map onto clinical manifestations , focusing on the common and distinct gyral pattern changes across the disorders in addition to their correlations with specific clinical features. This comprehensive understanding of the role of brain gyrification pattern on the pathophysiology may help to optimize the prediction and diagnosis of psychiatric disorders using objective biomarkers, as well as provide a novel nosology informed by neural circuits beyond the current descriptive diagnostics. These major psychiatric disorders are presently differentiated based on their specific clinical representations, but a part of their symptoms transcends the diagnostic categories. A transdiagnostic approach may be useful for accurate diagnosis in the initial stage of illnesses and for clarifying the nature of their relationships among disorders 5. Although preceding studies revealed shared genetic variations within a range of psychiatric disorders6, including common genetic-risk loci between SCZ and BD reported in a recent large-scale genome-wide association study (GWAS)7, it remains unclear how the disorders are trans-diagnostically characterized by neuroanatomical features, i.e., inter alia gyrification patterns. Thus, the common and distinct alterations in gyrification pattern across major psychiatric disorders have yet to be established.Previous studies demonstrated that established psychiatric disorders, such as schizophrenia (SCZ), bipolar disorder (BD), major depressive disorder (MDD), and autism spectrum disorder (ASD), are generally associated with neurodevelopmental pathology9. Very preterm children and adults showed significant changes in brain gyrification pattern11 that were associated with cognitive and psychopathology scores11, suggesting the impact of obstetric complications for the development of brain gyrification. As obstetric complications such as perinatal hypoxia and preterm birth were associated with locally reduced gyrification in psychosis13, the abnormal microenvironment in utero may impact the development of gyrification deficits which might be related to future psychopathology. Contrary to gray matter volume, which can be affected by age14, disease process15, and psychotropic drugs16, cortical gyrification patterns may be a more static neurodevelopmental marker. Therefore, it may be useful for feasible early intervention17. Although the gyral patterns may be a static neurodevelopmental marker, recent studies propounded a putative gyral pattern trajectory model that healthy individuals have a non-linear decline of gyrification index (GI) with age19. Patients with schizophrenia may also exhibit GI reduction over time20, suggesting multiple pathological processes at varying clinical stages. Although it is largely unknown whether patients with other psychiatric disorders exhibit gyral pattern changes during the course of the illness, such a potential longitudinal change may partly explain the conflicting results of patients with psychiatric disorders having hyper-, hypo-, or normal gyrification patterns36.Anomalous patterns of brain gyrification are assumed to be a consequence of pre/perinatal neurodevelopmental insult because cortical folding starts at 10 weeks of gestation to the third trimester of pregnancy (primary gyri emerge until 28 weeks of gestation and higher-order gyri develop thereafter) and its pattern remains rather stable after birthWe systematically reviewed recent neuroimaging findings of anomalous gyral patterns in major psychiatric disorders at varying illness stages. This review article aims to integrally understand the gyral findings by focusing on the gyral pattern trajectories. Moreover, we propose an overarching model that spans the diagnoses through the transdiagnostic considerations, which may aid in clinical diagnosis and prediction of the disorders, and also transcend the limitations of the established nosological systems.37. We searched for studies in PubMed and Google Scholar using the terms (schizophrenia OR bipolar disorder OR major depressive disorder OR autism spectrum disorder OR high risk) AND . We further performed a cited reference search starting with the identified studies in Web of Science, and added several relevant reports. The searches were rerun just before the final analyses in June 2020. Two of the authors (D.S. and Y.T.) independently conducted a hand search and resolved their disagreement in study selection by consensus.We aimed to systematically review the studies published between May 1, 1997 and June 30, 2019 that investigated the gyral pattern in major psychiatric disorders, including the high-risk state both clinically and genetically for psychosis, by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement38 and the Structured Interview for Prodromal Symptoms /the Scale of Prodromal Symptoms (SIPS/SOPS)39. All studies that investigated psychiatric or physical conditions other than the aforementioned states were excluded. Studies using non-T1-weighted protocols were also excluded. In all, we included 71 articles  with MRI data in patients with major psychiatric disorders, individuals at high-risk for psychosis, and healthy controls. Patients met the Diagnostic and Statistical Manual of Mental Disorders (DSM), 3rd, 4th, or 5th edition criteria or the International Classification of Disease diagnostic (ICD), 10th revision criteria for each psychiatric disorder. In addition, high-risk individuals were siblings of the patients or met the diagnosis criteria, such as the Comprehensive Assessment of At-Risk Mental States (CAARMS)40 arranged for a case-control study design. This scale contains six items, categorized into two dimensions including selection and comparability, ranging between zero  up to six  stars. In this review, the NOS stars ranged from four to six and the average was 5.6 41, was standardly used to quantify cortical folding due to its easy interpretation and implemental simplicity. After that, the automated GI (A-GI) was developed by adapting the GI to a fully automated 2-D method in order to improve reliability and reproducibility in larger cohorts42. However, these methods were two-dimensional analyses for limited brain areas, which may be biased by slice orientation, buried sulci, and anomalies of sublobe regions. With the recent technological developments in 3-D image reconstruction and surface-based morphometry, the measurement of local GI (LGI) has widely been accepted in psychiatric researches. The index is calculated by dividing the pial surface area by the corresponding outer surface area for each vertex43. The measurement of LGI has methodological advantages over other methods by taking into account the inherent three-dimensional nature of the entire cortical surface. Several studies employed other approaches, such as the mean curvature computed by normalized summation of the amplitude and frequency of the simulated folding44 and the sulcal index (SI), which is calculated by the ratio between the sulcal area and the area of the corresponding outer cortex45, while using the same 3-D mesh of the cortical surface.In earlier studies, the GI, the ratio of the total folded cortical surface over the perimeter of the brain that was manually traced on 2-D coronal sections46, and then decreased with decreasing velocity thereafter47. During adolescence, the GI was reported to decline steadily with an annual decrease of around 1%, especially in the frontal and occipital cortices, where sulcal widening and reduced sulcal depth occurred together48.MRI studies in healthy subjects, including longitudinal assessments, revealed the typical developmental trajectory of the GI. After birth, the entire cortical GI increased and reached its peak by 2 years of age (approximately 20% increase at 2 years)51. Individuals with at-risk mental state (ARMS) have an increased GI in widespread cortical areas regardless of the outcome 24, whereas the left occipital hyper-gyrification pattern may be specific to the ARMS subgroup who later develop psychosis17. Subjects with schizotypal features, who are also at increased risk for developing psychosis, exhibit an increased GI in the prefrontal and parietal cortices53.Several MRI studies have reported anomalous patterns of brain gyrification prior to the onset of overt psychotic symptoms , and methodological advantage to assess gyral patterns [priority to the measures using 3-D mesh model of the cortical surface ], the gyrification pattern trajectories in each illness were summarized in Fig. 58, whereas patients in their mid-thirties and older mostly exhibit a decreased GI or SI in widespread cortical areas, particularly on the frontal cortices64. Although few MRI studies have examined the anomalous gyral patterns in mood disorders during adolescence and young adulthood, patients with BD likely exhibit increased frontal curvature during their mid-thirties compared with healthy controls28, but have reduced frontal GI or SI in their early forties and afterwards61. Compared with healthy controls, patients with MDD exhibit reduced frontal GI during their thirties33, and then increased frontal GI around their forties and afterwards65. Patients with ASD have delayed gyral development compared with typically developing controls during infancy19, transition to an increased GI in widespread cortical regions during childhood68, and lastly approach normal gyrification pattern in adulthood and thereafter34. Given the lack of longitudinal evidence, this framework is not able to explain why different trajectories should occur in disorders with differing phenotypes, and our model  into those with early (illness duration <3 years), middle (3–10 years), and late (10 years and afterwards) illness stages, and then conducted a subgroup analysis on the basis of 33 relevant MRI studies to see how the disease process could impact on gyrification pattern changes  are characterized by greater frontal and lesser parietal hyper-gyrification patterns compared with those without deficit syndrome36. Neurological soft signs (NSS) in SCZ patients, which are subtle neurological deficits in the execution of motor or sensory tasks69 and potentially link to cerebellar gyral changes70, are negatively associated with LGI in widespread cortical areas29. In patients with MDD, the severity of depressive mood and number of depressive episodes are inversely correlated with LGI in the lateral frontal cortices, lateral parietal cortices, and fusiform gyri65. Autistic symptoms, especially communication impairments and repetitive behaviors, are significantly correlated with the right parietal GI in patients with ASD and in their unaffected co-twins71. The right prefrontal GI is correlated not only with general cognition in patients with different mental states67, but also with specific cognitive subdomains such as executive function in SCZ32, working memory in BD61, and metacognition in ASD35.The severity of positive psychotic symptoms, including verbal hallucination, in SCZ was reported to be correlated with LGI in the right frontal and temporo-limbic region72, remain elusive. However, rapid and efficient genetic manipulation techniques in animals, in addition to computational neuroscience approaches, have been employed to clarify the mechanisms73. Moreover, neuroimaging studies in patients with neuropsychiatric disorders have reported associations of gyral pattern changes with various genotypes75. Here, we propose possible mechanisms of brain gyrification by dividing the gyral constructions into (1) primary gyri and (2) higher-order gyri. We further discuss how the upstream factors controlling cortical folding are involved in forming disease-specific gyral pattern trajectories.Developmental mechanisms of cortical folding, which are necessary for obtaining higher brain functions76, their folding patterns may be mainly determined by intrinsic genetic mechanisms. Although previous studies have shown that main gyral formation can be modulated by several genes such as Cdk577 and Tbr278, we focus on the fibroblast growth factor (FGF) gene in the present review, because of a relative abundance of literature that reported its relevance to psychiatric disorders. However, the genetic mechanism of FGF-2 gene should be considered with caution, because this gene was not hit by GWAS7. Altered expression of FGF-2 gene could be a consequence of other upstream processes and it would also have more downstream consequences. FGF-2 and its coupled FGF receptors (FGFRs), whose genes were differentially expressed throughout the central nervous system tissues, were reported to regulate neuronal proliferation and differentiation  as well as axonal sprouting and ensheathment (on oligodendrocytes) during a developmental stage80. Later in life, FGF-2 and FGFRs are thought to be involved in the maintenance of neuronal tissue (on tissue lesions) as well as learning and memory 79. Mice lacking FGF-2, FGFR-1, and FGFR-2 expressions showed psychosis-related behavior, cognitive deficits, and increased anxiety that coincided with cortical volume reduction, while administration of FGF-2 could ameliorate depression-like behaviors in animals81. A series of experimental approaches using gyrencephalic mammal ferrets85 led to a hypothesized pathway, where FGF signaling induces progenitor cell proliferation in the subventricular zone (SVZ), resulting in a neuronal increase preferentially in cortical upper layers that is responsible for protrusion of the cortex 64 or radial diffusivity99 were located in the overlapping region in SCZ patients, and further that speech connectedness correlating with LGI and DC explained a thought disturbance, cognitive impairment, and functional outcome, irrespective of diagnostic boundaries111. Taken together, it is suggested that abnormalities in local GI are related to brain dysconnectivity of the corresponding area as neural substrates for various clinical symptoms and cognitive performance.An experimental study on the consequences of prefrontal resection revealed the eruption of additional fissures around the lesion and rerouting of intact cortico-striatal projections5.Previous neuroimaging studies demonstrated disrupted functional or structural connectivity in numerous psychiatric disorders by adopting a transdiagnostic approach113, but the hypo-connectivity within the frontoparietal executive network may be more marked in SCZ patients than in BD patients114. Young patients with SCZ and ASD likely exhibit shared atypical default mode network (DMN) and salience network (SN) functional connectivities, which are related to the social functioning score115. A large-scale multidiagnostic comparison of diffusion tensor imaging (DTI) data suggested white matter microstructural abnormalities of the corpus callosum commonly in SCZ, BD, and ASD patients, possibly reflecting disturbed extensive networks subserving emotional regulation116, but alterations of the tracts connecting neocortical areas may be specific to SCZ patients109. On the other hand, MDD patients do not have altered white matter connectivity109. Functional disconnectivity in the frontal and temporo-limbic regions may underlie positive psychotic symptoms in SCZ118, whereas altered intracortical couplings in frontoparietal brain circuits may be associated with prominent negative symptoms119. Children with ASD were reported to have increased short-range connectivities within the frontal lobe120 but reduced long-range connectivities across different brain areas121. Among them, altered functional connectivities of the somatosensory cortex, which are considered to be disease-specific changes, may be associated with autistic symptoms such as social communication deficits122.Both SCZ and BD patients have compromised connectivity centered on the frontal regionIn summary, patients with major psychiatric disorders may have both common and distinct connectivity abnormalities in neural circuits involving several brain regions, some of which can explain certain clinical features.Based on the patterns of local connectivity and variations in neurodevelopmental gene expression across disorders described above, commonly and differentially altered gyrification patterns in patients with major psychiatric disorders may represent common and distinct clinical manifestations. We propose an overarching model that spans the diagnoses to clarify how deviated gyral pattern trajectories map onto clinical manifestations Fig. .Fig. 4Ov29 and delayed childhood development123, the widespread hyper-gyrification pattern in early childhood presumed in SCZ and BD patients may underlie their delayed infant milestones 124. Such a delay is greater in SCZ patients than in BD patients125, probably due to the greater genetic burden of neurodevelopmental risk in SCZ patients126. Longitudinal reductions of the frontal GI around early adulthood and thereafter commonly observed in SCZ and BD patients (more prominent changes in SCZ patients than in BD patients) may be associated with progressive frontal gray matter reduction that is also commonly observed in SCZ102 and BD104, and is related to executive dysfunction127. As transdiagnostic impairments mainly in the anterior-cingulo-insular network in chronic SCZ and BD patients link to general executive dysfunction128, the cognitive deficit may result from common frontal-related disconnection.As the NSS in SCZ patients is correlated with both LGI129. The oxytocin receptor (OXTR) genotype was reported to affect brain functional connectivity130. As a neural correlate of social deficits shared in ASD and SCZ114, disturbed functional connectivities in diverse cortical regions, including DMN/SN-related brain regions, may partly be derived from genetic variations in the OXTR gene130, which are associated with the risk of both disorders132.The shared widespread hyper-gyrification pattern suggested in SCZ and ASD patients during late childhood is expected to be related to social deficits . The oxytocin system is known to play a key role in social cognition and behavior133. A common relationship between right prefrontal GI and general cognition in a range of psychiatric disorders suggests a neural mechanism shared across diseases134, whereas distinct relationships between right prefrontal GI and cognitive subdomains by each disorder can reflect a set of discrete dysfunctions135. Thus, further studies are required to examine which hypotheses explain the associations between anomalous patterns of focal gyrification and cognitive impairments in major psychiatric disorders.Emotional dysregulation during adolescence, which is commonly observed in conventionally defined diagnoses, may be explained in part by the hyper-gyrification pattern common to SCZ, BD, and ASD patients in the frontal region. Such dysregulation may be mediated by abnormal emotional regulation circuitry 128. As supported by the relationships of fronto-temporo-limbic disconnectivity with delusions, hallucinations, and disorganization symptoms in SCZ patients118, anomalous gyral patterns in the corresponding region may lead to the generation of positive psychotic symptoms. For verbal hallucinations in particular, aberrant connectivity of the arcuate fasciculus136 may lead to a series of abnormal activation, mainly in the language-related area as follows:137 (1) Hypofunction of the frontal midline structure  activates the speech area; (2) increased activation in the primary auditory cortex139 converts the generated inner speech into external language stimuli; and (3) altered neural circuit of self-reflective processing  gives otherness to the voice, resulting in the verbal hallucination. In addition, deviated patterns of frontoparietal gyrification may be involved in deficit syndrome in SCZ patients. The medial prefrontal and lateral parietal regions constitute the principal part of the DMN141, whose abnormalities can induce severe primary negative symptoms 143. However, a recent study demonstrates that functional dysconnectivity seen in SCZ patients seems to be driven by genetic diathesis rather than clinical expression144. Hence, these maps should be interpreted with caution.Disturbed functional connectivity of the dorsal prefrontal cortex and anterior temporal or posterior inferior parietal cortices are reported as schizophrenia-specific impairments , possibly underlying their unique symptomatologyRelationships between the specific clinical symptoms of BD and gyrification pattern or brain connectivity have not been well documented.145, they exhibit the frontotemporal hypo-gyrification pattern in early childhood. ASD patients have different developmental signs  than SCZ patients146, which may be due to a distinct genetic mechanism. Autistic symptoms, such as impaired social reciprocity and communication, in ASD children may partly be explained by parietal gyral pattern changes. The findings of disturbed connectivity and deactivation in the somatosensory cortex147, which are correlated with autistic symptoms, support this postulation. Increased bottom-up and reduced top-down processing in the somatosensory cortex in ASD, presumed by increased long-range feedforward connectivity and reduced long-range feedback connectivity in the comparable area, can be implicated in some core features of ASD148.Although ASD patients do not meet developmental milestones within typical limits65. Although depression and its-related pathopsychological characteristics  in MDD patients are associated with compromised connectivity in the affective network and DMN150, attenuated frontal-striatal reward network connectivity in proportion to depression severity is common in BD and MDD patients151. A recent cluster analysis demonstrated that a melancholia component is distributed equivalently across conventional psychiatric diagnoses152. Further studies are warranted to clarify whether depressive symptoms and their neural substrate are transdiagnostic or disease-specific.Depressive symptoms in MDD patients were reported to correlate with gyral pattern changes in the lateral frontal cortices, lateral parietal cortices, and fusiform gyrin = 207)26] as opposed to those on other cortical indices [hitherto largest sample of patients (n > 4000)153 in a previous study investigating cortical thickness]. Thus, confirmatory studies using large-scale multi-site longitudinal brain MRI datasets are needed.Although increasing neuroimaging evidence supports anomalous patterns of brain gyrification in several psychiatric disorders, there have been few longitudinal studies investigating the gyral pattern trajectory in each disorder or direct comparisons of gyrification patterns among major psychiatric disorders. Sample sizes in previous studies on cortical gyrification were small [hitherto largest sample of patients  and diagnosis . Such biomarkers will help optimize the prediction and diagnosis of psychiatric disorders.A previous study demonstrated that the deviated gyrification patterns can differentiate patients with schizophrenia from healthy controls with a favorable classification accuracy6. Similarly, as anomalous gyral patterns play a pleiotropic role in psychopathology, gyral findings may provide a novel nosology informed by neural circuits, which is beyond the present classifications in the psychiatric field.Current diagnostic criteria for psychiatric disorders rely only on descriptive syndromes based upon a consensus of experts. In contrast, the Psychiatric Genomics Consortium previously reported cross-disorder effects of genetic variants, highlighting shared and distinct biological causes of major psychiatric disordersThis review provides the transdiagnostic considerations of anomalous gyrification patterns in major psychiatric disorders. Diverse alterations of gyrification patterns at varying stages of major psychiatric disorders may reflect both molecular and biomechanical mechanisms. Patients with major psychiatric disorders exhibit commonly and differentially altered gyrification patterns, which suggests corresponding neural circuit changes involving the frontal and other brain regions, representing common  and distinct  clinical manifestations. A comprehensive understanding of the role of brain gyrification pattern in the pathophysiology of major psychiatric disorders may aid in the development of objective biomarkers for both prediction and diagnosis, as well as provide a novel nosology informed by neural circuits.Supplementary Information


Here we present a transgender male adolescent with an androgen receptor-positive serous borderline ovarian tumour in the setting of testosterone treatment for medical gender transition. To our knowledge, this is the second report of borderline tumour in a transgender individual and the first in an adolescent, an age group in which borderline tumours are extremely rare. We discuss the specific considerations of treating ovarian tumours in the transgender male population, the incompletely understood role of androgens in the genesis of ovarian epithelial neoplasia, and an emphasis on assessing cancer risk in transgender patients based on patient anatomy. Some studies report polycystic ovarian pathology following testosterone treatment, with others reporting no treatment sequelae.2 Independent of concerns surrounding testosterone treatment, many transmasculine individuals are electing to retain their uterus, fallopian tubes, and ovaries and require screening for malignancies involving these organs.Gender diversity is increasingly recognised and the number of patients presenting for gender-affirming care has increased. Transmasculine individuals, those who are designated female at birth and have a masculine gender identity, may elect treatment with exogenous testosterone to produce secondary sex characteristics in line with their gender identity.3We present a trans-male adolescent with an androgen receptor (AR)-positive serous borderline tumour (SBT) discovered shortly after starting on testosterone therapy. Because of the small number of cases of ovarian neoplasms in adolescents, with even fewer in the transgender population, the potential role of sex steroids in the genesis and pathogenesis of these tumours is largely unknown. Gynaecologic and medical providers treating trans youth must take into account each patient’s goals with regard to hormone therapy and gender-affirming surgery while simultaneously assessing health risks associated with patient anatomy. This case report was prepared using the CARE guidelines.A 17-year-old transgender male with obesity, anxiety, and no prior abdominal surgical history presented to the emergency room with acute right lower quadrant pain and nausea. Medications included fluoxetine, norethindrone acetate to achieve menstrual suppression, begun 7 months prior, and subcutaneous testosterone cypionate, begun 12 weeks prior. Past medical and gynaecologic history included normal development with menarche at age 13 years and regular menstrual cycles until initiation of testosterone and norethindrone acetate. Exam demonstrated a palpable, tender, mobile mass extending 4 cm above the umbilicus. Laboratory evaluation was reassuring. Ultrasound demonstrated a large right-sided mass with solid and cystic components and absent vascular flow.Due to concern for adnexal torsion, urgent surgery was recommended. After counselling regarding the risk, benefits, and fertility implications of ovarian cystectomy versus salpingo-oophorectomy, the patient and his parents elected salpingo-oophorectomy. He expressed plans for future gender-affirming surgery, including gonad removal. Intra-operative examination under anaesthesia showed Tanner V pubic hair, hirsutism, and clitoromegaly. A midline vertical incision was made. The right adnexa was torted three times in the presence of a large right ovarian mass with an intact ovarian capsule. A right salpingo-oophorectomy was performed. Inspection of the uterus, left tube and ovary, omentum, and palpation of the upper abdomen, liver edge, diaphragm, and pelvic and para-aortic lymph nodes showed no gross abnormalities. An omental biopsy and pelvic washings were performed.Pathological examination showed a 15 × 14 × 9 cm tumour, with tan-red fleshy excrescences lining the internal surface Fig. . HistoloPostoperative treatment, monitoring, and further gender-affirming hormone therapy were discussed by a multidisciplinary team involving paediatric endocrinology, oncology, gynaecology, pathology, and adult medical oncology. In the absence of peritoneal implants or extra-ovarian disease, the tumour was considered low risk. Given the potential for contralateral ovarian disease after removal of an SBT, surveillance of the remaining ovary was recommended. Testosterone was restarted 2 months following the surgery after discussing risks and benefits with the patient and his family. He continued on norethindrone acetate daily to obtain adequate menstrual suppression. Surveillance ultrasound of the remaining ovary obtained 6 months postoperatively was normal.4 Other ovarian neoplasms reported in this setting include one serous cystadenoma,4 two mature cystic teratomas,5 and one endometrioid adenocarcinoma.6We present an SBT in a trans-male adolescent receiving testosterone for medical gender transition. The sole previous report of SBT in a transmasculine individual occurred in a 38-year-old receiving testosterone therapy.7 SBTs are non-invasive ovarian epithelial tumours distinct from frank carcinoma. In our paediatric hospital, borderline tumours account for <1% of ovarian neoplasms among patients aged <21 years.9 The overall survival for patients with stage 1 disease does not differ from the general population.Ovarian epithelial tumours are rare in adolescents and carry a more favourable 10-year survival rate than the same diagnoses in adults.10 Patients with polycystic ovary syndrome (PCOS), who are exposed to high levels of endogenous androgens, have not shown an increased risk in ovarian cancer overall; however, Olsen et. al. showed a modest increased risk of SBT in overweight women with PCOS and high circulating androgens .11 Clinical studies have failed to show an association between elevated androgen levels and ovarian cancer risk,12 and attempts to treat chemotherapy-refractive ovarian tumours with androgen deprivation have yielded moderate responses at best in small numbers of patients.13 Prior studies investigating endogenous androgens may not be applicable to exogenous testosterone treatment given to achieve male range levels and, in the case of transgender youth, for pubertal induction.The role of testosterone treatment in tumour progression is uncertain as a putative role for androgens and the AR in the development or proliferation of ovarian tumours has not been established. Androgen signalling has a role in granulosa cell maturation and differentiation, although in vitro exposure of ovarian cancer cell lines to androgens does not result in cell proliferation.14 our multi-disciplinary team carefully weighed the risks and benefits of restarting testosterone therapy and, in the context of a completely resected tumour and ambiguous risks associated with endogenous steroids, ultimately recommended restart. Appropriate tumour surveillance was also unclear as there is no data to guide management in this area. The team recommended at least 5 years of periodic transvaginal ultrasounds of the contralateral ovary unless oophorectomy was completed sooner. While transvaginal ultrasounds were deemed of higher sensitivity, transabdominal were prioritised given patient preference.The presence of a sex hormone-sensitive cancer is a contraindication to testosterone therapy, but there are no formal recommendations for the use of testosterone in patients with SBT. Given the importance of gender-affirming therapy, which has been shown to reduce suicide risk and improve overall well-being,15 Keeping in mind that significant barriers to care exist for transgendered persons, all providers must be cognizant of and consider the health risks posed by each patient’s anatomy, for example, that transmasculine patients may retain their ovaries, and should screen patients appropriately.Attempts to estimate the prevalence of reproductive cancers in the transgender population have been unsuccessful. Current guidelines suggest routine screening based on retained internal organs in line with cisgender screening recommendations.This manuscript details the first reported borderline ovarian tumour in a transmasculine adolescent receiving testosterone. The role that testosterone treatment played in the development, growth, and recurrence risk of his tumour is largely unknown. Further study regarding the prevalence and management of ovarian tumours in transmasculine individuals is needed. We propose the creation of a tumour registry for reproductive tract tumours in the transgender population to gather longitudinal data and increase our understanding of the role that gender-affirming hormones play in the origin and progression of these tumours.


DNA damage is well recognized as a critical factor in cancer development and progression. DNA lesions create an abnormal nucleotide or nucleotide fragment, causing a break in one or both chains of the DNA strand. When DNA damage occurs, the possibility of generated mutations increases. Genomic instability is one of the most important factors that lead to cancer development. DNA repair pathways perform the essential role of correcting the DNA lesions that occur from DNA damaging agents or carcinogens, thus maintaining genomic stability. Inefficient DNA repair is a critical driving force behind cancer establishment, progression and evolution. A thorough understanding of DNA repair mechanisms in cancer will allow for better therapeutic intervention. In this review we will discuss the relationship between DNA damage/repair mechanisms and cancer, and how we can target these pathways. DNA damage can alter nucleotide sequences and lead to expression of dysfunctional proteins that impact normal cellular physiology. Sources of DNA damage can be endogenous or exogenous and include reactive oxygen species (ROS) or ionizing radiation . DNA damGenotoxic agents cause structural changes in DNA by disrupting covalent bonds between nucleotides, preventing accurate replication of the genome . SignifiEndogenous agents induce replication stress or generate free radicals derived from the oxidative metabolism, whereas exogenous agents such as ionizing or ultraviolet (UV) radiation and chemotherapy induce structural changes such as single strand (SSB) or double strand breaks (DSB) in DNA via base modifications, helix-distorting bulky lesions, or cross-links of DNA strands, and are repaired by biochemically distinct DNA repair pathways . DSBs arDNA lesions affect a huge number of cells in the human body, occuring at a rate of 10,000 to 1,000,000 molecular lesions per cell per day . UnrepaiOne of the main sources of DNA damage is ionizing irradiation, which can cause direct or indirect DNA damage leading to changes in the structure of DNA that affects nuclear stability . IonizinAfter DNA damage occurs, the DNA repair proteins should identify the site of the damage and determine whether to repair the damage or push the cells towards apoptosis through a DNA damage check point. Apoptosis or programmed cell death (PCD) plays a vital role in maintaining tissue homeostasis by removing diseased or injured cells. Mitochondrial fragmentation within such cells leads to caspase activation and cell death when cells pass through critical checkpoints ,18. ConvAbnormal cell proliferation is one of the hallmarks of cancer , but theDNA repair pathways are encoded by a class of proteins that detect DNA double stand breaks, chromosomal fragmentation, translocation and deletions, and can correct some alterations . Cells sDDR mechanisms include multiple DNA repair pathways, damage tolerance processes and cell-cycle checkpoints . DNA repThe tumor-suppressor protein Tp53 identifies the presence of DSB and activates the signaling pathways that regulate tumor progression and promote apoptosis. Mutations in the p53 gene affect DNA damage repair and promote cancers . A functWell-studied DNA repair pathways including base excision repair (BER) for SSBs, nucleotide excision repair (NER) for bulky adducts, and non-homologous end joining (NHEJ) and homologous recombination (HR) for DSBs. In addition, there is also DNA mismatch repair (MMR) for the correction of replication errors such as base-pair mismatches and loops/bubbles arising from a series of mismatches .In mammalian cells, the major DDR-signaling components include the protein kinases ATM and ATR, which are induced by DSBs and replication protein A (RPA) that binds to single-stranded DNA (ssDNA) ,37. The Furthermore, DDR is affected by chromatin structures that may be modified in response to DNA damage . One of The most well-known cancer treatments function based on generating DNA damage, such as radiotherapy and chemotherapy. These types of treatments are efficient, although they cause dose-limited toxicities in normal cells. The rapid proliferation of cancer cells compared with normal cells is due to an impaired DDR. However, the rationale underlying the resistance to cancer therapy is associated with common DNA repair mechanisms. For instance, it has been reported that the treatment of glioblastoma is difficult as a result of the unique properties of their DDR machinery . These fGenerally, one or other aspects of the DDR are defected in all cancer cells due to alterations of the behavior of cells during tumor evolution. Therapeutic outcomes are improved when there is a decrease or loss in the DDR factors. There is an exception of poor resistance to the therapeutic effect in the case of disorders in p53 and other pro-apoptotic proteins ,50. HoweIn addition, in a phase I trial on PARP inhibitor as a single agent in patients with BRCA mutations using oral PARP inhibitor olaparib in order to prove the safety of olaparib as a single agent, the patients with BRCA-mutated breast, ovarian, or prostate tumors showed a positive response toward this inhibitor . In the The discovery of CRISPR/Cas9 technology, which is based on genome editing, could be performed efficiently through targeting the genes that cause cancers and cancer therapy. A CRISPR/Cas9 system was utilized to target the oncogene HER2 leading to inhibition of cell growth in breast cancer cell lines. The addition of PARP inhibitors increased the inhibitory effect . Poly ” and “ALKBH family dioxygenases” .Ionizing irradiations, including ultraviolet (UV) light, damage the DNA molecules by generating thymine dimers in the DNA chain between neighboring thymines, causing distortion of the double helix due to the weak hydrogen bond among dimers . EventuaMost DNA damage is repaired by removing the damaged bases by re-synthesizing and rebuilding the damaged region. The direct reversal mechanism is more effective in repairing specific types of damaged DNA that happen repeatedly, such as exposure to UV light. This leads to pyrimidine dimers and adds methyl or ethyl groups at the O(6) position of the purine ring which cause alkylated guanine residue alteration . This meBase excision repair is an essential DNA repair pathway that corrects DNA damage from oxidative, alkylating and deamination events ,80. BER The main biological function of BER is to remove uracil produced by cytosine deamination from the DNA. In addition, the uracil N-glycosylase (UNG) enzyme eliminates the uracil (U) from both single-stranded DNA (ssDNA) and double-stranded DNA (dsDNA) ,84. The The BER pathway uses mainly DNA glycosylases as the first enzyme to identify the DNA damage and stimulate the elimination of damaged bases . When DNDNA AP endonuclease or a DNA AP lyase cleaves the DNA backbone, and the activity of AP endonuclease produces a single-stranded DNA nick 5’ to the AP site, while the activity of DNA AP lyase generates parallel nick 3’ to the AP site . In addiPre-mutagenic cytosine (C) damage is eliminated from DNA by human endonuclease III homologue (hNTH1). 5-hydroxycytosine is involved in the BER repair pathway by playing a critical role in improving the possibility of the repairing process using adenine that results in C to T transition mutations . FurtherNucleotide excision repair (NER) is one of the major DNA repair pathways to protect the cells against DNA lesions that vary structurally and chemically. The most prevalent lesions are produced from additions of bulky covalent adducts initiated by nitrogenous bases and are affected by UV light, ionizing irradiation, electrophilic chemical mutagens, drugs and chemically active endogenous metabolites . NER detects DNA damage through two mechanisms, including global genomic NER (GG NER) and transcription-coupled NER (TC NER). Detection of damaged DNA is an important step in any DNA repairing process. The structural changes in the whole genome are recognized by the GG-NER sub pathway, which repairs the transcribed and un-transcribed DNA strands. The genome is constantly scanned and any disfigurement of the helix will be identified. The TC-NER sub pathway is involved when the damage affects the DNA failure in the NER function, which might lead to UV- sensitivity and a high incidence of cancer , for insDNA mismatch repair is a system for recognizing and repairing erroneous insertions, deletions and mis-incorporations of bases that may arise during DNA replication and recombination, and mismatch repair also repairs some forms of DNA damage. Defects in MMR increase the spontaneous mutation rate, and also induce multistage carcinogenesis . In addiHuman exonuclease 1 (hExo1) is an enzyme involved in MMR. It preserves genomic integrity by the nucleolytic processing of DNA intermediates. A 5’ structure-specific nuclease family of exonucleases and endonucleases also has a hExo1 enzyme which functions in various DNA repair pathways. MMR is responsible for the activation of primary exonuclease. Moreover, during double strand break repair (DSBR), MMR contributes to removing the damaged DNA. Furthermore, hExo1 is essential for enhancing telomere recombination at transcription-induced telomeric structures. On the other hand, hExo1 provides the damaged region with a nick 5′ to produce 5′-3′ hydrolysis on the double-stranded DNA. The activity of 5′–3′ hydrolysis requires the binding of hExo1 with MutS (MMR protein) which is ATP-dependent in a mismatch. Exonucleolytic activity is regulated by the interaction between hExo1 and several MMR proteins such as MutL and the DNA lesion recognition proteins MutSα and MutSβ  109,110110.Two mechanisms are mainly used to repair the double strand breaks, including homologous recombination (HR) and non-homologous DNA end joining (NHEJ) as shown in The NHEJ pathway uses a variety of proteins to identify, remove, polymerize and ligate the ends of the DNA. The most difficult damage to repair is the DSBs, which are extremely cytotoxic . EndogenHRR is a complicated process pathway that activates to repair DSB damages. This pathway has various proteins, and this repairing mechanism takes place in S and G2 phases in the cell cycle . A limitThe induction of DNA damage and the defect of the DNA damage response (DDR) are responsible for genetic instability, probably associated in the pathogenesis of monoclonal B-cell lymphocytosis (MBL) and chronic lymphocytic leukemia (CLL) . HoweverCell cycle checkpoints are control mechanisms that regulate the order, integrity and fidelity of the cell cycle. These include ensuring correct replication of chromosomes, and their accurate segregation at mitosis . ChromosThe cell cycle has various checkpoints that can be activated in the presence of DNA damage. These checkpoints are responsible for permanent cell cycle arrest or apoptosis of unrepaired DNA damage. However, the repaired cells are progressing to further stages of the cell cycle .Cancer chemotherapy and radiotherapy are designed to cause apoptosis in cancer cells by inducing catastrophic DNA damage such as DSBs. Traditional therapeutic strategies have been developed based on DNA damage response properties of cancer cells that often have specific abnormalities in the pathway . The abnChemotherapeutic agents induce DNA damage and cancer cell death via immunogenic cell death, apoptosis and other forms of non-apoptotic death including senescence, mitotic catastrophe and autophagy . RadiothExposure to chemotherapy can cause several early and late long-term toxicities including ovarian failure , bone loss, weight gain, neurotoxicity, neurocognitive changes, cardiac toxicity and secondary malignancy. Such effects have the potential to reduce quality of life and overall health status. Understanding such chemotherapy-related toxicities is of utmost importance .Whilst the effects of cytotoxic chemotherapy on normal bystander cells are widely studied, the specific effects of treatments on cancer genomes are also of importance. Persistence of DNA abnormalities introduced into cancer cells  can result in further genomic instability. A similar outcome is also envisaged for radiotherapy. Hence, further studies are needed to understand the long-term effect of radiotherapy and chemotherapy ,136.DNA damage and misrepair can persist within normal bystander cells as well as cancer cells, leading to clonal evolution with more aggressive features. Such abnormalities include the formation of abnormal nuclear bodies called micronuclei .Micronuclei (MN) are small extranuclear bodies formed during cell division when the chromosome or a part of the chromosome fails to join the mitotic spindle during M phase . MN are Several studies have described the effects of the exposure to genotoxic agents that result in chromosomal aberrations and genomic instability of cancer cells leading to clonal evolution and progression . GenotoxIn cancer cells, mutated p53 alleles lead to reduced apoptosis. It has been shown that the cells with mutated p53 formed more MN after being treated with chemotherapy or irradiation compared to the cancerous cells with wild-type p53 gene. Thus, p53 protein expression is essential for the balance between cell cycle arrest, DNA repair and apoptosis induction .Nuclear anomalies are initiated by structural errors in a chromosome or are due to an abnormal number of chromosomes. Such anomalies include nucleoplasmic bridges (NPB) and nuclear buds (NBUD) and are biomarkers of genotoxic events and manifestations of chromosomal instability that often indicate cancer risk. Genetic damage events such as MN, NPB and NBUD provide valid measures of misrepaired DNA breaks . MN, NPBClonal evolution can contribute to the development of human cancers and the response to treatment . ChemothToxicity associated with chemotherapy is a major therapeutic challenge that is caused by chemotherapy-induced DNA damage and inflammation. Chemotherapy causes selective pressures that create tumor heterogeneity and subsequent clonal evolution . Target The clonal evolution that causes genomic instability could be responsible for more aggressive behavior of cancer cells . This maInvestigating DNA damage is essential in the diagnosis and prognosis of several cancers. The formation of some important biomarkers in the cells such as micronuclei (MN), nucleoplasmic bridges (NPB) and nuclear buds (NPB) can be used as an indicator of DNA damage due to exposure to cytotoxic or DNA damaging agents . HoweverDuring the past decades, PARP inhibitors have been combined with single-agent therapies to improve treatment efficacy. This combination is used in the treatment of ovarian cancer and breast cancer with BRCA mutations. Several clinical trials indicated that this particular procedure in treatment is preferable, especially after investigating several predictive biomarker populations .Well-managed mechanisms are responsible for maintaining genome stability and repair of damaged DNA. Genomic instability leads to defects in the normal cellular cells, causing a tendency to convert into cancer cells, which may also occur due to a mutation in the repairing genes . RecentlThe innovative diagnostic methods including DNA damage analysis are improving gradually, especially for precision medicine, and help in analyzing a large amount of new potential biomarkers leading to facilitation of the detection of early disease stages and disease prognosis. These biomarkers are ones such as phosphorylated histone 2Ax (γH2AX), 8-hydroxy-2′-deoxyguanosine (8-OHdG) or 8-oxo-7,8-dihydro-2’-deoxyguanosine (8-oxodG) . The nov


Individuals that maintain healthy skeletal tissue tend to live healthier, happier lives as proper muscle function enables maintenance of independence and actuation of autonomy. The onset of skeletal muscle decline begins around the age of 30, and muscle atrophy is associated with a number of serious morbidities and mortalities. Satellite cells are responsible for regeneration of skeletal muscle and enter a reversible non-dividing state of quiescence under homeostatic conditions. In response to injury, satellite cells are able to activate and re-enter the cell cycle, creating new cells to repair and create nascent muscle fibres while preserving a small population that can return to quiescence for future regenerative demands. However, in aged muscle, satellite cells that experience prolonged quiescence will undergo programmed cellular senescence, an irreversible non-dividing state that handicaps the regenerative capabilities of muscle. This review examines how periodic activation and cycling of satellite cells through exercise can mitigate senescence acquisition and myogenic decline. Given its many important functions, it is unsurprising that muscle strength is positively correlated with better quality of life and negatively correlated with all-cause mortality –4.The relationship between muscle strength and morbidity is more apparent in geriatric populations where sarcopaenia, age-related muscle atrophy, can lead to falls, disability and mortality. For example, the majority of hip fractures occur within individuals over 65 years of age –9.Fortunately, skeletal muscle has remarkable regenerative capabilities, and age-related muscle loss can be drastically attenuated with exercise. On a physiological level, regular exercise has been shown to increase vascularization and perfusion, important for waste removal; muscle efficiency and greater recruitment of myofibres; flexibility and muscle tension; and bone strength and density, required to support muscles –12.On the cellular level, exercise has been shown to increase mitochondrial numbers and quality, enhance innervation by neuromuscular junctions, stimulate supporting cells in the interstitial area of muscle , and stimulate satellite cells to activate for muscle repair and growth –16.In this review, we address the role of quiescence in muscle regeneration, the mechanisms that prevent senescence in quiescent muscle stem cells, and how exercise contributes to long-term satellite cell viability at a cellular and molecular level.2.Pax7 and sequentially express myogenic regulatory factors (MRFs)  as they proliferate and then differentiate [Molecular and genetic studies in mice have greatly elucidated our understanding of the mechanisms that govern satellite cell function during the growth and regeneration of skeletal muscle –20. Saterentiate –24. Pax7rentiate –27.FiguPax7 but not Myf5. The remaining 90% of the satellite cell population are committed cells that have expressed Myf5 and appear to form a short-term self-renewing population. Transplantation and serial injury experiments have demonstrated the satellite stem cell population to be capable of replenishing the stem cell population in addition to re-establishing the pool of committed satellite cells [Approximately 10% of the satellite cell population appear to be a long-term self-renewing stem cell population expressing te cells .Central to a satellite cell's behaviour is the immediate microenvironment that envelops the cell with structural proteins, and the various signalling factors from other nearby cell types. The nearest structures in proximity to a quiescent satellite cell include matrices of the fibrous sheath of basal lamina closest to the apical side of the satellite cell, and the plasma membrane of the myofibre at the basal side of the satellite cell. Satellite cells are often closely associated with capillary endothelial cells, as muscle tends to be a highly vascularized tissue . Other cWhile the young niche favours stem cell quiescence, the aged niche provides cues that promote activation and differentiation ,29,37–473.Homeostatic quiescence and activation is critical for establishing short- and long-term regenerative potential of the muscle by activating satellite cells and creating new progenitors for muscle repair, while preserving a small population of stem and committed satellite cells that can enter quiescence for the future regenerative demands.+/Myf5−) will change their preference for asymmetric self-renewal or symmetric expansion of the stem cell pool. Under normal homeostatic turnover or minor damage, satellite cells preferentially undergo asymmetric division that will produce one stem cell (Pax7+/Myf5−) and one committed cell (Pax7+/Myf5+), which can then become a progenitor and undergo successive rounds of division [In response to injury or inflammation, satellite cells will activate and enter the cell cycle to begin dividing and creating new cells for regeneration. Depending on the degree of regeneration required, satellite stem cells  routinely performed on animal models to investigate muscle regeneration [Unlike the serious injury models and techniques . Despite lower protein synthesis, metabolism and general cellular activity, quiescent satellite cells still require cellular processes to actively maintain quiescence. These processes generate cellular waste, organelle damage and mitochondrial ROS from energy production (b) [Reversible quiescence is necessary in maintaining long-term regenerative potential, as a subset of regenerative stem cells and progenitors need to be preserved to adequately respond to future demands. However, periods of prolonged satellite cell quiescence may negatively impact long-term viability, leading to impaired regenerative potential a. Despitoduction b [72–74,tion (b) . Accumultion (b) ,79–83.Fb). During deep quiescence, accumulation of dysfunctional proteins and organelles that would otherwise be diluted through rounds of cell division can increase cytotoxicity leading to senescence and apoptosis [Quiescent satellite cells under prolonged periods of quiescence are at risk of proteotoxicity b. Duringpoptosis –86. To cRpt3 demonstrate the importance of the ubiquitin–proteasome system in maintaining quiescence [Rpt3 significantly depletes the quiescent satellite cell population in resting muscle. Moreover, post-injury muscle regeneration is disrupted under Rpt3 knockout conditions, with a significant decline in Pax7-expressing quiescent satellite cell numbers at both 5 and 15 days post injury.The ubiquitin–proteasome system is one of the primary systems involved in pruning the proteomic landscape. This system is critical for maintaining cell identity. For example, Pax7 expression is regulated by Nedd4, a ubiquitin-ligase that is expressed during both quiescence and activation . Satelliiescence . DisruptAutophagy also plays a pivotal role in the cell's capacity to maintain cellular integrity through recycling of intracellular components, such as defective or surplus proteins and organelles ,88. For Atg7, an essential component of macroautophagy, demonstrate the requirement for a basal level of homeostatic autophagy in preventing quiescent satellite cells from transitioning into senescence [Atg7 overexpression is able to rescue the proliferative defect and reduce numbers of senescent satellite cells in geriatric mice [Pharmacological inhibition of autophagy and satellite cell-specific ablation of nescence . Indeed,ric mice .All cells accumulate DNA damage from several intrinsic and extrinsic sources during ageing . Satelli0 display a detectable low level of energy metabolism and predominantly derive their energy needs from glycolysis, unlike most G1-arrested cells that rely on oxidative phosphorylation [in vitro [Quiescent satellite cells in Grylation –100. Desrylation , the abirylation . Recent rylation ,103, andin vitro .INK4a (Cdkn2α), which inhibits multiple quiescence-inducing pathways and increases DNA damage through a ROS-positive feedback loop [0 quiescence to activation required for creating new progenitors and consequently are unable to keep up with muscle degradation. Indeed, muscle cross-sections of adult and geriatric mice compared to young mice exhibit signs of muscle decline: fibre atrophy, loss of innervation, and re-expression of embryonic myosin heavy chain and central nucleation [Unfortunately, these protective mechanisms in place are not enough to maintain long-term satellite cell viability and regenerative capabilities of muscle over the lifetime of an individual. Quiescent geriatric satellite cells eventually enter a pre-senescent state by de-repression of p16ack loop ,104. Gercleation ,105–107.c,d).It appears the autophagy and mitophagy pathways active during prolonged quiescence are not sufficient to prevent satellite cells from transitioning into senescence . What, tfigure 25.Exercise bestows several benefits to overall health, including improved bone strength, offset obesity , and impERTM:R26RBrainbow2.1Pax7Cre mice reveal that clonal complexity is maintained during homeostatic ageing and undergoes clonal selection during severe muscle injury [The muscle regeneration field has been focused on muscle formation during embryogenesis and regeneration following severe injury and disease progression. Less clear are the mechanisms regulating satellite cell activity during homeostasis, response to eccentric exercise and ageing. The satellite cell population maintains a level of functional heterogeneity, with subpopulations of satellite cells mounting differential responses depending on environmental stimuli ,114. Sate injury . This suEccentric exercise enhances myofibre hypertrophy, and stimulates satellite cell activation and proliferation . AerobicParadoxically, activation of satellite cells through exercise enhances muscle function, yet the age-related dysfunction of satellite cells arises due to their heightened propensity to activate and differentiate. As discussed earlier, this is in part due to age-related changes intrinsic to satellite cells ,48–52, aCurrent understanding of the factors that activate satellite cells during eccentric exercise is limited as most molecular studies describe satellite cells either in the non-stressed or severely injured state. It appears that satellite cell activation during exercise is mediated by elements released from the myofibre and interstitial cell populations. Signalling cascades that appear to be responsible for driving satellite cell activation in response to exercise induced muscle stress include IGF1, IL-6/JAK/STAT3, hippo and SIRT1 pathways ,144–147.et al. observed that the hypertrophic effect of IGF1 was approximately halved in the absence of satellite cells in irradiation experiments [in vitro studies on C2C12 and human primary myoblast cultures failing to demonstrate any significant increase in proliferation following treatment with this IGF1 splice variant [IGF-1 is released from muscle fibres following mechanical strain and exercise, driving muscle hypertrophy ,148. Bareriments . Supporteriments . Intereseriments . However variant ,153.Interleukin 6 (IL-6) is a pro-inflammatory cytokine that is released from growing muscle . IL-6 haNon-myogenic cells that reside within the interstitial spaces of muscle appear to also play a role in the IL-6 signalling axis post-exercise, namely FAPs and infiltrating eosinophils. FAPs provide functional support for satellite cells and influence their activation ,159–163.et al. that demonstrate Rho-dependent mechano-signalling to repress YAP during quiescence to prevent satellite cell activation [Hippo signalling through YAP and Taz has been demonstrated to play a role in satellite cell activation and proliferation –168. Inttivation . These ftivation .+-dependent activities and act as metabolic sensors [Lastly, SIRT1 is another signalling effector that has been implicated in satellite cell activation and is upregulated in muscle following exercise ,172. SIR sensors . SIRT1 i sensors . Deletio sensors . Indeed, sensors . Since SDespite the well-established beneficial effect of resistance training, exercise alone does not prevent all age-related defects in skeletal muscle. Concomitant with sarcopaenia is a change in muscle composition within geriatric muscle: a shift of type 2 towards type 1 myofibres ,176. Eve6.Higher quality of life and happiness is strongly associated with an individual's ability to exercise self-agency, and maintaining locomotion is a key aspect of this pursuit. Skeletal muscle health and exercise deserve greater attention in today's world, where a sedentary lifestyle is the norm, while obesity and cardiovascular disease are the leading causes of death. Although age-related muscle atrophy is the focus of many geriatric studies, it is clear that the decline in satellite cell number and function coincides with the gradual muscle loss that begins much earlier, at approximately 30 years of age.Many additional mechanisms behind satellite cell function decline in ageing remain to be discovered. However, it appears to be multi-factorial and involve defects and misregulation of cell maintenance, quiescence and activation pathways that prevent cell damage. It is evident that satellite cells are activated through various signalling pathways following exercise. Of particular relevance, cellular processes involved in the upkeep of cellular integrity  are upregulated during activation and proliferation. Moreover, satellite cells increase their cytoplasm during rounds of proliferation, which dilutes cellular waste and dysfunctional organelles between daughter cells. It is evident that waste and DNA damage accrued within periods of satellite cell quiescence are most effectively managed during periods of activation. Frequent activation of muscle satellite cells through exercise is a key process required to offset age-related waste/damage accumulation that leads to senescence. Physical inactivity becomes more detrimental with age as satellite cells accumulate higher levels of cellular waste and DNA damage during longer periods of deep quiescence.Currently, our understanding of satellite cell behaviour in response to exercise is relatively limited compared with more severe models of injury. Future work in this field is needed to decipher the clonal dynamics of satellite cells following exercise. For example, is satellite cell replacement through asymmetric division sufficient to respond to exercise-induced stress, or is pre-expansion of the satellite cell pool required to mount a more robust response? Moreover, what is the threshold and range of exercise-induced mechanical stress that drives satellite cell activation, and perhaps different clonal dynamics? Are certain subpopulations of satellite cells more sensitive to mechanical stress within the normal range of exercise? Elucidating these mechanisms will reveal important information relevant to combating age-related muscle decline, as well as designing therapeutics to offset muscle atrophy that arises from sedentary lifestyle, space flight and disease.


Case presentation. Mr GM is a 65-year-old sexually active Anglo-Saxon man who have long-standing BPH symptoms unresponsive to medical therapy. While he had an uneventful bilateral superselective PAE using gel foam, there were signs to suggest of PGN, and this was treated conservatively. The patient presented to the emergency department 5 days later with a painful, dark penile glans and accompanying urinary dysuria and hematuria. Clinical examination confirmed evolving PGN. He received 10 courses of hyperbaric oxygen therapy (HBOT) with complete resolution of his PGN.  Prostate artery embolization (PAE) is a novel endovascular procedure to treat men with benign prostatic hyperplasia (BPH) symptoms who wish to maintain sexual potency postoperatively. However, serious treatment-related adverse events (TRAEs) of PAE such as penile glans necrosis (PGN) can be devastating and require urgent attention.  While superselective embolization is usually always performed, nontarget embolization may occur, as intravascular particles may reflux into adjacent vessels. In this unique and extremely rare case report of PGN following PAE, complete resolution was achieved with HBOT. Proposed benefits of HBOT include anti-inflammation, promotion of neovascularization, and induced rate of collagen deposition, resulting in a faster and more effective resolution of PGN. Prostatic artery embolization (PAE) is a relatively safe and effective treatment for men with lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH) , 2. The Common treatment-related adverse events (TRAE) include urinary tract infection, acute urinary retention, dysuria, and persistent urinary symptoms , 2. HoweThis case report has received institutional ethics review board approval and patient informed consent. Mr GM is a 65-year-old sexually active man who has long-standing BPH symptoms. He has tried oral Tamsulosin therapy with minimal clinical efficacy and is bothered by the retrograde ejaculation. He has a normal erectile function and is sexually active. His other medical history includes hypertension, hyperlipidemia, and gout.Following discussion regarding various minimally invasive BPH surgeries, he has elected to undergo PAE to improve his urinary flow while at the same time preserve his sexual function. Preoperative planning was undertaken using computer tomography angiography (CTA) pelvis which showed a prostatic volume of 138 cc (68 × 60 × 65 mm).A single operator, who had 15 years of experience in endovascular procedures and 5 years of experience in PAE, performed bilateral superselective PAE under local anesthesia with mild sedation. The total time taken for PAE was 118 minutes. Under ultrasound-guided left brachial artery puncture, a 4 French CXI guide catheter placed into the anterior division of the internal iliac arteries on both sides. Headway duo microcatheter was used for selective right prostate artery catheterization. This was uneventful with good uptake of embolic into the prostate with no observed collateral circulation. On the left access to the prostate artery was difficult. It came off the anterior division of the internal iliac artery with two other vessels, both of which went to the bladder. It was very difficult to select the prostate artery despite it being quite large. This was eventually catheterized using a synchrosoft guidewire with a very marked hook shape on the end. Flat-panel CT showed a satisfactory appearance to the preembolization picture with the only prostate selected. During the course of the embolization, it became clear that collateral vessels from the lateral prostatic artery to the penis had opened up . This waImmediately postembolization, Mr GM complained of perineal discomfort and urinary frequency. These symptoms are thought to be secondary to some off-target embolization to the tip of the penis as the arteries to the penis opened up during the course of embolization of the left-sided prostate artery. The patient developed a small area of punctate purple discoloration at the tip of the penis with sensitivity within the distal urethra and hypersensitivity and a painful glans penis. Since the patient was able to void, he was discharged home with simple analgesia.However, the patient presented to the emergency department 5 days after embolization with a painful, dark glans penis consistent with an evolving PGN . He repoFollowing a discussion on his condition and various treatment options, he was referred to receive HBOT and completed 10 courses of therapy. At a follow-up visit 4 weeks following his last HBOT session, he reported resolution of his penile pain, glans discoloration, dysuria, and hematuria. The patient reported normal penile sensation, regained normal erection, and engaged in satisfactory sexual activity. Clinical examination showed almost complete resolution of his PGN.Preoperative workup includes CTA of the prostatic vessels to determine underlying prostatic vascular anatomy since multiple pelvic vessel anastomoses can present considerable technical challenges . If signWhile the exact mechanism by which HBOT works is debatable, it is theorized that HBOT improves the oxygen concentration in a person's blood, thereby increasing the amount of oxygen reaching the areas that need to heal . There aThis unique but devastating case of PGN secondary to PAE illustrates the importance of discussing the risk of nontarget embolization with patients, and that HBOT can be an effective treatment option. As the practice of PAE takes off, education and mentoring are essential for its safe uptake worldwide. Clinicians must understand PAE's role with its strengths and weaknesses to enable optimal patient selection, ensure the best results, and minimize complications.


How does cognition regulate innate behaviors? While the cognitive functions of the cortex have been extensively studied, we know much less about how cognition can regulate innate motivated behaviors to fulfill physiological, safety and social needs. Selection of appropriate motivated behaviors depends on external stimuli and past experiences that helps to scale priorities. With its abundant inputs from neocortical and allocortical regions, the lateral septum (LS) is ideally positioned to integrate perception and experience signals in order to regulate the activity of hypothalamic and midbrain nuclei that control motivated behaviors. In addition, LS receives numerous subcortical modulatory inputs, which represent the animal internal states and also participate in this regulation. In this perspective, we argue that LS sub-circuits regulate distinct motivated behaviors by integrating neural activity from neocortical, allocortical and neuromodulatory inputs. In addition, we propose that lateral inhibition between LS sub-circuits may allow the emergence of functional units that orchestrates competing motivated behaviors. The septum is a large central region of the brain that is separated from the striatum by the lateral ventricles. It is subdivided into medial, lateral, and triangular areas comprising different cell-types with different developmental origins and connectivity . In rodeBased on the anatomy described above, LS is ideally positioned to integrate cortical signals in order to regulate the activity of hypothalamic and midbrain nuclei that control specific motivated behaviors. In contrast with the relatively well-characterized extrinsic connectivity of LS with cortical and subcortical brain regions, the intrinsic circuitry of LS remains largely unexplored, limiting our ability to understand how LS integrates and processes cortical signals. A major idea of this opinion piece is the importance of the largely unexplored intra-septal sub-circuits in LS function regulating motivated behaviors. We argue that the integration of cortical inputs enables the recruitment of different LS sub-circuits owing to its intrinsic connectivity. We hypothesize that these circuits are comprised of molecularly heterogeneous neurons with specific cortical inputs and sub-cortical outputs. We discuss the notion of parallel processing based on the existence of parallel circuits that process cortical signals independently, and of functional units that compete directly, each shaping the activity of one another. The main benefit of functional units over parallel pathways is the ability to orchestrate competing cortical signals that promote rival behaviors  in order to disinhibit a selective set of downstream subcortical nuclei and enable coordinated behavioral outcomes .We first review classical lesion and stimulation studies that shed light on the critical role of LS in the regulation of motivated behaviors. We then explore how contemporary circuit-based studies of LS offer mechanistic insights into how it integrates cortical inputs to regulate hypothalamic and midbrain activity and associated motivated behaviors. Based on these key studies, we reject a global integration model and put forward parallel processing and functional unit models, contrasting them with the current state of the literature. This opinion piece aims at providing a blueprint for studying how LS molecular heterogeneity, intrinsic connectivity and output territories help to shape motivated behaviors.Early on, LS was proposed as a part of the limbic system for the regulation of mood, emotion and motivation , 14. PioLesions applied to LS often yield opposing effects depending on their extent and location  and LS eGABA→VTADA circuit , which in turn project to the lateral hypothalamic area (LHA), causing an increase in the firing rate of a subset of LHAGABA neurons in mice actively approaching food . Le. LeGABA→ing food . Optogening food . Chemogeing food , 35 causing food . Importaing food  went beying food , 33. Thiing food . In conting food , 38.Fig.SST neurons receiving monosynaptic inputs from the hippocampus receive very limited inputs from the PFC  fibers originating from the different subnuclei of the lateral septal nucleus formed massive horizontal connections in the rostrocaudal axis. Projections to the contralateral, congruent subnuclei were also detected” [Possible interactions between LS circuits). A similar lateral inhibition mechanism mediated by striatal medium-sized spiny neuron collaterals has been proposed to synchronize active ensembles and suppress unsynchronized cells in the striatum, allowing the emergence of functional units [Although most LS neurons send long-range projection to subcortical areas , severalithin LS , 46, 47.etected” . These cal units . This obal units . In the al units –51, a haal units , while, al units . Potent al units , 54 and al units , 56 inpual units , 43.In summary, we propose that intra-septal collaterals mediate lateral inhibition in order to promote the emergence of functional units comprised of heterogeneous pools of LS neurons. In this framework, functional units integrate complementary inputs to facilitate a motivated behavior while suppressing antagonistic ones. Lateral inhibition may thus shape the activity of competing sub-circuits and orchestrate mutually exclusive behaviors.Sst+ neurons in rdLS to promote food seeking while CA2 pyramidal neurons projects to dLS neurons to facilitate social aggression  and Drd3  neurons receive prominent inputs from vHPC [Crhr2-expressing (Crhr2+) neurons also receive preferential inputs from vHPC and from which hippocampal region specifically  and activates the hypothalamic–pituitary–adrenal axis in response to an acute stressor [Crhr2+ neurons also impairs stress-induced avoidance behavior [Crhr2+ neurons projecting to AHA also inhibit GABAergic neurons projecting to vlPAG to mediate stress-induced avoidance behavior , oxytocin –68, cort LS Fig.  and theiV1a neurons which, in turn, inhibit LS neurons that do not express this receptor and are otherwise tonically active [To illustrate how neuromodulation may orchestrate the recruitment of intra-septal circuits, here we focus on the well-established action of AVP in LS to regulate rodent social behaviors . AVy active —another y active . This suSeptal release of AVP is also critical for male rodents during social aggression. Intra-LS injection of AVP promotes offensive aggression in rats  while V1Activity-dependent labeling strategies, trans-synaptic tracing approaches as well as high-throughput screening methods will be instrumental to test the predictions laid out in this perspective. Recent advances in activity-dependent labeling systems have catalyzed the study of the neural substrates for memory stabilization and recall . The abiMouse genetic systems combined with trans-synaptic tracing approaches allow tracing the relationship of inputs and outputs in highly divergent neural pathways (TRIO technique) . BecauseGal) mediate distinct sub-processes of parental behavior such as motor control, social interaction and motivational and neuroendocrine processes through projections to specific downstream regions [SST neurons respond to electrical foot shocks, whose activity tracked and predicted non-freezing epochs in a context-specific manner [DA stimulation is sufficient to promote male mouse aggression [DA projections to LS [DA neurons through a putative dCA2-dLS-VTAGABA-VTADA circuit. Future work should thus test whether single dLS or distinct dLS neurons disinhibit VMHvl and VTADA concomitantly to facilitate male rodent aggression. In this regard, the advent of high-throughput and projection-specific screening methods has allowed rethinking the classification of neurons into specific cell-types based on their projection features [Although all LS neurons send long-range projections to subcortical areas , it rema regions . In cont regions . In thisc manner . These rc manner  and VTADgression  at leastns to LS . Both dCns to LS  to promons to LS , 33. An features , 105. Thfeatures . EmployiDRD3 neurons [DRD3 activity [DRD3 remains to be established, an intriguing hypothesis is that changes in the E/I ratio could stem from increased lateral inhibition proceeding from neighboring LS neurons.We proposed three successive models for understanding how LS integrates and processes cortical inputs in order to regulate motivated behaviors. The first model of global integration can be rejected based on our knowledge of LS anatomy. The major feature of the last two models is the existence of distinct parallel pathways within LS, disinhibiting the activity of separate subcortical areas and therefore regulating different motivated behaviors. Some of these parallel circuits nonetheless integrate synergistic cortical signals and coordinate the activity of several subcortical nuclei respectively. The main difference between the second and third models lies in the critical role of lateral inhibition between parallel pathways. We propose that lateral inhibition within LS, akin to the inhibition described in the striatum  allows t neurons . These eactivity . AlthougIn humans, very little attention has been paid to the septum verum, which is well developed when compared to other mammals . Althoug


Remote acute subdural hematoma following a decompressive craniotomy or craniectomy is a rare phenomenon. Only few cases of postoperative contralateral acute subdural hematomas have been reported in the literature review till date. This case report details a case of a 32-year-old hypertensive male who presented with severe headache, multiple episodes of vomiting, slurring of speech, nystagmus and ataxic gait for one day. Computed tomography (CT) scan of head revealed a right sided cerebellar hemorrhage with effacement of fourth ventricle and upstream hydrocephalus. A right suboccipital craniectomy and hematoma evacuation were performed. A repeat CT scan of head was done at six hours post surgery; which revealed a contralateral (left-sided) subdural hematoma involving the fronto-parieto-temporal region. The patient improved following conservative management.Contralateral acute subdural hematoma following evacuation of hematoma is a rare, but a potentially life-threatening complication; therefore, we should try to detect such contralateral hematoma and prevent clinical deterioration. Decompressive craniotomy or craniectomy is performed if there is no response to medical therapy in the increased intracranial pressure state. However, many complications may occur following the procedure ,2. RemotA 32-year-old male from Kathmandu presented to our center with headache, multiple episodes of vomiting, slurring of speech and tendency to fall on the right side while walking for one day. Headache began suddenly in the bilateral occipital region, was continuous and severe. The patient had a history of hypertension; however; he was non-compliant to the medication. He was a known smoker and drank alcohol regularly. There was no history of head trauma prior to the incident. The patient had family history of hypertension in his father. On physical examination, the patient's blood pressure measured 220/120 mmHg and pulse rate was regular at 64 beats/min. Clinical examination of central nervous system demonstrated pupil of equal size with normal light response, Glasgow Coma Scale (GCS) score of 14 and nystagmus in the right eye.Emergent CT scan of head was performed which revealed a right-sided cerebellar hemorrhage with edema, effacement of fourth ventricle and obstructive hydrocephalus Figure .Specific hematological investigations, liver function tests and coagulation profile were all within the normal range. Mannitol 20% infusion to control the intracranial pressure was started. Triple antihypertensive medications  were administered to control the blood pressure.Right paramedian suboccipital craniectomy and hematoma evacuation were performed in the prone position with head in a horseshoe headrest. Intra-operatively, the dura was tight and hematoma was under pressure. After the surgery, headache and vomiting subsided and GCS score was 15. A routine repeat CT scan of head was done at six hours post surgery, which revealed a contralateral (left-sided) remote subdural hematoma involving the fronto-parieto-temporal region Figure .The patient was managed conservatively for the ASDH with decongestant (intravenous mannitol 20% for five days) and monitoring as his GCS score was 15. The patient was followed up after two weeks. During the follow-up, the patient was stable without any complaint of headache or vomiting.Intracranial hemorrhage (ICH) is a devastating disease. The overall incidence of spontaneous ICH worldwide is 24.6 per 100,000 person-years with approximately 40,000 to 67,000 cases per year in the United States . The mosFor many years, decompressive craniectomy has been used in the management of patients with elevated intracranial pressure and cerebral edema. However, it may release the tamponade effect and result in brain shift which exposes these patients to remote ICH .Four cases of supratentorial hematoma following microvascular decompression for trigeminal neuralgia were reported by Nozaki et al., among which two of the patients had same side and rest had contralateral ASDH . SimilarA case of contralateral ASDH reported by Lv et al. had slight contralateral ASDH on pre-operative cranial computed tomography . We re-eThere are reports of intracranial hematoma in patients operated with head holder pins . Our patAlthough the exact causes of postsurgical remote hemorrhages remain unclear, the following factors should be considered: (1) excessive drainage of cerebrospinal fluid, which may cause brain distortion and laceration of the bridging veins; (2) excessive rotation and flexion of the neck, which may obstruct jugular venous drainage on the contralateral side and cause subsequent venous hemorrhagic infarction in the supratentorial regions (Hanakita and Kondo); (3) a sudden increase in cerebral blood flow with defective autoregulation, damage to cerebral vasculature secondary to perioperative parenchymal shift, previously undetected contusion and bleeding secondary to decompression and coagulopathy ,17.Intraoperative sonography with probe gently placed over dura can sometimes identify remote hematomas, which could lead to timely intervention and prevention of life-threatening mass effect by hematoma expansion . Any uneThe natural course of ASDH is highly variable; although most of them resolve spontaneously with conservative management, few do not disappear and may require surgical intervention. Patients with GCS score >8, age <65 years and with small ASDH will have the best functional outcomes . Our patContralateral supratentorial subdural hematoma following craniectomy and evacuation of hypertensive cerebellar hematoma is a rare, but a potentially life-threatening complication. High index of suspicion is required if patients do not improve after craniectomy and evacuation of cerebellar hematoma. This is to ensure serial neurological examinations of the patient and brain imaging if needed following craniectomy and evacuation of cerebellar hematoma for early detection of contralateral supratentorial subdural hematoma in order to decrease morbidity and mortality.


Pathogen identification is a critical step during diagnosis of infectious diseases. Matrix-Assisted Laser Desorption/Ionization Time-Of-Flight mass spectrometry (MALDI-TOF-MS) has become the gold standard for identification of microorganisms cultured on solid media in microbiology laboratories. Direct identification of microbes from liquid specimen, circumventing the need for the additional overnight cultivation step, has been successfully established for blood culture, urine and liquor. Here, we evaluate the ability of MALDI-TOF MS for direct identification of pathogens in synovial fluid after liquid enrichment in BacT/Alert blood culture bottles. Influence of synovial specimen quality on direct species identification with the MALDI BioTyper/Sepsityper was tested with samples inoculated from pretested native synovia with concomitant inoculation of blood or pus, or highly viscous fluid. Here, we achieved >90% concordance with culture on solid medium, and only mixed-species samples posed significant problems. Performance in routine diagnostics was tested prospectively on bottles inoculated by treating physicians on ward. There, we achieved >70% concordance with culture on solid media. The major contributors to test failure were the absence of a measurable mass signal and mixed-specimen samples. The Sepsityper workflow worked well on samples derived from BacT/Alert blood culture bottles inoculated with synovial fluid, giving concordant results to identification from solid media. Host remnant material in the inoculum, such as blood or pus, had no detrimental effect on identification score values of the BioTyper system after processing with the Sepsityper workflow, and neither had the initial viscosity of the synovial sample. Over the last decades, the numbers of prosthetic joint replacements have continuously increased and are forecast to increase even further with the ageing population . This inFor focused therapy of PIJ, identification of pathogens from synovial fluid is highly relevant. Consequently, aspiration of synovial fluid with microbiological analysis is recommended by the AAOS guide-lines for joint infections . HoweverFor microbes cultured on solid media, Matrix-Assisted Laser Desorption/Ionization Time-Of-Flight Mass Spectrometry (MALDI-TOF MS) has become the gold standard for species identification. This technology has brought significant changes in processing of microbiological probes and replaced most cost- and time intensive phenotypic biochemical assays. For identifying microbial species out of liquid culture, MALDI-TOF is already regularly used for blood specimen  and Here, we examined whether BacT/Alert blood culture vials inoculated with synovial fluid were suitable for the Sepsityper workflow, if this yielded microbial identification concordant with the standard culture procedure, and if different levels of host residue influence these results.Several experimental factors influence MALDI-TOF mass spectrum quality when bacteria are analyzed from clinical samples. Residual host material ionizes along with microbial markers. If the host material is in excess, this can lead to spectra representing the host rather than the microbe. Consequently, a main goal of sample pre-processing is eliminating host material, and enriching for microbial cells. A possible option is amplification through liquid culture. This may however introduce several components into the sample interfering with the MALDI-TOF process . In oldeTo test if the residues contained in synovial inoculum had an influence of species identification, we used a total of 23 native synovial samples  over a cIn order to test if this procedure also worked outside artificial laboratory conditions, we prospectively applied it on positively flagged specimen from our routine diagnostics. There, specimen had been inoculated on ward by the treating physician, and the specific condition of the inoculum was unknown . A totalStreptococcus mitis) and solid agar (Streptococcus pneumoniae). Reliable distinction of S. pneumoniae from viridans group streptococci is important because of the different pathogenic properties of these organisms, and this has also previously been achieved by MALDI-TOF MS by others [Pathogen identification concordant with results from isolates cultured on solid agar was achieved in 30/37 (81%) samples at the first try, however 7/37 (19%) again not at levels required for species-level identifications. One sample gave discordant species-level matches for the bottle . Mixed cultures have previously been shown to be problematic, where the ration of the organisms is unequal [Five out of 37 samples (14%) contained mixed-species cultures of either  unequal ,18. AmonIn summary, the Sepsityper workflow also worked well on mono-species samples derived from BacT/Alert blood culture bottles inoculated with synovia. The major contributor to failed detection was the absence of mass signals. The level of concordant identifications in both our specimen groups was comparable to those achieved by others for synovia , or blooFor assessment of method feasibility, pediatric aerobic FCS-supplemented blood culture vials  were inoculated with refrigerated synovial fluid that was previously found to be culture positive by our routine diagnostic procedures. Samples were selected on the basis that they had to be viscous, ideally with large proportions of blood and/or pus. Positively flagged culture vials were processed by MALDI-TOF MS as described below.For prospective study, we used blood culture specimens, where the vials had been routinely inoculated by treating physicians with synovial fluid, transported to the microbiology lab, and cultivated in an automated microbial detection system  for up to 14 days. Only those samples that were made available for the study without delay were included for downstream processing by MALDI-TOF. The collection period was January 01, 2018 to March 07, 2019.2 for 48h and, under anaerobic conditions on Columbia agar supplemented with 5% sheep blood (bioMérieux) for 48 h at 37°C. Reference identifications from culture plates were performed using the same MALDI Biotyper system as below, using standard procedures.Standard microbiological cultures were performed on all specimen included into the study by plating on Columbia agar supplemented with 5% sheep blood (bioMérieux) under aerobic conditions, on Chocolate agar (bioMérieux) under atmosphere enriched with 9% C0g. The supernatant was removed by aspiration and discarded, and the pellet washed with 1 mL saline. After further centrifugation, the supernatant was decanted and the pellet was re-suspended to 300 μL with deionized water. After addition of 900 μL 100% ethanol the cells were again harvested by centrifugation for 2 min at 11500 xg. The supernatant then was decanted, any residual ethanol then was removed and the pellet was dried at room temperature.Direct processing of the samples with the Sepsityper kit  was carried out according to the manufacturer's instructions and as described in the literature for blood cultures . In detaFor extraction, 70% formic acid and an equal volume of 100% acetonitrile were added to the pellet and each mixed carefully. The sample was centrifuged for 2 min at maximum speed and 1 μL of the supernatant then was transferred to a sample spot on a MALDI target plate. After the sample spot had air dried it was overlaid with 1 μL matrix solution  and dried again. Three spots on the MALDI target plate were used for each sample. Afterwards identification of species was performed using a MALDI BioTyper SMART system using the standard settings .This study was approved by the Ethical board on the University Medical Center Göttingen . Patients have given written consent to participate in studies.