The coordinated function of such proteins not only drives the continuous remodeling of microtubules during mitosis and cytokinesis but also assists the positioning of the PPB, the mitotic spindle, and the phragmoplast, affecting tissue patterning by controlling cell division plane (CDP) orientation. The affinity and the function of such proteins is variably regulated by reversible phosphorylation of serine and threonine residues within the microtubule binding domain through a number of protein kinases and phosphatases which are differentially involved throughout cell division. The purpose of the present review is to provide an overview of the function of protein kinases and protein phosphatases involved in cell division regulation and to identify cytoskeletal substrates relevant to the progression of mitosis and cytokinesis and the regulation of CDP orientation.Progression of mitosis and cytokinesis depends on the reorganization of cytoskeleton, with microtubules driving the segregation of chromosomes and their partitioning to two daughter cells. In dividing plant cells, microtubules undergo global reorganization throughout mitosis and cytokinesis, and with the aid of various microtubule-associated proteins (MAPs), they form unique systems such as the preprophase band (PPB), the acentrosomal mitotic spindle, and the phragmoplast. Such proteins include nucleators of  Owing to their sedentary life style and their encasement within the barriers of rigid cell walls, plant cells adopted unique mechanisms for regulating fundamental eukaryotic processes such as cell division and cell division plane (CDP) orientation establishment  involved in microtubule organization and dynamics. Among these proteins belong motor proteins from the kinesin . It is likely that γ-tubulin interacts with the FASS B″ subunit of protein phosphatase 2A  are essential for spindle formation and the establishment of spindle bipolarity , and it e arrays .Microtubule dynamics are largely controlled by plus end binding proteins, including end-binding protein 1 isoforms , which is involved in the tethering of phragmoplast margins to the CPFS . KCBP waInteractions of kinesin motors with protein kinases may be reciprocal and may convey targeted transport or activity regulation to the kinase counterpart. For example, never in a mitosis (NIMA)-related kinase 6 (NEK6) is negatively regulated by the armadillo-repeat kinesin 1 . Also, Nhttps://string-db.org/cgi/network.pl?taskId=jBYrCeTF9nPv; Microtubule severing by the Arabidopsis KATANIN1  has not Apart from several MAPs that have been proven or predicted to be regulated by phosphorylation, tubulin has also been identified as a target of the atypical kinase domain of the protein phosphatase PROPYZAMIDE HYPERSENSITIVE 1 PHS1; . So far,Since MAPs play a role in microtubule dynamics while being regulated by reversible phosphorylation, kinases and phosphatases are master regulators of microtubule reorganization throughout cell cycle. Several kinases were implicated in phosphorylating MAPs, namely CDKs, AURs, MAPKs, and NEKs.in vitro to be phosphorylated by CDK , MKK6, and MPK4/MPK6 , MKK4/MKK5, and MPK3/MPK6. YODA is implicated in several types of asymmetrical divisions, e.g., first division of zygote and stomatal development . Howeverthe root . These othe root . Interacthe root . Interesthe root .The last family of kinases involved in regulation of mitotic microtubule structures is NEKs. This family of Ser/Thr protein kinases is highly conserved in eukaryotes, where it supervises crucial points in mitosis and cell division . In planThe reversibility of phosphorylation is ensured by cooperation between kinases and phosphatases. Numerous protein phosphatases were found in plants, with Ser/Thr specific phosphoprotein phosphatases (PPPs) being a prominent group among them. PPPs encompass large number of proteins, which can be grouped in several protein families. Three of these families were implicated to regulate microtubule dynamics during cytokinesis .Type one protein phosphatases  were predicted to be part of cell cycle regulation , which iMore progress was achieved in solving the function of protein phosphatase type 2A (PP2A). These PPs consist of three subunits—scaffolding (A), regulatory (B), and catalytic (C). They were characterized in both monocots  and dicoMetallo-dependent protein phosphatases (PP2C) might be part of cell division machinery as well, since knockout mutants display improper cell division orientation . These pAlthough plenty of research has been done in elucidating the role of kinases in microtubule reorganization during cell cycle, phosphatases involved in these events remain largely understudied. The cause of this lies mainly in the fact that these phosphatases form multiprotein complexes, which is a serious challenge for both analysis and evaluation. Nevertheless, the current advances in understanding the role of PP2A in regulating microtubule dynamics shows it is not an impossible task.In summary, reversible phosphorylation of several different MAPs is essential for regulating microtubule dynamics and organization during the plant cell division. The affinity of MAPs for microtubules can be downregulated or restored pending on their phosphorylation status. To this extend, several protein kinases and phosphatases have been shown to target cytoskeletal proteins with various roles in the regulation of mitotic spindle and phragmoplast assembly and progression. However, many questions remain unanswered and are expected to be addressed in the near future:How phosphorylation may affect microtubule nucleation during acentrosomal mitotic spindle formation?Is phosphorylation related to the transition from PPB to mitotic spindle?How phosphorylation really controls microtubule bundling during phragmoplast expansion?Which phosphatases are reinstating microtubule binding of MAP65 proteins?Which mechanisms allow the regulation of the same cytoskeletal proteins  by different protein kinases  with a different biological outcome ?How global phosphoproteomics analyses will help to decipher reversibly phosphorylatable cytoskeletal substrates in model cell suspension systems that can be synchronized?How differential (phospho)proteomics comparing wild types with protein kinase/phosphatase mutants will advance our knowledge in the identification of cytoskeletal substrates?TV drafted the manuscript and drawn The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Varicella zoster virus (VZV) is the causative agent of chickenpox (varicella) and shingles (herpes zoster). VZV and other members of the herpesvirus family are distinguished by their ability to establish a latent infection, with the potential to reactivate and spread virus to other susceptible individuals. This lifelong relationship continually subjects VZV to the host immune system and as such VZV has evolved a plethora of strategies to evade and manipulate the immune response. This review will focus on our current understanding of the innate anti-viral control mechanisms faced by VZV. We will also discuss the diverse array of strategies employed by VZV to regulate these innate immune responses and highlight new knowledge on the interactions between VZV and human innate immune cells. Varicella zoster virus (VZV) is a medically important human herpesvirus and infections are extremely common, with seroprevalence rates >90% in most populations around the world. Primary VZV infection causes chickenpox (varicella). The virus then establishes life-long latency in sensory neurons from where it can reactivate years later to cause shingles (herpes zoster), which is typified by a skin rash with a dermatomal distribution. Following herpes zoster rash resolution, many individuals continue to experience severe neuropathic pain, termed post-herpetic neuralgia (PHN), that can persist for months to years .VZV is a member of the alphaherpesvirus family and is closely related to herpes simplex virus type 1 (HSV-1). VZV is genetically stable, a property which is demonstrated by little nucleotide variation between isolates . The VZVin vitro utilizing human cells and infection of human tissue xenografts implanted in severe combined immunodeficient (SCID-hu) mice, as well as observations from the simian varicella virus (SVV) infection of non-human primates, which has been used to model VZV infection in vivo  and lungs. Dissemination of infection may result in a number of serious complications, including VZV encephalitis, cerebellar ataxia, demyelinating neuropathy, myelitis, and pneumonia , 21.During primary infection, despite a robust immune response, VZV is not completely eliminated from the host but rather the virus gains access to neurons in the sensory ganglia and establishes a life-long latent infection –24. The Reactivation from latency causes herpes zoster (shingles), a neurocutaneous disease which occurs in 10–20% of seropositive individuals and involves anterograde axonal transport of virus from the reactivating ganglia to the innervating dermatome –33. The Herpes zoster rash development is often preceded by a prodrome of dermatomal pain and is clinically characterized by a unilateral cluster of lesions typically across a single dermatome, accompanied by localized pain of varying intensity, and neuritis. The cutaneous lesions contain infectious virus and provides another reservoir for virus transmission to other susceptible individuals . OccasioHerpes zoster has the potential to severely impact an individual's quality of life. The most common complication of herpes zoster is PHN which is a pain persisting for months to years after herpes zoster rash resolution . PHN occProgrammed cell death is a critical component of the intrinsic and innate immune response, as it allows for the rapid elimination of damaged or infected cells . Viral iIn the context of VZV, apoptosis has been the most comprehensively investigated programmed cell death pathway. Apoptosis contains distinct biochemical pathways, which are highly complex and involve an energy dependent cascade of molecular events , 48. ThrInterestingly, VZV has been shown to modulate apoptosis in a cell type specific manner. Specifically, VZV induces apoptosis in multiple skin cell types such as MeWo cells  and humaVZV has also been shown to induce apoptosis in immune cells such as T cells, B cells, and monocytes –56, howeIn contrast to some skin cell types and immune cells, VZV does not induce apoptosis in neurons . This waThe ability of VZV to protect neurons from apoptosis induction was attributed to ORF 63, using a recombinant virus which was able to express only one copy of the diploid ORF63 gene . HoweverCell type specific modulation of apoptosis is a crucial component of VZV research due to its link to VZV pathogenesis. As VZV establishes life-long latency in neurons of the DRG, the inhibition of apoptosis in neurons is critical for viral maintenance of latency and the establishment of reactivation . In contOther VZV gene products have also been shown to play a role in apoptosis inhibition. For example, VZV ORF66 inhibits apoptosis in T cells, as evidenced by T cells undergoing apoptosis more readily when infected with a virus in which ORF66 protein expression is impaired . InvestiIt is clear VZV encodes multiple ORFs with anti-apoptotic mechanisms, demonstrating the importance of modulating apoptosis for viral replication and spread. Interestingly, when expressed alone or deleted from VZV, these genes have an anti-apoptotic effect in cell types where VZV is known to induce apoptosis. It will be important to determine whether these gene products delay the onset of apoptosis in vulnerable cell types during VZV infection as this could be a critical component of VZV pathogenesis in the skin and during reactivation. Furthermore, it would be beneficial to determine whether VZV can protect against other forms of cell death, as when apoptosis is inhibited other cell death forms such as necroptosis can occur to limit viral spread . HSV-1 hThe innate immune response to VZV involves the recognition of viral pathogen associated molecular patterns (PAMPs) via PRRs, which triggers inflammatory cytokine secretion and/or cell death. Of the Toll-like receptors (TLRs), Wang and co-workers demonstrated that exposure of monocytes to VZV induced TLR2 and NFκB dependent secretion of interleukin (IL)-6. Furthermore, this report suggested sensing of VZV involved cell-surface TLR2 binding to virion envelope glycoproteins . RecentlTLR3 is known to be expressed in human neurons and peripheral nerve Schwann cells , 83, thuRetinoic acid-inducible gene I (RIG-1) is a cytoplasmic PRR which senses both RNA and DNA viruses and can result in the production of the type I IFN response . KnockdoMonocytes and other myeloid cells are also able to sense virus through NLRs, which trigger a pro-inflammatory response through inflammasome formation . InteresAnother intrinsic defense mechanism limiting VZV infection in human skin is the formation of promyelocytic leukemia (PML) cages in infected epidermal cells, which trap VZV nucleocapsids resulting in inhibition of virion assembly . Wang anInterferons (IFNs) are key anti-viral cytokines that mediate their activity through the induction or upregulation of a suite of interferon stimulated genes (ISGs), which have a range of anti-viral activities . Recogniin vivo observations. More than 30 years ago a clinical trial to evaluate the efficacy of IFNα in inhibiting VZV infection in children suffering from cancer indicated that IFN treatment could limit the dissemination of severe varicella lesions  to modulate type I IFN signaling and viral replication . Multiplin vivo and in vitro, with VZV infected pDCs significantly inhibited in their capacity to produce IFNα after stimulation with a TLR9 agonist  have the capacity to secrete significant amounts of IFNα following appropriate stimulation . Work fr agonist . More re agonist    T cells . These f T cells . The imp T cells .in vitro showed no significant decrease in cell viability or evidence of apoptosis (in vitro MDDC infection model to demonstrate that the VZV vaccine strain (V-Oka) and virulent VZV clinical isolates equally infect these immune cells  , 127, exin vivo . We extenfection . FurtherVZV infection of human DCs has been shown to result in the modulation of cell-surface receptor phenotype and immune functions. Mature MDDCs, like their immature counterparts, are also susceptible to productive VZV infection  which reMoreover, VZV has been reported to reduce cell-surface expression of apoptosis receptor Fas on infected immature and mature MDDCs, whereas surface levels of MHC II remain unchanged . HoweverVZV infection of pDCs and epidermal cells has been observed to occur in the absence of an increase in the type I cytokine IFNα production , 113. ThInterestingly, Gutzeit and colleagues reported the secretion of signature Th1 cytokines (IFNγ and IL-12) was enhanced following infection of MDDCs with (v-OKA) but blocked by a VZV clinical isolate. This impairment of IL-12 secretion was shown to be due to a viral disruption of signaling downstream of TLR2, and proposed to be most likely caused by a VZV glycoprotein within the virion envelope . Thus, VMonocytes and macrophages play a key role in pathogen sensing, immune defense against infection and are important players in resolving inflammation . These c+ cells from varicella patients harbor detectable copies of VZV ORF62 and VZV gB transcripts . Expression of CD16 (FcγRIII) on NK cells allows engagement of IgG antibodies bound to a target cell, which typically occurs during anti-pathogen immune responses. VZV infected and bystander NK cells, however, potently downregulate cell-surface expression of CD16 , which whallenge . A thirdhallenge , which whallenge , potentiin vitro characterization of inhibited NK cell function by VZV.Not only does VZV regulate detection of infected cells, we have recently shown that it directly impairs NK cell function . Both inin vitro that VZV diminishes NK cell secretion of both IFNγ and TNF (Lastly, an important function of NK cells is the secretion of immune modulating cytokines. In relation to the control of VZV, IFNγ, and TNF are readily secreted by NK cells and have strong inhibitory effects on VZV replication , 172. Th and TNF  (Figure  and TNF . This seVZV has co-evolved with the human host for millions of years . In thatThere are still many areas of VZV encoded innate immunity manipulation that warrant further investigation. For example, exploring whether VZV protect against other forms of cell death, as when apoptosis is inhibited other cell death forms can occur to limit viral spread. Additional study will be required to fully define the role of type III IFNs during VZV infection. Specifically it will be of interest to understand the distinct activities of type I, II, and III IFNs in regulating infection as this will potentially dissect the roles played by distinct IFNs in regulating infection during different phases of the viral lifecycle. Despite VZV being shown to modulate immune functions of different DC subsets, the molecular mechanisms and VZV proteins directly responsible for these immune evasion strategies has yet to be elucidated. Finally, recent data showing NK cells and other immune cells within PBMC compartment can be infected with VZV provides an avenue to gain a deeper understanding of the impact VZV infection has on immune cell functions and the importance of these cells in viral pathogenesis.Modulation of the innate immune response ultimately effects the formation and effectiveness of the adaptive immune response. Therefore, it is clear VZV can modulate components of the intrinsic, innate and adaptative immune response to ensure viral dissemination and the establishment of life-long latency. It is critical to dissect the mechanisms of this immunomodulation to provide important insights into VZV pathogenesis which will likely be of benefit when designing new generation vaccines and anti-virals. Furthermore, the study of herpesvirus modulation of immune responses also enhances our general understanding of the complexity of the human immune system.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


During the past decade numerous studies highlighted the importance of long non-coding RNAs (lncRNAs) in orchestrating cardiovascular cell signaling. Classified only by a transcript size of more than 200 nucleotides and their inability to code for proteins, lncRNAs constitute a heterogeneous group of RNA molecules with versatile functions and interaction partners, thus interfering with numerous endogenous signaling pathways. Intrinsic transcriptional regulation of lncRNAs is not only specific for different cell types or developmental stages, but may also change in response to stress factors or under pathological conditions. Regarding the heart, an increasing number of studies described the critical regulation of lncRNAs in multiple cardiac disorders, underlining their key role in the development and progression of cardiac diseases. In this review article, we will summarize functional cardiac lncRNAs with a detailed view on their molecular mode of action in pathological cardiac remodeling and myocardial infarction. In addition, we will discuss the use of circulating lncRNAs as biomarkers for prognostic and diagnostic purposes and highlight the potential of lncRNAs as a novel class of therapeutic targets for therapeutic purpose in heart diseases. Although the majority of the human genome is transcribed into RNA molecules, only ∼2% of these transcripts code for proteins, thus, scientists have started to explore the wide universe of non-coding RNAs (ncRNAs) as crucial regulators of physiological and pathological cell function. Numerous studies demonstrated the involvement of small ncRNAs like microRNAs (miRNAs) in cardiovascular disease , whereasThe term cardiovascular disease (CVD) comprises a wide range of pathologies. However, in order to adequately address the importance of lncRNAs in distinct diseases and to highlight specific molecular modes of action, we will focus on a selection of lncRNAs associated with cardiac hypertrophy and myocardial infarction. In addition, myosin heavy-chain-associated RNA transcripts (Mhrt)  . Mhrt was (Mhrt) . Inducibs (Mhrt) . Importacardiac hypertrophy-associated transcript (Chast) to be upregulated in hypertrophic cardiomyocytes  prevented hypertrophic cardiac growth and preserved cardiac function in TAC operated animals. Of note, silencing Chast was cardio-protective in a preventive approach, as well as in a clinically more relevant therapeutic approach with repeated GapmeR injection starting 4 weeks after induction of pressure overload in mice. Strikingly, the human CHAST transcript was able to induce hypertrophic cell growth in murine cardiomyocytes in vitro, suggesting functional conservation. Furthermore, CHAST was upregulated in hearts of patients with aortic stenosis, where cardiac hypertrophy occurs as a compensatory response to increased afterload, highlighting the therapeutic potential of CHAST for the treatment of cardiac hypertrophy in humans.Using a microarray approach to compare the lncRNA transcriptome of TAC versus sham operated mice, Viereck and colleagues identified the conserved lncRNA myocytes . Chast ecardiac-hypertrophy-associated epigenetic regulator (Chaer). Following TAC surgery Chaer-knockout mice showed less hypertrophic cardiac growth, reduced fibrosis and preserved cardiac function in comparison to wildtype control animals  appeared to be upregulated during the first 4 weeks after TAC followed by a long term repression. Meg3 interaction with p53 facilitates transcriptional activation of matrix metalloproteinase-2 (MMP-2) and subsequent remodeling of ECM composition  activation and rearrangement of the extra cellular matrix (ECM), resulting in fibrosis and impaired cardiac function. By performing lncRNA array analysis in CFs of mice undergoing 13 weeks of TAC, Piccoli et al. identified over 1400 deregulated lncRNAs in CF fractions of hypertrophic mouse hearts . The mosposition . Consecumyocardial infarction associated transcript (MIAT) was first described in a large scale single nucleotide polymorphism (SNP) association study from a Japanese population in 2006. In this study the presence of six SNPs in the MIAT locus was associated with an increased risk for MI  has been described to control CF functions in vitro and in vivo. Wisper is transcribed from a cardiac-specific super-enhancer region and was found to be highly upregulated in the border zone after MI in mice  to regulate alternative splicing of lysyl hydroxylase 2 (LH2 or Plod2), which has been associated with fibrosis-related disorders    is transcriptionally repressed after ischemia reperfusion injury and showed anti-apoptotic potential by regulating the Bcl2l2 repressor miRNA miR-29b-1-5p   and mitoA (Mdrl)  were dow29b-1-5p  in vitroAs highlighted above lncRNAs are crucial regulators of pathological cardiomyocyte growth, fibrosis and cell survival in hypertrophic and infarcted hearts . Throughmyocardial infarction-associated transcript 1 (Mirt1) for example was shown to be involved in the regulation of the acute inflammatory response after MI , whose plasma levels are associated with left ventricular (LV) remodeling after MI and increased risk of developing heart failure , were associated with LV cardiac remodeling in these patients from the same study. Moreover, Zhang et al. reported increased plasma levels of LIPCAR and the paternally-imprinted lncRNA H19 in patients with coronary artery disease (CAD), especially in those subjects with concomitant chronic heart failure  and MHRT as further independent predictors for heart failure  or RNA interference (RNAi) methods. Antisense drug therapies have already been applied in clinical trials targeting protein-coding mRNAs with one compound already on the market for the treatment of familial hypercholesterolemia [Mipomersen ] and anoin vivo, as they are able to enter the nucleus, thus, enable targeting of nuclear transcripts as well. GapmeRs consist of a DNA core flanked by two locked nucleic acids (LNA) sequences complementary to the target mRNA or lncRNA sequence. By chemically ‘locking’ the ribose backbone of the nucleotide structure, LNAs display a higher stability, target specificity and RNase H activation potential resulting in enhanced knockdown efficiency (Currently, GapmeRs are the most promising class of ASOs used for pharmacological silencing of lncRNAs ficiency . To dateficiency  and Meg3ficiency ] and MI ficiency ]. In allficiency , highligficiency .in vivo appears to be more challenging and requires the use of viral-mediated gene delivery, nanoparticles, or RNA mimics. Overexpression of lncRNAs using viral gene delivery poses several obstacles including the efficiency of lncRNA upregulation itself. The second challenge is to overexpress the target lncRNA in its endogenous subcellular localization – in other words, to enhance the function of cis regulatory lncRNAs via ectopic overexpression. AAV vectors that are commonly used for gene therapy approaches have relatively low packaging limit. Hence, they cannot be used for lncRNA transcripts longer than 3–4 kb. Furthermore, depending on the pathological context, a transient or stable overexpression may be needed for the therapeutic treatment. Of note, the targeted lncRNA should be overexpressed in a cell type specific manner, as lncRNAs may have varied functions in different cells or organs (In contrast to silencing approaches, therapeutic overexpression of lncRNAs r organs . Despiter organs ,c. Althoin vivo experiments have revealed that modulation of lncRNAs offers a promising new therapeutic approach to treat cardiovascular diseases, albeit the silencing or overexpression approaches still require further refinements. Nevertheless, large screening approaches are often performed in animal models of CVD and lncRNAs are not always conserved among species but this is a prerequisite for clinical translation. However, as the field of lncRNAs as potential therapeutic targets is still in its infancy it is not unlikely that in the near future lncRNAs will emerge as valuable new tools for the treatment of numerous diseases, including CVDs.In summary, a vast number of lncRNAs are dynamically regulated upon initiation and progression of CVDs. Many have important biological functions and/or have the potential to serve as a novel class of circulating biomarkers. Several LH wrote the manuscript and prepared the display items. CB and TT guided the manuscript preparation and critically revised it.TT has filed patents about the diagnostic and therapeutic use of several cardiovascular lncRNAs and is a founder of and holds shares in Cardior Pharmaceuticals. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


A 28-year-old G3 P1 SAB1 female with no prior health concerns was found to have a foetus with short femurs on prenatal ultrasound following an abnormal maternal serum screen result. Fluid obtained by amniocentesis revealed an elevated α-fetoprotein level with absence of an acetylcholinesterase band and normal male karyotype . Follow-up ultrasound 3 weeks later again demonstrated short femur lengths, but no other abnormalities. At birth, the child was noted to have multiple dysmorphic features, including short humeri and femurs, coarse facial features, retrognathia and yellowish hypertrophic gums in addition to hyperbilirubinaemia and thrombocytopenia. Radiological studies demonstrated bony demineralization with profound diaphyseal cloaking in the long bones. Genetic testing diagnosed I-cell disease. N-acetylglucosamine-1-phosphotransferase. Nearly all lysosomal hydrolases are elevated in the plasma and body fluids of affected individuals because of the failure of targeting lysosomal acid hydrolases to the lysosomes. It is characterized by the presence of cytoplasmic inclusions in cultured fibroblasts (I-cell phenotype).1,2 There is a significant amount of variability in the disorder in terms of age of onset, tissue/organ involvement and radiological findings.2 Despite the heterogeneous manifestations, the disorder typically presents between 6 and 12 months of age with clinical symptoms that include marked growth deficiency, coarse facial features, severe skeletal abnormalities, developmental delay and gingival hyperplasia.3–5 The presenting radiological findings at that time are often of severe dysostosis multiplex, although these findings vary depending on the stage at which they are found.1,2Mucolipidosis II (I-cell disease) is a lysosomal storage disorder caused by deficiency of Recognizing the potential prenatal and early postnatal findings of I-cell disease allows earlier diagnosis. Given the universally fatal prognosis, early diagnosis is crucial in helping affected families plan and cope with the outcome. We present a case with both prenatal and early postnatal findings of the disease.A 28-year-old G3 P1 SAB1 female with no prior health concerns was found to have an abnormal integrated maternal serum screen indicating a 1 : 7 risk for trisomy 18. Foetal ultrasound at 19 weeks gestation revealed short femurs (< 2.5%) and an otherwise normal examination. A multidisciplinary approach was taken, including a genetics consult. The family history was notable for one nephew with “weak bones”. The patient and her husband reported that they were of Yemeni ancestry and distantly related. A recommended amniocentesis was performed, which showed increased α-fetoprotein at 2.26 MoM and absence of an acetylcholinesterase band. Chromosome analysis revealed a normal male karyotype . Follow-up ultrasound at 22 weeks gestation again demonstrated short femurs, measuring 3.5 cm (< 2.5%) . BiparieThe baby was born by C-section at 37 4/7 weeks gestation owing to foetal decelerations. Upon delivery, the infant was found to have hoarse cry, weak reflexes and low tone. Multiple dysmorphic features were discovered, including short humeri and femurs; bowed lower legs; narrow chest; large ear lobes; retrognathia; yellowish hypertrophic gums and a low, flat palate; hypertrichosis of the bilateral temporal region; and light hair colour that was atypical for his ethnic background. He exhibited diffuse patchy ecchymoses on the trunk and persistent thrombocytopenia as well as hyperbilirubinaemia. Echocardiogram showed a small atrial septal defect and a large patent ductus arteriosis. The infant also experienced respiratory distress, requiring continuous positive airway pressure ventilation.Radiological investigation at that time revealed the following:diffuse demineralization of bony structures profound diaphyseal cloaking of the long bones  and 3relatively short humeri and femora poorly formed and irregular appearing proximal humeral and femoral metaphyses  and 3thickened and poorly formed clavicles thickened and shortened ribs with an abnormally increased cardiothoracic ratio poorly formed iliac bones with flattening of the acetabular roofs unusual bowing of the distal ulna and radius with metaphyseal cupping thickening of the proximal phalanges and minimal narrowing at the proximal aspect of the metacarpal bones.GNPTAB gene analysis revealed homozygous c.376_379delTTAG deletion mutations. This deleterious mutation has not been reported previously in individuals with I-cell disease.Genetics service was consulted. Tests revealed elevated levels of multiple plasma and leukocyte lysosomal hydrolases, consistent with a diagnosis of I-cell disease. The patient was eventually discharged to the care of hospice and passed away at 5 weeks of age. Additional information regarding the case was limited as an autopsy was declined by the family.N-acetylglucoseamine-1-phosphotransferase enzyme activity was low, consistent with I-cell disease. Soon after obtaining these results, the family chose to terminate the pregnancy at 15 weeks. Chorionic villous testing was again obtained during a fifth pregnancy, and testing revealed that this child was neither affected nor a carrier of the abnormal GNPTAB gene. This child was born at full term without any health concerns.However, the parents did follow-up with genetics several months later for future family planning. When the wife became pregnant again later that year, chorionic villous sampling was obtained at 10 weeks gestational age and sent to test for I-cell disease. Uridine diphosphate-3,5 It is caused by mutations in the GNPTAB gene, located on chromosome 12, and inherited in an autosomal recessive manner. In the appropriate clinical setting, such as when a family history of the disorder is known, foetal I-cell disease can be suggested sonographically by the demonstration of abnormally shortened long bones and intrauterine growth retardation.6 Other sonographic features that have been described in the literature include periosteal cloaking of the femora and humeri and transient maxillary defects.7 In our case, the only abnormality found on prenatal ultrasound was bilateral short femora (< 2.5%). No other signs of intrauterine growth retardation or additional sonographic abnormalities were present. In the absence of a known family history, prenatal diagnosis of I-cell disease remains difficult as many other conditions can present with similar findings.I-cell disease is a rare lysosomal storage disorder that typically remains undiagnosed until later in the first year of life, as facial features coarsen, growth failure becomes increasingly apparent and the Hurler-like clinical picture develops.1 in 1978 discussed the specific radiological features of the disorder and distinguished I-cell disease from other storage disorders.The postnatal features of I-cell disease are more classic and have been better characterized in the literature. A study of nine cases of the disease by Lemaitre et alearly stage; and Stage B, a late stage.1 Stage A includes the neonatal period and the first 2 months after birth, while Stage B starts after the age of 4 months.1In their study, the authors divided the radiological manifestation of I-cell disease into two groups—Stage A, an early stage is typically characterized by a storage osteopathy with bone structural and modelling abnormalities, stippling of the epiphyses and elements of a storage disorder.1 These signs evolve during the intermediate stage with disappearance of the bone structural abnormalities and the signs of a storage disease becoming more pronounced.1 In the late stage, the skeletal manifestations are of an early and severe dyostosis multiplex.1 The late stage findings, while apparent at 4–6 months, continue to become more obvious as the patient grows older.The early stage findings described, I-cell disease typically goes undiagnosed until later in the first year of life. In the study by Lemaitre et al,1 seven of the nine cases were diagnosed after the neonatal period. More recently, David-Vizcarra et al8 attempted to better define the natural history and early osteodystrophic features of I-cell disease. They described neonatal radiographic findings in 15 cases of I-cell disease that were similar to those seen in neonatal hyperparathyroidism.8 Later studies have also presented cases manifesting similar radiographic findings with markedly elevated alkaline phosphatase and parathyroid hormone levels as well as normal serum calcium levels suggesting severe secondary hyperparathyroidism.9 However, the aetiology of severe secondary hyperparathyroidism in I-cell disease is unclear.8,9 In their study, David-Vizcarra et al8 concluded by emphasizing the need for further studies regarding the pathophysiology of osteodystrophy in I-cell disease and the need for more definitive characterization of the early clinical manifestations.8Despite the early stage of the disease, including diffuse bony demineralization, shortened long bones with periosteal apposition, poorly formed metaphyses with cupping, thickened and shortened ribs and clavicles, flattened acetabular roofs and rectangular metacarpals with coning of the proximal ends. However, it is the dramatic degree of periosteal apposition, or diaphyseal cloaking, seen in the long bones that sets this case apart from previously reported cases.Our case demonstrates many of the features described in the Diaphyseal cloaking is thought to be due to increased remodelling of the bone. It is typically unilamellar, although it has been described in some cases as general periostitis. In earlier studies, it has been described as a poorly defined contour or a double outline image. In addition, it is typically seen in the diaphyseal region of the bones.In the current case, the degree of cloaking was more dramatic than in previously reported cases of I-cell disease. In addition, the cloaking did not have the appearance of simple periosteal apposition, but demonstrated a more solid appearance. Adding to the uniqueness of the case, the cloaking was not confined to the diaphyses but rather extended to the metaphyseal regions.10 Perhaps the dramatic degree of periosteal cloaking in our case represents excessive subperiosteal new bone formation in the setting of subperiosteal haemorrhage either in addition to, or even as opposed to, sequelae of secondary hyperparathyroidism. Unfortunately, an autopsy was not performed on our patient. Future studies with note of any associated thrombocytopenia as well as pathologic correlation are needed to investigate this hypothesis.Another unique aspect of our case is the persistent thrombocytopenia, which has not been previously described in reported cases of I-cell disease presenting in the neonatal period. Could this also relate to the marked degree of periosteal cloaking in our patient? Subperiosteal haemorrhage, as seen in cases of infantile scurvy, can appear similar to diaphyseal cloaking, although in the former case this appearance is not confined only to the diaphyseal regions.Given the universally fatal prognosis of I-cell disease, early diagnosis is crucial in helping affected families cope with the outcome. While prenatal sonographic features of the disorder are non-specific, recognizing them in the appropriate clinical setting is paramount in making the diagnosis. When the prenatal diagnosis is not made, radiologists can play an important role in suggesting the possible diagnosis. We have presented a case with prenatal short femurs and dramatic neonatal osteodystrophic features. In addition to supporting the classically defined radiological manifestations of early I-cell disease, we also offer a unique hypothesis that early stage finding of diaphyseal cloaking could also relate to subperiosteal haemorrhage. Further studies are needed to better understand the pathophysiology behind the characteristic early osteodystrophy seen in I-cell disease. Larger case series are also necessary to fully characterize the early manifestations of the disease. With continued work in these areas, earlier diagnosis of this universally fatal disease may be possible.I-cell disease is a rare lysosomal storage disorder that typically goes undiagnosed until later in the first year of life, as facial features coarsen, growth failure becomes increasingly apparent and a Hurler-like clinical picture develops.Findings on prenatal ultrasound are variable but may include abnormally shortened long bones, intrauterine growth retardation, periosteal cloaking of the femora and humeri, and transient maxillary defects.early stage from the neonatal period through 2 months after birth is typically characterized by storage osteopathy with bone structural and modelling abnormalities, stippling of the epiphyses and elements of a storage disorder. The late stage starts after the age of 4 months and is typically characterized by skeletal manifestations of an early and severe dyostosis multiplex.The The pathophysiology of the early osteodystrophy seen in I-cell disease is currently poorly understood. Better defining the early clinical and radiological manifestations is key to achieving earlier diagnosis of this universally fatal disease.Despite exhaustive efforts undertaken by the researchers to contact the family of the deceased patient, they could not be reached, and thus informed consent could not be obtained. However, the case report has been sufficiently anonymized so as to prevent harm to the patient's family as confirmed by Dr Ezhuthachan, Head of Neonatology at Henry Ford Hospital.


Among the advanced MRI techniques, manganese-enhanced MRI (MEMRI) involves the use of active manganese contrast agents that positively enhance brain tissue signals in T1-weighted imaging with respect to the levels of connectivity and activity. Depending on the routes of administration, accumulation of manganese ions in the eye and the visual pathways can be attributed to systemic distribution or their local transport across axons in an anterograde fashion, entering the neurons through voltage-gated calcium channels. The use of the paramagnetic manganese contrast in MRI has a wide range of applications in the visual system from imaging neurodevelopment to assessing and monitoring neurodegeneration, neuroplasticity, neuroprotection, and neuroregeneration. In this review, we present four major domains of scientific inquiry where MEMRI can be put to imperative use — deciphering neuroarchitecture, tracing neuronal tracts, detecting neuronal activity, and identifying or differentiating glial activity. We deliberate upon each category studies that have successfully employed MEMRI to examine the visual system, including the delivery protocols, spatiotemporal characteristics, and biophysical interpretation. Based on this literature, we have identified some critical challenges in the field in terms of toxicity, and sensitivity and specificity of manganese enhancement. We also discuss the pitfalls and alternatives of MEMRI which will provide new avenues to explore in the future.Understanding the mechanisms of vision in health and disease requires knowledge of the anatomy and physiology of the eye and the neural pathways relevant to visual perception. As such, development of imaging techniques for the visual system is crucial for unveiling the neural basis of visual function or impairment. Magnetic resonance imaging (MRI) offers non-invasive probing of the structure and function of the neural circuits without depth limitation, and can help identify abnormalities in brain tissues  The visual system is a vital and complex component of the central nervous system that receives and processes electrochemical information for visual perception. Not only does it comprise the specialized sensory organ , but also the optic nerve fibers, the visual brain nuclei, as well as the feedforward and feedback pathways to and from the visual cortex  Figure . To undein vivo. Among the advanced MRI techniques, manganese-enhanced MRI (MEMRI) has substantiated in the past two decades as a valuable tool for visualizing the architecture and physiology of the brain and the peripheral structures. MEMRI has a number of advantages over existing MRI techniques including blood-oxygen-level-dependent functional MRI (BOLD fMRI), diffusion tensor imaging, and other contrast-enhanced MRI systems. In its ionic form (Mn2+), manganese is paramagnetic, which makes it a suitable contrast agent that positively enhances T1-weighted MRI intensities in local tissues as a result of contrast uptake over a defined period of time. Manganese (II) chloride (MnCl2) is the most commonly used exogenous salt in the delivery of Mn2+ to the central nervous system in vivo. MEMRI is useful in basic and preclinical neuroscience because Mn2+ can be actively transported along axons and can accumulate in brain tissues with respect to the level of connectivity and activity, thereby aiding in enhancing neuroarchitecture contrast and in functional brain mapping  mapping  as well as neuroplasticity, neuroprotection, and neuroregeneration  offers non-destructive probing of the structure and function of the neural circuits without depth limitation. It can also help identify abnormalities in brain tissues  mapping   tend to act as a Ca2+ analog by passing through voltage-gated calcium channels, making MEMRI an effective technique for visualizing neural activity in vivo. To bolster this hypothesis, mice deficient in L-type Ca2+ channel 1.2 (Cav1.2) were found to have a near 50% reduction in signal enhancement in MEMRI compared to control mice  Mn2+ biochemistry in neuronal milieu is similar to that of Ca2+ (except for their magnetic properties). Due to its unpaired electrons, Mn2+ is paramagnetic and acts as a positive contrast agent with short T1 relaxation time. As a result, tissues with high concentrations of Mn2+ generally appear as regions with bright signals in T1-weighted images.Due to its similarities with Carol mice . These r2+ ions are anterograde tract tracers, traveling away from the soma and toward projection terminals of neurons, then crossing the synapses before entering neighboring neurons. They can localize into the endoplasmic reticulum or Golgi bodies, and be actively transported along axons  and various anhydrous and hydrated forms. Since mammalian body fluids have around 300 mOsm/L of osmolarity  determine the sensitivity and specificity of MEMRI for neuronal tract tracing; (b) determine the doses at which Mn2+ becomes toxic; (c) clarify the mechanism of how Mn2+ enters the cells, and (d) decipher the mechanism through which Mn2+ is transported across the cellular milieu. In this section, we will examine important studies that utilize MEMRI to trace neuronal tracts in the visual system. A summary of the relevant MEMRI protocols used is provided in Early methods of neuronal tract tracing involve the use of biotinylated dextran , horsera pathway . The rat rodents , and is  rodents , age , and calcium channels  of injectate to mouse eyes there is a volumetric effect. At low volumes (<0.25 μL of 200 mM) a transient effect on visually evoked potentials which reverses after 24 h was observed with Mn2+ but not with saline  is an example of such. This compound is consisted of Mn2+ ions and fodipir (dipyridoxyl diphosphate) as a chelating agent, and was approved for clinical use for pancreatic and hepatobiliary imaging (in vivo catecholamine release triggered by MnDPDP administration prevents the potentially negative ionotropic effects of Mn2+ ions on cardiac function (2+ may account for the favorable cardiovascular safety of MnDPDP (One of the most important aspects for the future of Mn imaging , myocard imaging , and dia imaging . Initial imaging  until cl imaging . MnDPDP  imaging . Also, ifunction . The redf MnDPDP  with lowf MnDPDP .2 injection (2+, MnDPDP possesses MnSOD-mimetic activity which is dependent on the manganese ions that are bound to the fodipir part (With regards to the visual system, intravitreal MnDPDP injection allows MEMRI tract tracing in the rat retina and optic nerve similar to intravitreal MnClnjection , while snjection . MnDPDP njection . While tpir part . MnDPDP pir part . On a nepir part . It is ipir part . Though pir part . Human epir part , while tpir part . Also, r2+ safety, one of the essential goals for future MEMRI studies would be to decipher the metabolic arena (2+ in the neuronal milieu as that would aid in developing better studies and understanding not only structure and function but also mechanism of disease progression and protocols for differential diagnosis and prognosis. Employment of nanotechnology such as nanoparticle-based delivery of Mn2+ may deliver Mn2+ to the eye and the visual pathway more specifically without altering the blood–ocular or blood–brain barrier (2+ ions can improve Mn2+ entry duration and MEMRI sensitivity while minimizing toxicity and injection frequency (Apart from Mnic arena  and tran barrier . Additiorequency . MRI harrequency . Awake drequency .2+ is distributed in biological systems while avoiding the pitfalls of Mn2+ toxicity. Uncovering the mysteries behind Mn2+ detection mechanisms is the key to opening new doors for MEMRI as a non-invasive and useful in vivo tool in studying different aspects of ophthalmology and visual neuroscience.In summary, MEMRI has considerable potential for unveiling the neural circuits of the visual system in relation to development, impairments, plasticity, and restoration. There are many unknown functional and disease processes involving the visual system that may be deciphered with the help of MEMRI. However, more work has to be done in regard to understanding precisely how MnNo datasets were generated or analyzed for this study.WD, MF, CL, and VA wrote the manuscript. KC proposed the topic and edited the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Despite the remarkable number of scientific breakthroughs of the last 100 years, the treatment of neurodevelopmental disorders  remains a great challenge. Recent advancements in genomics, such as whole-exome or whole-genome sequencing, have enabled scientists to identify numerous mutations underlying neurodevelopmental disorders. Given the few hundred risk genes that have been discovered, the etiological variability and the heterogeneous clinical presentation, the need for genotype—along with phenotype-based diagnosis of individual patients has become a requisite. In this review we look at recent advancements in genomic analysis and their translation into clinical practice. The identification of genetic mutations associated with neurodevelopmental disorders (NDDs) along with routine diagnosis based on patients’ characteristics is aiding the delivery of personalized therapies. Dora Tarlungeanu and Gaia Novarino at the Institute of Science and Technology in Klosterneuburg, Austria, review recent advances in genetic technologies, such as whole exome sequencing, that can lead to early intervention, guide choice of treatment and prompt genetic counseling. Introducing the mutations associated with NDDs into model organisms or stem cells is revealing some of the mechanisms underlying NDDs and enabling the evaluation of novel therapeutic strategies that target core symptoms of the disorders. To accelerate the implementation of individualized treatments for NDD the authors highlight the need to adopt interdisciplinary research approaches and to keep clinical staff updated on the latest findings in NDD genetics. Neurodevelopmental disorders (NDDs) affect more than 3% of children worldwide and can be attributed to mutations at over 1000 loci2. In addition, the clinical heterogeneity of NDDs make diagnosing a lengthy and costly process, complicating the quest for personalized medicine. However, the identification of bona fide genetic risk factors and the use of functional genomics to progress from mutation to phenotype represent a solid foundation for the development of individualized therapeutic approaches. In this review, we begin by mentioning some features of these disorders and continue by emphasizing the importance of genomics in determining the etiology of NDDs. We then describe advantages and limitations in the use of animal or stem cell models to study patient-specific genetic mutations. Finally, we discuss successful examples of translational research creating an evidence-based framework of how personalized medicine can advance the treatment of NDDs.Understanding the etiology of NDDs faces many challenges that range from delineating the heritable genetic components to defining individual factors that predispose to NDD risk and identifying the precise mechanisms through which these factors together lead to the disorder3. ASDs, with an estimated prevalence of 1 in 68 births3, represent an issue of public concern. Typically, ASDs have been classified into syndromic—Rett syndrome (RS)4, Fragile X syndrome (FXS)5, and tuberous sclerosis (TSC)6—and nonsyndromic. Evidence suggests that the causes involve both genetic and environmental factors7. Patients diagnosed with ASD often present with other comorbidities such as intellectual disability (ID)8, epilepsy9, and motor abnormalities10. Intellectual disability affects ~1.5–2% of the Western population11. The severe forms of ID are thought to have a genetic origin, but in at least 50% of cases, the cause remains elusive. Over the past years many autosomal or X-linked mental retardation genes have been identified12, with FMR1 (FXS) being one of the most common inherited monogenic causes of ID and ASD in male patients13. The core features of ASD and ID often coexist with recurrent seizures or epilepsy. Epileptic seizures are due to abnormal neuronal activity such as excessive excitation or hypersynchronization, which can occur as a result of developmental defects or due to brain insults  later on in life. With over 65 million people affected worldwide, epilepsy is the most common, chronic neurological disorder14. Although in many cases seizures can be controlled by existing anti-epileptic drugs, the treatment gap is still large15. Genetic underpinnings for epilepsies have been long recognized and over the past 20 years a significant number of epilepsy-risk genes have been identified17.NDDs are a group of early onset neurological disorders, including autism spectrum disorders (ASD), intellectual disability (ID) and language disorders among others. ASDs are characterized by early dysfunction in social interactions, communication deficits, and the presence of repetitive and restricted behaviors18. Given such a high individual variability, a plethora of variants associated with NDDs have been found in hundreds of different genes, ranging from single nucleotide changes (single nucleotide variants (SNV)) to loss or gain of up to thousands of nucleotides (copy number variants (CNV)).On average, a newborn acquires between 50 and 100 new genetic variants, resulting in 0.86 new amino acid-altering mutations  per individual20. CMA set the stage for genetic variation detection, but the advent of whole-genome and whole-exome sequencing (WGS and WES) led to the identification of many inherited and de novo germline variants that significantly contribute to total NDD risk24 ; however, the individual common genetic variant liability is lower than that for rare genetic mutations26. Likewise, in the case of epilepsy, rare CNVs have been shown to explain ~3% of individuals suffering from idiopathic generalized epilepsy27. In addition, ~300 de novo mutations were identified in patients suffering from epileptic encephalopathies. These mutations emphasize the convergence on specific biological pathways due to their enrichment in certain gene sets including genes regulated by the fragile X protein28. Finally, germline mutations do not explain all NDD cases, indicating that other genetic defects also come into play. For example, postzygotic  mutations explain a significant proportion of NDD cases31. Along with the previously identified CNVs, such mutations have meaningful implications for risk prediction, diagnosis and patient management32.Sequencing of the human and other mammalian genomes has provided an important set of tools to start understanding the human genetic variation. The first steps to elucidate the genetic heterogeneity of NDDs were done by using karyotyping or fluorescence in situ hybridization (FISH). As the need for more accurate detection of nucleotide variations in the context of developmental disabilities grew, chromosome microarray (CMA) technology was developed and rapidly implemented as part of first-line evaluation for children with a NDDk24 Fig. . In the Thus, the abovementioned technologies represent powerful tools for the molecular genetic dissection of patients affected by NDDs. Their introduction into clinical practice and association with routine phenotype-driven diagnosis holds promise for personalized diagnosis and therapy of NDDs.33 and on treating associated rather than core symptoms of the disorder. Thus, for the majority of people with NDDs, the outcomes are poor or very poor in adulthood34. Given such challenges, we must ask how genetics may contribute to their improvement.The early occurrence of genetic glitches and the relatively late onset of symptoms that enable the diagnosis of NDDs, represent a major pitfall in identifying the cause and delivering the right kind of therapy. To complicate things further, for most NDDs, therapies hinge largely on behavioral or educational interventions35 and 10 out of 118 probands undergoing WES benefited from a revised diagnosis and clinical assessment36. Similarly, WES with targeted gene analysis  influenced decisions on antiepileptic drug selection and reconsideration of surgical interventions37. Lastly, since NDDs are associated with cognitive and behavioral abnormalities, genetic information can guide the choice of behavioral treatment38. However, despite these advantages, the multiple guidelines proposing the use of genetic testing for individuals with NDDs are not implemented routinely in clinical practice20. This lack of use is either due to scarcity of resources or due to a lack of medical staff prepared to analyze and interpret genetic results. To circumvent this issue, a proper dissemination of up-to-date findings about NDD genetics to clinical staff is desirable. In addition, genetic counseling should inform parents about recurrence risk assessment.First and foremost, genetic testing can lead to active monitoring and early intervention, even before the onset of the disorder. Furthermore, knowing the genetic cause of a disorder may reveal the role of a specific biological pathway in its onset. Thus, targeted pharmacological interventions could be made with already existing drugs. Studies reported that 55% of 187 genetic findings led to changes in clinical managementAn ideal model of a human disorder is characterized by construct validity (model mimics the genetic insult that causes the disease), face validity (the model’s phenotype resembles that of the human disease), and predictive validity (the model and the patients respond similarly to certain treatments). Several systems  have been used to generate models of NDDs that can partially reproduce disease features and can be of interest for understanding underlying mechanisms Fig. .Fmr1 KO) (FXS)39, Dravet syndrome (DS-Scn1a KO)40, ASD Nrxn1a KO41, Nlgn3 KO42, Phelan-McDermid syndrome (PMDS-Shank 3 KO)43 or RS (Mecp2 KO)44. Mice share 95–98% of their genomic information with humans, have a relatively rapid reproduction time, are cost-effective and allow scientists to precisely manipulate their genome in a temporal/spatial specific manner. However, mice also present with important limitations. For example, assessment of higher brain functions, such as language and facial recognition, is difficult in large screens. To overcome some of these limitations, non-human primates can be employed to model complex behavior and higher cortical functions45, whereas zebrafish and invertebrates can be used for high-throughput genetic screens46.The most favored model organism, the mouse, has been extensively employed for modeling neurological disorders with a known genetic cause, such as FXS 49, PMDS50, DS51 and Timothy syndrome (TS)53. The experimental tractability, the ability to model diseases directly from affected individuals and the unlimited source of cells are just some of the advantages of stem cell-based models. Conversely, the high heterogeneity among iPSC clones, the immature identity of neurons differentiated in vitro, the lack of high-order connectivity and the difficulty to model lamination in a 2D system are some of the obvious shortcomings of iPSC-derived disease models. Fortunately, recently several researchers have developed protocols for the generation of 3D cortical organoids (mini-brains/spheroids), providing avenues to study features of cortical lamination and brain development in vitro55, thus contributing additional tools for studying the mechanisms underlying NDDs56.Alongside animal models, in vitro reprograming of stem cells has enabled the generation and analysis of human neurons. Employing either human embryonic stem cell (hESC)-derived or human induced pluripotent stem cell (hiPSC)-derived neurons, researchers have recapitulated several neuronal synaptic defects for monogenic forms of NDDs such as RSAxiomatically, the biggest advantage of genetic studies is to provide clues about the underlying neurobiology of NDDs and to transition those clues into clinical practice Fig. .57 and drugs approved for ameliorating comorbidities such as irritability and anxiety, while in many cases the core symptoms of NDDs remain unsolved.At present, the available treatments for NDDs consist of a combination of behavioral therapies58, PTEN- associated macrocephaly59 or 15q11-13 duplication syndrome60. Multiple clinical trials are investigating the pharmacokinetics and pharmacodynamics of rapamaycin and its analogs  for treating TSC with associated ASD62. Likewise, increasing levels of (IGF1) -like growth factor 1 and brain-derived neurotrophic factor via transcriptional modulation improves physiological and behavioral anomalies in RS mouse models64 and IGF1 administration leads to a higher endurance to social and cognitive testing in patients with RS65 or PMDS66.However, the combination of genetics and functional analysis led to the discovery of several molecular pathways involved in NDDs that were targeted to evaluate novel therapeutic strategies. Particularly, inhibiting the mechanistic target of rapamycin (mTOR) rescues physiological, morphological and behavioral abnormalities in mice modeling diseases associated with protein translation defects such as TSC67. However, contrary to what was predicted by a decade of studies in FXS animal models, administration of mavoglurant, an mGluR5 antagonist68, or arbaclofen, a GABA B receptor agonist70, to adolescents and adults with FXS showed no significant improvement in behavioral traits in a randomized, double-blind, placebo-controlled phase 2 trial. Conversely, in a mouse model of PMDS with complete deletion of Shank3, researchers reported decreased mGluR5 signaling in the striatum and cortex. Administration of a benzamide derivative resulted in augmentation of mGluR5 activity and rescue of functional and behavioral defects in mice. Thus, pharmacological treatments aimed at increasing mGluR5 activity may represent an option for patients with SHANK3 mutations72. The contrasts between mGluR5 activity in FXS and PMDS suggest that the dysfunction leads to distinct phenotypes in different brain regions/genetic backgrounds. Hence, genetically discriminating between different forms of NDDs and identifying the convergence of the common molecular pathways underlying NDD pathophysiology are important goals . Using antisense oligonucleotides (ASOs)  vectors75. However, making ASOs and AAV amenable to translation into clinical trials is challenging due to their safety, pharmacokinetics and distribution in the brain76. In a similar vein, WES of consanguineous families with ASD, ID and epilepsy led to the identification of mutations in the gene BCKDK (Branched Chain Ketoacid Dehydrogenase Kinase), encoding an enzyme regulating the catabolism of the branched-chain amino acids (BCAAs). The Bckdk mouse model displays an abnormal brain amino acid profile and dietary supplementation with the missing BCAAs reverses certain neurological phenotypes  Fig.  the patepes Fig. . FurtherSCN8A, KCNQ2) is an effective diagnostic tool for patients with epilepsies as it can influence anti-epileptic drug selection, adverse effect minimization and consideration for surgery, based on each patient’s genetic script37. In the case of people with SHANK3 deletions, they tend to have more advanced receptive communication skills than verbal language ability79 and therefore could benefit from assistive communication strategies that may not have been in mind unless the genetic cause of their ASD was known.In addition to identifying new targets for therapy, genetic findings are useful for personalizing existing pharmacotherapy or behavioral interventions. In this sense, WES with targeted gene analysis . Nonetheless, important barriers remain in order to translate these approaches to non-ion channel epilepsy genes and loss-of-function mutations81. Likewise, recent observations indicate that metformin, a worldwide first-line therapy for type 2 diabetes, rescues core phenotypes in adult FXS mice due to normalization of ERK signaling, eIF4E phosphorylation and matrix metalloproteinase 9 expression (MMP-9)82. Given that the previously mentioned clinical trials with mGluR5 antagonists have failed, metformin represents a new therapeutic avenue for clinical studies involving FXS patients. Administration of oxytocin, which is a peptide usually administered to initiate uterine contractions that also appears to be involved in modulating social behavior, improves ASD-like social deficits in several mouse models83 and in a Shank3-deficient rat84, but the clinical effectiveness of oxytocin on ASD should still be considered tentative due to mixed findings85.Recently, a very common trend uses genetic findings for the application of targeted drug repurposing based on single gene defects Fig. . Such anThe quick development of novel and efficient sequencing technologies made the identification of genetic causes for a number of NDDs possible. Using these techniques, an underlying genetic cause of many NDD cases can be identified. This progress allows the design of personalized therapeutic strategies and the implementation of genetic counseling. Furthermore, studies employing animal and human cell models carrying specific genetic glitches are underscoring potential novel therapeutic approaches.86, as well as the capability of researchers and clinicians to work side by side, will be essential.In the past few years, potential treatments derived from genetic and functional analysis made it to clinical trials. Although several clinical trials have failed, the treatment of some NDDs seems much closer. Due to the very complex nature of NDDs, interdisciplinary approaches combining genetics, functional genomics, robust biological models and objective measures of response, such as biomarkersData for this review was collected by typing the following keywords into PubMed: genomics, genetics, personalized therapy, neurodevelopmental disorders .


Objective: To provide a systematic review of how rejection of care, aggression, and agitation are described and operationalized in existing measures of dementia-related behaviors with a particular focus on whether these behaviors are conceptualized as separate phenomena in rating scales. Methods: We reviewed two systematic reviews of behavioral measures in dementia to evaluate their definitions and operationalization of rejection, aggression, and agitation. Additionally, we conducted a systematic review of English-language peer-reviewed articles published from 1980 to 2017 to update the previous list instruments and identify additional measures that were not captured in previous reviews. Results: 43 instruments  developed to measure behavioral symptoms were included. Of these, 25 (58.1%) included items related to rejection of care; 32 (74.4%) included aggression items; and 35 (81.4%) had agitation items. Descriptions and definitions of the behaviors were highly variable across instruments. 13 of 23 general measures and 3 of 20 symptom specific measures included items separately representing all three behaviors while the rest of the measures lacked items measuring one or two behaviors of our interest. Conclusions: The review demonstrated that rejection, aggression, and agitation are measured in most scales yet their measurement is highly variable and they are often not distinguished from each other. Researchers and clinicians need to consider each symptom in its own right and revise existing instruments to address possible misnomers to improve measurement of dementia behaviors.


Females and males differ in the energy consumption and nutritional requirements which are based on the interactions between environmental factors and sex hormones . The stuConserved pathogen-associated molecular patterns (PAMPs) of microbes can bind various pathogen recognition receptors like toll like receptors (TLRs). Since TLR expression differs between sexes, TLR3, 7, and 9 are expressed higher in females and TLR2 and TLR4 in males, it can influence strength of TLR-dependent responses. Macrophages from male mice generate a higher TLR4- and TLR2-dependent Th1 response to clear infections, while estrogen regulates immune response via modulation of endosomal TLRs and TLR8 expression thus hormonal balance determines the overall response in females –13. TLR3in vitro presence of testosterone leads to a higher production of Th1 by peripheral blood cells with a higher Th1:Th2 ratio in men  TLR7, GATA1, FOXP3, and CD40L. It is surmised that skewed inactivation, mutations or under certain physiological conditions, approximately 10–15% of these genes may be activated , 49. In Sex steroid levels change rapidly for women when they are menopausal while in males the change is gradual. While aging is associated with changes in immune cells in both sexes , in womeBesides the known inherited genes, there is some evidence that non-inherited maternal antigens (NIMA) that are not encoded by the offspring but passed along from the mother may have a role in sex-biased immune response. However, the role of NIMA in various diseases has not been consistent . The strThe reason why sex-bias immunity exists may lie in the evolution and preservation of mankind. Evolutionarily, during reproductive years, an enhanced response to infections should help maintain health for reproduction. In aged women, reproductive function is not required, enhanced immune reactivity along with changes in immune cells during aging causes sex-specific differences in immunity. The sex-specific expression of genes may explain why women with a similar genetic background show higher immune reactivity or develop autoimmunity at a higher rate than men. Also, the circadian rhythm of sex-hormone-dependent immune system and microbiome could control metabolic profile of an individual. Microbial-metabolites are involved in various signaling pathways as well as immune pathways like differentiation of T cells via binding to receptors of gut immune cells and epithelium. Similar functions also occur in other tissues. Thus, combined with variable X inactivation in cells and pleiotropic nature of many genes, it is likely that sex-hormones impact immune system and its ability to break tolerance to pathogens, environmental or endogenous. Although there is a plethora of evidence suggesting a sex-bias in innate and adaptive immunity that can impact response to infections, vaccinations and onset of various diseases, there is no consensus on treating diseases based on the sex of a patient. The challenge is to be able to define the role of a single receptor or hormone in humans. Animal models have provided some information though more research is required to define the pathways that determine sex-specific immune response during inflammation.The author confirms being the sole contributor of this work and approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Soluble organic compositions of extraterrestrial samples offer valuable insights into the prebiotic organic chemistry of the solar system. This review provides a summary of the techniques commonly used for analyzing amino acids, amines, monocarboxylic acids, aldehydes, and ketones in extraterrestrial samples. Here, we discuss possible effects of various experimental factors  in order to highlight potential influences on the results obtained from different methodologies. This detailed summary and assessment of current techniques is intended to serve as a basic guide for selecting methodologies for soluble organic analyses and to emphasize some key considerations for future method development. For most extraterrestrial samples, the organic content can be divided into two main components: 1) insoluble organic matter (IOM)―a macromolecular fraction that is insoluble in organic solvents  insolubl,3,4. Theungrouped chondrites) and they constitute the bulk of the meteorite materials analyzed for soluble organics. The letters designating the categories of carbonaceous chondrites represent typical chondrites within each group , with the exception of the CH group which is assigned the letter ‘H’ in reference to its high metal and iron content. The Cungrouped category represents meteorite specimens with unique mineralogical and chemical properties that currently do not have enough known specimens to warrant the creation of a new class. Following the mineralogic class, a petrologic type is often assigned to indicate the relative degree of parent body alteration, with types 1–3 having experienced aqueous alteration at low temperature  and types 4– 6 having experienced varying levels of thermal alteration  )Ion exchange chromatography provides separation of molecules based on charge by utilizing resins that are typically composed of beads of polymers, with electrolytes covalently bound to the resin beads . Third, the chromatography columns are rinsed with 12 bed volumes of ultrapure water . Fourth, the resin is recharged with fresh H+ mobile ions using 2 bed volumes of 1.5 M double distilled hydrochloric acid (ddHCl) (until the eluting solution has an acidic pH). Finally, the chromatography columns undergo a final water rinse using 12 bed volumes of water .Prior to use, cation exchange chromatography columns are typically rinsed to minimize potential sources of contamination  Do not allow resins to dry, which may allow cracks to form, and (2) The water rinses performed after the NaOH wash and the ddHCl recharging steps are important to execute in order to return the columns to a neutral pH environment without exposing the columns to a pH shock that may otherwise crack the resins.The separation and detection of meteoritic soluble organics is most commonly performed using gas chromatography-mass spectrometry (GC-MS), or high-performance liquid chromatography coupled to a UV fluorescence detector (HPLC-FD), and/or a mass spectrometer ). Both GC and LC separation techniques offer different analytical advantages, and certain meteoritic organic compounds have been detected using only one method and not the other. GC is generally used for analyzing relatively volatile, low molecular weight, and thermally stable compounds, while LC techniques are more appropriate for analyzing non-volatile and thermally unstable analytes. The chromatographic separation technique best suited for a particular study is also dependent on the concentrations of the analytes in the sample and the level of instrumental sensitivity needed. Typically, LC methods using a fluorescent detector are one to a few orders of magnitude more sensitive than GC methods. On the other hand, if stable isotopic measurements are needed and sufficient sample mass is available, then GC protocols are followed. Nevertheless, LC and GC methods can be mutually beneficial; a small fraction of a sample can be analyzed using LC as an initial assessment of concentrations to provide feedback for further LC or GC analyses.Detection methods vary depending on the chromatographic separation technique used. For GC analysis, parent molecules are typically ionized via electron impact ionization, and characteristic fragmentation patterns can be compared to mass spectral libraries for compound identification. LC techniques are more amenable to parallel detection methods . Positive electrospray ionization is the most common ionization method for LC due to high sensitivity. Unlike electron impact ionization, the electrospray method results in minimal mass fragmentation. Other fragmentation methods within the ion optics of the instrument are possible to gain structural information, and different mass analyzers  provide different resolutions and scan speeds. A more thorough review of mass spectrometry is outside the scope of this manuscript.While some compound classes can be separated chromatographically as underivatized samples ), most meteoritic analyses involve an intermediate chemical derivatization step to convert the target analytes to more GC- or LC-amenable derivatives. o-phthalaldehyde-N-acetyl-l-cysteine (OPA/NAC) derivatization for LC (S)-(+)-2-pentanol )The types and abundances of soluble organic compounds extracted from a meteorite sample depend on: (1) the solvent type, (2) the extraction temperature, and (3) the duration of the extraction process. In order to optimize an extraction protocol for meteorite samples, each of the above factors should be tested on a suite of meteorite powders and procedural blanks, and monitored for total yields, reproducibility, potential reaction by-products when derivatization steps are used, and isotopic fractionation (if stable isotopes are measured). In practice, meteorite powders are not commonly accessible for method development. Industrial sediments  and otheSuccessive solvent extractions of meteorite powders have been shown to yield larger abundances of soluble organics ,115,133.S)-1-phenylethyl esters have yielded a substantially higher total abundance of monocarboxylic acids compared to other techniques [S)-2-methylbutyl ester derivatives have yielded a particularly high relative abundance of acetic acid  compared to other studies  [13C-enriched isotopic values for acetaldehyde and propionaldehyde and relatively 13C-depleted isotopic compositions for acetone and butyraldehyde, compared to measurements obtained via aqueous extraction and derivatization with PFBHA [Several different derivatization and chromatographic techniques have been tested for meteoritic amino acid analyses , though chniques , and anae total)  Table 3S-1-phenyth PFBHA ,114,121.This review compiles and summarizes the range of analytical techniques applied to studies of extraterrestrial amino acids and structurally related amines, monocarboxylic acids, aldehydes, and ketones, to help facilitate data comparisons between studies, and to provide guidance for method selections for future sample analyses. Potential sources of variability among datasets are discussed, including compositional heterogeneity of meteorite samples, and the influences of differing extraction and purification protocols, derivatization methods, and chromatographic separation techniques. With these factors in mind, some potential considerations to implement for future analyses may include: (1) maintaining consistency in methodologies applied across studies to allow for more informative cross-comparisons of datasets; (2) carrying out direct comparisons of methodologies during method development experiments in order to gain a better understanding of the various effects of different analytical techniques; and (3) reporting detailed meteorite sample information for each soluble organic study to track compositional variability within single meteorite specimens.


In this work, we have attempted to characterize transcription signatures using the phenome-interactome maps where each of the traits under study including the intermediary phenotypes has a distinct set of genes forming the hubs. Furthermore, we have identified various clinical, biochemical, and radiological parameters which show significant correlation with distinct hubs. We observed a number of novel pathways and genes including those that are non-coding RNAs implicated in AIT2DM.We showed that they appear to be associated with pathways, viz. tyrosine kinase JAK2, NOTCH thereby recruiting signaling molecules such as STAT5 and Src family kinases on the cell surface regulated them and our analyses comprising significant hubs suggest that thigh subcutaneous adipose tissue plays a role in pathophysiology of AIT2DM.We performed a systematic analysis of genes implicated in thigh subcutaneous adipose tissue of Asian Indian Type 2 Diabetes Mellitus (AIT2DM) and created a phenome-interactome network. This analysis was performed on 60 subjects specific to limb thigh fat by integrating phenotypic traits and similarity scores associated with AIT2DM. Using a phenotypic attribute, a contextual neighbor was identified across all the traits,  Asian Indian Type 2 diabetes mellitus (AIT2DM) and its association with obesity is relatively well-known showing a distinct disease phenotype. With over 415 million people diabetic worldwide as of 2015, it is predicted that diabetic population in India is alarming and would rise to 140 million by 2040  . The inclusion and exclusion criteria on control and case subjects with variables have been defined appropriately  ratio, and BMI were obtained by standard methods performed on all samples. Supine blood pressure was measured using mercury sphygmomanometer after 10 min of rest. Blood samples were obtained at 8:00 am after an overnight fast of at least 8 h. The adipose tissue biopsy was taken from either the left or the right thigh depending on the site of the fracture, the primary indication of the surgery. Various biochemical parameters  were measured on Kopran AU/400 fully automated analyzer  and Kyoto Encyclopedia of Genes and Genome (KEGG) analyses. A statistical significance (probability) of 0.05 was obtained for analyzing the data all through.The microarray analysis was performed on raw data with a focus to prioritize DEGs. The amplified RNA was fragmented and hybridized to Affymetrix GeneChip PrimeView Human Gene Expression array containing 49395 probes, representing all known transcripts of the human genome. The raw data generated was quality checked (QC) using Affymetrix expression console and Transcriptomic Analysis Suite (TAS) 4.0 software. Post scanning the hybridized arrays and resulting biological replicates for the two sets of case-control groups, bioinformatics analysis using R and Bioconductor was done. The raw data was first normalized using robust multiarray analysis (RMA) and two fold change cut-off was used to infer the differentially up-regulated or down-regulated genes using the pipeline  on selected genes . The pre-processing involved reducing the noise resulting from CHAT variations and subsequently determining the actual biological change or flux of DEGs forming hubs. Identification of DEG hubs with changes in expression profiles in diseased/undiseased conditions was performed keeping in view of the topological/contextual neighbors and a QQ plot was generated. The list of DEGs forming significant hubs against the inferred p-value led to the identification of crucial genes. Furthermore, cluster analysis for co-expressed genes forming the hubs based on the phenotypic traits, viz. HOMA-IR, HOMA-B, Leptin, ß-cell dysfunction were considered using iCTNet   are in agreement with each other , viz. OBSL1, an Obscurin which is associated with insulin-like growth factor binding protein (IGFBP2), ZC3H15 (HT010), a zinc finger CCCH-type containing 15, PHLL1, a photolyase like protein and hnRPR, heterogeneous nuclear ribonuclear protein. Whereas, OBSL1 expression is directly associated with insulin growth factors, the latter three proteins are either associated with circadian rythms, abdominal aortic aneurysms (AAA) leading to negative side of diabetes .From CHAT networks, we observed a significant number of hubs that are topologically important and preferentially associated with a range of phenotypes of interest. When CHAT was used to compare contextual and degree-based hubs, the latter seem to be enriched in pathways related to obesity and adipogenesis due to the fact that the proteins tend to be more connected to each other when compared to random. In comparison, contextual networks are considerably observed to be more “biologically distinct” as they are highly connected than a connection specific to context of interest. Furthermore, centrality/betweenness analysis of the co-expression networks and pathways were validated with the contextual networks and compared with the attributes (phenotypic traits). An average of 2.5 connected nodes per attribute was seen showing a preferential association with a range of phenotypes of interest Figures , 4. Howep-value heuristics and contextuality using CHAT analysis for identifying high dimensional gene expression data for validation. The existing approach based on identifying contextually important neighbors is in accordance with the principle of scale free property of networks. In this study, many key genes along with their enriched pathways underlying molecular mechanisms of obesity, lupus, adipose tissue, fatty acid pathways were obtained  as negative regulator of insulin signaling has been well-documented where TGFβ exerts its effect by inhibiting adipose cell differentiation by stimulating the expression and incorporation of fibronectin and collagen into the extra cellular matrix (ECM). This increase in ECM synthesis has been demonstrated to inhibit insulin signaling in 3T3-L1: a commonly used model of adipose cell differentiation  as part of its normal physiological role on sexual maturation , analyzing genetic information from a wide array of phenome-interactome levels is likely possible. While we observed marked differences in clinical, biochemical, and radiological, cellular and molecular phenotypes, the role of qualitative changes in the form of phenotypic traits associated with the DEGs and the hubs positively correlating with the onset of diabetes is established.Our findings beyond doubt strongly support the concept of “sick fat or adiposopathy,” specifically “sick thigh fat” as one of the underlying diseases  of AIT2DM Bays, . In lighIdentification of distinct hubs containing the DEGs would serve as circulatory biomarkers of adipose tissue pathology. From our analyses, the thigh adipose tisssue in AIT2DM subjects showed pathologic alteration, the so called “sick thigh fat” characterized by a large number of DEGs enriching distinct transriptional signatures. These transcription signatures were further characterizing using the phenome-interactome maps, where each of the traits under study including the intermediary phenotypes were found to be associated with distinct set of genes forming the hubs. These hubs, containing the DEGs (including non-coding RNAs associated with the novel pathways) can serve as biomarkers of thigh adipose sick fat for understanding the pathogenesis of AIT2DM. Additionally, they are also known to play a role in the process of adipogenesis, and therefore support the nutrient overflow hypothesis of Asian Indian phenotype. Notable among them are LINC01128 enriched with regulatory elements, RAS Guanyl Nucleotide-releasing Protein (RASGRP1) associated with high fat diet induced obesity enhancing adipocytes and lymphaniogenesis which could be plausible drivers for unhealthy fat depositions inside the body. In addition, we have the chance to study markers for healthy fat, where researchers have identified the adipose tissue specific fat markers in animal genomes  but as this study is contemplating the human subjects of interest, we haven't mapped the phenome interactome networks with eutherian population albeit the fact that LINC01128, RASGRP1, and PPARG which we have shown could be diet based markers. As we have identified various clinical, biochemical and radiological parameters, which show significant correlation with these hubs, therefore, these clinical parameters can possibly be taken as surrogate markers of sick thigh fat for epidemiological study purpose and the creation of criteria for the diagnosis of various stages of this organopathy. There is need of further investigation, comparing the process of adipogenesis and sick thigh fat in different depots of adipose tissue, including larger number of subjects, considering gender dichotomy and across the various stages of natural history of diabetes.PT and SM were involved in collecting samples, biochemical characterization of the tissues. PT performed the microarray analyses of the samples. AS and PS analyzed the DEGs using RMA. PT, NG, and KM performed qPCR validation. PT and PS wrote the first draft. PS developed the systems integration of phenotypic traits. SM, KM, and PS proofread the manuscript. All authors read and approved the proof of the manuscript before submission.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


This article presents magnetic mineral characteristics, trace metals, and REE geochemistry of river sediments that serve as inlets to Lake Limboto, Sulawesi, Indonesia related to article entitled “Lithogenic and anthropogenic components in surface sediments from Lake Limboto as shown by magnetic mineral characteristics, trace metals, and REE geochemistry” [1]. River sediments were obtained from three rivers, namely Alopohu, Bionga, and Talumelito. Sieved sediments were subjected to magnetic susceptibility measurements as well as geochemical analyses that include AAS analyses for trace metals and ICP-OES for REE. Extracted magnetic grains were also subjected to magnetic hysteresis analyses as well as XRD and SEM analyses. These data are invaluable in identifying the contribution of each river (and its catchment area) to the surface sediments of Lake Limboto. In general, the mass-specific magnetic susceptibilities of these three river sediments are much higher than that of the surface sediments in Lake Limboto 3O4) as the predominant magnetic mineral. Moreover, the presence of magnetite (Fe3O4) in the extracted grains is verified by the X-Rays diffractograms shown in Hc (coercive force), Hcr (coercivity of remanence), Ms (saturation magnetization) and Mrs (magnetic saturation remanence) for all samples.The morphologies of the extracted grains are shown in SEM images in 2Sampling of sedimentary samples was conducted in six locations (see


Ear self-mutilation have been reported in schizophrenia, Mechanical damages to the auditory canal, like cleaning ear with hard and unsterile objects are predisposing factors of otomycosis.Aspergillus flavus. A traumatized external ear canal skin can present favourable condition for fungal growth in the psychiatric population.We present a case of repeated self-induced auricular trauma in schizophrenic patient. Aural swab were collected and examined by direct microscopy and culture, revealing  Factors predisposing to this infection canal range from existing diseases, such as seborrheic dermatitis, eczema, psoriasis, climatic conditions and trauma They are different types of deliberate self-mutilating behaviours like self-cutting, bite, burns or ulcerations. Sometimes, especially among psychotic inpatient eye, tongue, ear or genital self-mutilation have been reported 2A 56 year-old man with a 15 year history of schizophrenia, receiving inpatient care in a psychiatric unit, under continuous oral treatment with haloperidol (20 drops 3 times a day) presents multiple induced lesions of the auricle and the auditory canal Fig. 1Eartwo weeks prior to examination the patient complain of itching and show skin lesions with erythema, scaling and red papules on the auricle, history of repeated ear self-injury was recorded, psychiatric staff noted that ear-self injuries were applied by fingers and wooden sticks from hospital garden, itching persists for more than two weeks ago. Moreover, there were no clinical signs of fungal infection on hands and nails.The diagnosis of acute otitis externa was made in day 2, in the presence of itching on manipulation of the auricle and objective findings at otoscopy, such as the infection confined to the ear canal with greenish fuzzy growth and local area hyperhemic and bleeding.Sterile cotton swab were collected under aseptic condition from external canal of the patient, the samples were inoculated on blood agar for routine bacterial culture and also on Saborauds Dextrose Agar (SDA) for fungal culture.Direct microscopy by Lactophenol Cotton Blue (LPCB) wet amount preparation revealed septate acute angle dichotomous branching fungal hyphae.Aspergillus flavus, with rough and colourless conidiophores and biseriates phialides  of aerobic incubation, powdery masses of yellow-green colony developed , the isohialides Fig. 2AspPresent case was first managed by local toilet using dakin to remove the fungal debris from the ear canal. The patient was then started on clotrimazole 1% solution, ear drops were instilled into the affected ear three to four times a day during two weeks.After one week (day 14) due to the agitation of the patient an oral treatment was initiated itraconazole 100 mg twice daily for 7 days. Instruction for the paramedical staff to monitor the patient so that he no longer handles the ear. The patient were reviewed after 1 week and the ear canal was observed under the microscope to assess the response to treatment at day 21.Patient responded well to the treatmentMacroscopic colony morphology of Aspergillus flavus on SDA medium (day 10): surface is greenish-yellow with white border, texture is floccose3Self-mutilations are considered as pathological after the age of three years [7]Habit of cleaning the ear canal traumatized the skin and destroys cerumen protective barrier [10]Trauma of the ear inoculates fungal debris, support the colonization of the auditory canal and deposition of fungal conidia in the wound causing fungal infection [11]Damage to the auditory canal epithelium can lead to decreased excretion of the ceruminous and apocrine glands. These secretions maintain the protective properties of the keratin layers of skin by providing an acidic environment, which is bacteriostatic and fungistatic Aspergillus flavus as one of the most recovered species Aspergillus genus is the most common etiological agent of otomycosis, followed by Candida, many authors reported Otomycosis is well known for its recurrence if proper treatment is not initiated [18]The case highlights situation of ear self-injury related to schizophrenia disorders and co-occurring otomycosis.


In a previous issue of the Journal, Zhong et al. reported a retrospective study that compared the perioperative outcomes of the mesh-reinforced pancreaticojejunostomy with conventional pancreaticojejunostomy. They concluded that mesh-reinforced pancreaticojejunostomy was a safe and effective technique, as it provided a safe anchor site for suture, thus reducing the risk of pancreatic leakage. Considering these encouraging results, we present a further simple technique using ligamentum teres hepatis wrap around pancreatojejunostomy for prevention of postoperative pancreatic fistula after pancreaticoduodenectomy. Dear Editor,World Journal of Surgical Oncology in March 2018 [We really appreciated the paper written by Zhong et al. entitled “Mesh-reinforced pancreaticojejunostomy versus conventional pancreaticojejunostomy after pancreaticoduodenectomy: a retrospective study of 126 patients”, and published in the Another conclusion that we considered of considerable importance was the absence of statistically significant differences between the two groups in terms of intra-abdominal infection, despite the implantation of a foreign body .More than 80 different surgical methods have been described in order to perform a safe and effective pancreaticojejunostomy, but none of them has been proven to be superior to the others .Considering the encouraging results presented by Zhong et al. , we woulSteps of surgical procedures were the following ones: (i) a transverse subcostal abdominal incision was always performed; (ii) if the falciform ligament was not previously dissected/resected, the pedicled ligamentum teres hepatis was mobilized after division of the round ligament close to the umbilicus; (iii) the falciform ligament was always dissected from the ventral abdominal wall up to the junction with the coronary ligament; (iv) first, a Kocher maneuver was performed to assess relationship between the tumor and the superior mesenteric artery; (v) the second maneuver performed to assess resectability developed a plane of dissection between the anterior surface of the superior mesenteric vein/portal vein confluence and posterior surface of pancreatic neck to exclude tumor involvement; (vi) if resectability was confirmed, “demolition” phase of pancreaticoduodenectomy was completed; (vii) pancreaticojejunostomy with end-to-side anastomosis was always performed in a single layer of interrupted 4-0 polydioxanone suture ; (viii) hepatico-jejunal and duodeno-jejunal anastomoses were always performed in a single layer of interrupted 4–0 and 3-0 polydioxanone suture, respectively.Technical innovation consisted of many following steps: (i) ligamentum teres hepatis  was passed under pancreaticojejunostomy until covering posterior wall of the anastomosis; (ii) we completely wrapped the anastomosis with ligamentum teres hepatis; and (iii) subsequently, we anchored the ligamentum teres hepatis to the proximal side of the same, to the pancreatic capsule, and to the seromuscolar layer of the jejunal loop with interrupted 5-0 polydioxanone sutures, along the two angles and anterior wall of the anastomosis. A representation of the final result is shown in Fig. At present, ligamentum teres hepatis and falciform ligament are successfully used to prevent postoperative pancreatic fistulas following distal pancreatectomy  and erosStarting in June 2017, we successfully employed this new technique in 14 cases. According to latest guidelines by International Study Group of Pancreatic Surgery (ISGPS) , just twTherefore, we stress the need for a case-control study, cohort study, or prospective randomized study which might confirm the technique’s effectiveness, as it happened for the new technique by Zhong et al. .