Angptl4 and Pfkfb4) that were upregulated across rupture systems. Some of the identified genes, such as Rgs2, Adam8, and Lox, have been characterized in multiple rupture contexts, including ovulation. Others, such as Glul, Baz1a, and Ddx3x, have not yet been characterized in the context of ovulation and warrant further investigation as potential novel regulators. We also identified overlapping functions of mast cells, macrophages, and T cells in the process of rupture. Each of these rupture systems share local vasoconstriction around the rupture site, smooth muscle contractions away from the site of rupture, and fluid shear forces that initially increase and then decrease to predispose one specific region to rupture. Experimental techniques developed to study these structural and biomechanical changes that underlie rupture, such as patient-derived microfluidic models and spatiotemporal transcriptomic analyses, have not yet been comprehensively translated to the study of ovulation. Review of the existing knowledge, transcriptomic data, and experimental techniques from studies of rupture in other biological systems yields a better understanding of the physiology of ovulation and identifies avenues for novel studies of ovulation with techniques and targets from the study of vascular biology and parturition.Ovulation is a cyclical biological rupture event fundamental to fertilization and endocrine function. During this process, the somatic support cells that surround the germ cell undergo a remodelling process that culminates in breakdown of the follicle wall and release of a mature egg. Ovulation is driven by known proteolytic and inflammatory pathways as well as structural alterations to the follicle vasculature and the fluid-filled antral cavity. Ovulation is one of several types of systematic remodelling that occur in the human body that can be described as rupture. Although ovulation is a physiological form of rupture, other types of rupture occur in the human body which can be pathological, physiological, or both. In this review, we use intracranial aneurysms and chorioamniotic membrane rupture as examples of rupture events that are pathological or both pathological and physiological, respectively, and compare these to the rupture process central to ovulation. Specifically, we compared existing transcriptomic profiles, immune cell functions, vascular modifications, and biomechanical forces to identify common processes that are conserved between rupture events. In our transcriptomic analysis, we found 12 differentially expressed genes in common among two different ovulation data sets and one intracranial aneurysm data set. We also found three genes that were differentially expressed in common for both ovulation data sets and one chorioamniotic membrane rupture data set. Combining analysis of all three data sets identified two genes ( I.The process of ovulation is a highly spatiotemporally coordinated event that culminates in rupture of the wall of the ovarian follicle, which consists of somatic support cells, and expulsion of the gamete and its surrounding specialized cumulus cells . The rupAlthough similarities exist between these examples on a pathophysiological level, there are no current studies that compare transcriptomic pathways that lead to rupture across these systems. The process of rupture in ICAs and chorioamniotic membranes has been well characterized because the consequences of rupture in these systems can be life threatening . There hIn addition to the spatiotemporal transcriptomic changes that underlie rupture in each of these systems, there is evidence of structural and biomechanical changes that predispose rupture to occur. These changes include spatial alterations in pressure and fluid shear forces, vasoconstriction of microvasculature, and contraction of smooth muscle cells (II.(1)The follicle is the functional unit of the ovary and consists of an oocyte surrounded by somatic support cells known as the granulosa and theca cells . The folAlthough the structural changes associated with follicle rupture and ovulation are most distinct after the LH surge, structural asymmetry develops prior to this hormone surge during the follicular phase. This asymmetry can be seen during the formation of the antral cavity ICAs are structurally diseased regions of neurovascular tissue that form when, due to a variety of complex factors, a section of an intracranial blood vessel stretches, and the vessel wall weakens . The mos(3)et al., 2011; The chorioamniotic membrane forms early in fetal development when two membranes, the chorion and the amnion, fuse at 12 weeks gestation . The choIII.To assess common pathways between non-ovulation rupture systems and ovulation, we first surveyed the literature to find appropriate data sets for comparison. Several molecular pathways have been implicated in assessment of rupture risk of ICAs. While many of these pathways have been identified by examining expression patterns of individual genes within aneurysmal tissues, some studies have attempted to assess expression in a more comprehensive manner. Oligonucleotide microarrays have been used to compare expression of transcripts of ruptured and unruptured ICAs to control tissues and found no significant differences . This diThe data sets investigating chorioamniotic membrane rupture vary because chorioamniotic membrane rupture can be both physiological and pathological. Many comprehensive transcriptomic data sets relating to chorioamniotic membrane rupture focus on pathological rupture because of a compelling clinical interest in developing screening methods and treatments for PROM and PPROM. A comparison of chorioamnion samples from four term and four preterm deliveries identified 252 upregulated and 18 downregulated genes in the preterm group . They idPgr) in a zebrafish (Danio rerio) model   model . This stpulation . Other kd tissue . Note th(1)Using the selected data sets, comparisons were made between the reported DEGs to identify pathways that may be common between rupture processes , B. A coAngptl4) is an angiogenic factor and lipid metabolism regulator that has been characterized in cumulus cells and in cases of polycystic ovarian syndrome (PCOS) (Pfkfb4) is involved in stress and hypoxia responses within cells Angptl4 and Pfkfb4, were also found in the chorioamniotic membrane rupture data set (see Twelve genes were upregulated or downregulated in common among the two ovulation data sets and the ICA data set ( set see .Sat1) is upregulated in response to hCG in both bovine and human granulosa tissue (Ucp2) is reduced in cases of impaired ovulation associated with fetal exposure to hypothyroidism and mediates apoptosis, gap junction integrity, and progesterone synthesis in cumulus cells (Rgs2), NFKB inhibitor alpha (Nfkbia), and ADAM metallopeptidase domain 8 (Adam8) all increase in response to the hormonal trigger of ovulation in multiple mammalian models  is part of the peroxisome proliferator-activated receptor gamma (PPAR-gamma) pathway that mediates cholesterol influx in the ovary, is increased in early luteal stages, and is associated with altered fertility when mutated (Abca1 have been shown to be associated with decreased aneurysm risk (Glul), bromodomain adjacent to zinc finger domain A1 (Baz1a), and DEAD-box helicase 3 X-linked (Ddx3x) have been characterized in some reproductive contexts, but there are no published studies establishing a role during ovulation (Mpp7), the only transcript downregulated in the ruptured group, is responsive to oestrogen receptor signalling in granulosa cells and responsive to versican in cumulus cells   . This geBecause many of these overlapping transcripts participate in pathways driving ovulation and in aneurysm formation, rupture, and response to rupture, these transcripts warrant further experimental investigation. Future studies could investigate the roles of the transcripts listed in (2)Immune-related processes are known to be involved in both the ruptured vascular wall and ruptured follicles. Immune-related pathways may include the infiltration of external immune cells into the rupture system. Ruptured ICAs have larger populations of neutrophils, monocytes, M0 macrophages, and M2 macrophages . The cyt(3)The biomechanical forces and structural changes that contribute to ICA formation and rupture have been well characterized by studies investigating the pathophysiology of ICAs and stratification of patient risk. ICAs form in conditions of high neurovascular wall shear stress (WSS) paired with a weakened vascular endothelium due to cigarette smoke exposure, genetic disorders, or chronic hypertension . WSS is Low WSS leads to structural changes and remodelling that predispose aneurysms to rupture. Low WSS paired with high OSI leads to a proinflammatory state with increased reactive oxygen species, immune cell infiltration, and matrix metalloproteinase (MMP) production by inflammatory cells . Low WSS2 in ruptured aneurysms relative to 1.48 N/m2 in unruptured aneurysms, although both values were lower than the measured WSS in non-aneurysmal vessels  flow-imaging modalities have been used to assess fluid dynamics during aneurysm formation, growth, and rupture (in vitro . Intraviin vitro . AdditioV.The comparison between the data sets of (1)Angptl4 and Pfkfb4, were also identified in the ovulation–ICA comparisons  functions in the crosslinking of collagens and elastin , follicle stimulating hormone (FSH), growth differentiation factor 9 (GDF-9), and Activin A in both human and rat granulosa cells , which was upregulated in the ruptured tissue in both Ptgs2 is a major driver of ovulation that is temporally expressed during the LH surge and downregulated shortly afterwards (Ptgs2 regulates the activity of MMPs that facilitate membrane rupture (Ptgs2 messenger RNA (mRNA) is upregulated in term-labour relative to non-labour membranes (The three upregulated genes found in both ovulation data sets and in the chorioamniotic membrane rupture data set are listed in sons see . Since o elastin . Lox is turition . One of terwards . Functio(2)et al., 2011; et al., 2011, Immune cell infiltration plays a major role in chorioamniotic membrane rupture. Intrauterine infection increases the likelihood of preterm chorioamniotic membrane rupture and is associated with immune cell infiltration. Neutrophils are associated with preterm labour in the setting of intrauterine infection in vitro study of chorioamniotic membrane strength found that acute mechanical stretching in fact strengthens chorioamniotic membranes  release, and collagenase activity occurs following mechanical stretching of chorioamniotic membranes . Third, there are fundamental differences in the biology of these systems, specifically in relation to timing and pathophysiology. In humans, ovulation occurs over a period of hours, and while rupture of fetal membranes also takes place on this timescale, the formation of a rupture site may begin earlier in gestation. By contrast, rupture of ICAs occurs over a matter of years, or may not happen at all. Despite these differences in timing, the rupture events follow a similar pattern: initiation, growth and development of the rupture site, and finally rupture. With regard to pathophysiology, ovulation differs from the other rupture systems in that it is a purely physiological process. ICAs are always pathological whereas chorioamniotic membrane rupture can be pathological or physiological. Thus, while all rupture processes may not be the same, they do have some parallels that could be explored to further our understanding of each rupture system.While such comparisons are compelling, they are not without caveats. First, comparisons of DEGs may not be as effective as direct transcriptomic comparisons of sequencing data. Future studies of the genes identified in this analysis should include validation of findings from the referenced transcriptomic data sets. Second, the designs of the transcriptomic analyses used herein differed in some respects  rupture, chorioamniotic membrane rupture, and ovulation can all be described as rupture events.Angptl4, Pfkfb4) relating to vascularization, lipid metabolism, apoptotic regulation, and hypoxia response.These rupture events have overlapping transcriptomic signals .Table S3Complete list of overlapping upregulated and downregulated genes in comparisons between the intracranial aneurysm (ICA) and chorioamniotic membrane rupture (CMR) data sets.Table S2Complete list of overlapping upregulated and downregulated genes in comparisons between two ovulation data sets and one data set for chorioamniotic membrane rupture (CMR).


Phylogenetic analyses of HIV are an increasingly accurate method of clarifying population-level patterns of transmission and linking individuals or groups with transmission events. Viral genetic data may be used by public health agencies to guide policy interventions focused on clusters of transmission or segments of the population in which transmission is concentrated. Analyses of HIV phylogenetics in high-income countries have often found that clusters of transmission play a significant role in HIV epidemics. In sub-Saharan Africa, HIV phylogenetic analyses to date suggest that clusters of transmission play a relatively minor role in local epidemics. Such analyses could nevertheless be used to guide priority setting and HIV public health programme design in Africa for sub-populations in which transmission events are more concentrated. Phylogenetic analysis raises ethical issues, in part due to the range of potential benefits and potential harms . Potential benefits include (1) improving knowledge of transmission patterns, (2) informing the design of focused public health interventions for subpopulations in which transmission is concentrated, (3) identifying and responding to clusters of transmission, (4) reducing stigma (in some cases) and (5) informing estimates of the (cost-)effectiveness of HIV treatment programmes. Potential harms include (1) privacy infringements, (2) increasing stigma (in some cases), (3) reducing trust in public health programmes, and (4) increased prosecution of legal cases where HIV transmission, homosexuality or sex work is criminalised. This paper provides analysis of relevant issues with a focus on sub-Saharan Africa in order to inform consultations regarding ethical best practice for HIV phylogenetics. Phylogenetic analyses have shown different patterns of HIV transmission in ‘generalised’ epidemics in sub-Saharan Africa as compared with ‘concentrated’ epidemics in high-income countries, where such data are increasingly used by public health agencies.This ethical analysis of HIV phylogenetics in Africa explores how the use of genomic data regarding patterns of HIV transmission might inform the ethical development of local public health policy, practice and research.Using phylogenetic data to inform the design of HIV diagnosis and treatment programmes for people more likely to be the source of transmission to others can produce greater public health benefits per individual treated, but these programmes must avoid exacerbating stigma and injustice.Sequencing of the viral genome of HIV infections enables molecular and/or phylogenetic analyses of the relationships between viruses for public health and research purposes .1 2 ThisWorldwide, there has been a growing interest in the role of phylogenetic analysis in public health responses, including during the COVID-19 pandemic. There have also been increasing concerns, including among people living with HIV, that such analyses may result in greater infringements of human rights.5Phylogenetic analyses can inform public health priority setting as well as the design and implementation of specific policy interventions. Although previous work in viral genomics examined relatively large viral genetic groups , recent developments in next generation  HIV sequencing permit richer analyses of variations in viral genetic sequences within and between people living with HIV . These data can inform increasingly accurate assessments of, for example, (1) the dominant patterns of HIV transmission ; (2) the effects of treatment on transmission . The majority of phylogenetic analyses have been conducted in high-income settings, where epidemics tend to be ‘concentrated’ among certain groups or ‘key’ subpopulations such as men who have sex with men (MSM), people who inject drugs (PWID), etc. More recently, with wider access to sequencing technologies and relevant expertise, phylogenetic techniques have increasingly been used to understand transmission in low-income countries with large heterosexual epidemics, including in sub-Saharan Africa.3 8 9It might have been expected that phylogenetic analyses in sub-Saharan Africa would identify significant clusters of HIV transmission within ‘generalised’ epidemics . Such clusters might be amenable to highly focused public health responses similar to those used in high-income settings.Phylogenetic data from multiple sub-Saharan African contexts suggest that large clusters of transmission account for a minority of new infections. Although it remains possible that some (larger) clusters remain undetected, the available sub-Saharan African data suggest that most new HIV infections occur in long transmission chains where an infected person transmits HIV to 1 or 2 other people; large clusters of 10 or more people are extremely rare and linked transmission events may be spread out over long periods of time. Most infected people were found to not pass on the virus at all.8 11 12Even if clusters of transmission are not a significant feature of current African epidemics, phylogenetic analysis has nevertheless clarified the segments of sub-Saharan African populations in which onward HIV transmission events may be more concentrated, for example, young men (aged around 30–35) and women (aged around 20–25).Data demonstrating concentration of transmission, whether collected by researchers or public health agencies, could be used to improve access to treatment among relevant groups via (more) tailored public health services.Molecular epidemiological analysis can also help to evaluate the benefits of policy interventions. Phylogenetic data demonstrated, for example, that wider implementation of universal test and treat policies in sub-Saharan Africa produced indirect benefits beyond treated individuals by reducing transmission to others.8 15Molecular epidemiology is a rapidly advancing area of research and public health practice. Key ongoing developments include (1) innovations in laboratory technology, for example, increases in the level of detail (or ‘depth’) of HIV sequencing; (2) increases in laboratory capacity, for example, next generation sequencing infrastructure producing rapid results, (3) increases in the size of phylogenetic databases, for example, the accumulation and/or linking of more data from larger numbers of individuals and populations; (4) innovations in analytic approaches, for example, novel applications of mathematical techniques to phylogenetic data; and (5) wider availability of expertise in the use of such techniques.The accuracy of inferences regarding transmission of HIV from phylogenetic data is influenced by several factors including (1) depth of sequencing, (2) accuracy of sequencing , (3) population sampling, ; (4) availability of longitudinal data  and (5) the type of analysis used. As an example of recent results, the accuracy of identification of pairs of individuals involved in transmission events within relevant datasets has been reported to be over 95%.16There may sometimes be a significant degree of uncertainty regarding assessments of direct transmission , for example, because simple HIV genetic analyses could not exclude other possibilities such as (1) reverse transmission (B infected A), (2) common source of infection (person C infected both A and B), or (3) unsampled intermediaries (A infected person D who then infected B). However, more recent analytic approaches can exclude these possibilities with a much higher degree of certainty, if deep sequencing data are available on a large fraction of people living with HIV.9 19HIV public health policy responses are also evolving. In 2019, federal US public health agencies adopted the goal of eliminating local HIV transmission.22Elimination of HIV transmission remains a more distant goal in sub-Saharan Africa than in North America. However, public health use of phylogenetic data will be increasingly feasible in the global South. While ethical uses of such data may produce significant public health benefits, misuse could erode trust in public health services.Phylogenetic analyses of HIV are associated with both potential benefits and potential harms . Determining ethically acceptable uses of HIV genomic data often turns on the balance of potential benefits and harms and the fair distribution of such outcomes, as well as other ethical considerations . Below, we summarise relevant potential benefits and harms before discussion of how these can be evaluated in policy-making.In addition to advancing scientific knowledge, HIV genomic analyses can be associated with individual benefits  as well as public health benefits. At the population level, molecular epidemiology research and/or public health surveillance can be used to clarify patterns of HIV transmission at multiple levels, ranging from large segments of the population to small social networks and individual transmission pairs .9 25 TheIdentifying specific groups or subpopulations as more likely to be sources of transmission (than other subpopulations) can be a public health benefit via improved access to HIV diagnosis and treatment for these groups. This not only reduces the risk of AIDS among people living with HIV in these groups but also prevents new cases of HIV among their contacts. The number of new cases prevented will be proportionate to the likelihood that those who start treatment would otherwise have been the source of transmission to others. For example, sub-Saharan African phylogenetic data suggest that men aged around 30–35 are the source of a relatively large fraction of transmission events .26Phylogenetic analyses can also be used to identify clusters of transmission in social networks and/or specific individuals as the likely source of multiple transmission events .25 In prPhylogenetic analyses can sometimes reduce stigma. For example, if there are rumours that a particular group of people within a community are the source of an HIV outbreak, phylogenetic analyses can be used to show that the group in question are either not over-represented in a database of transmission events, or that an outbreak is not in any way linked to the group in question. Making people aware that such rumours are not true could, in principle, help to reduce stigma. This approach has been used to show that a high prevalence of HIV in villages in the Lake Victoria region has not resulted in significant spread of HIV to surrounding communities.9 27Phylogenetic analyses of HIV can be associated with a range of harms, burdens, or infringements on privacy and other individual liberties.The identification of individuals or groups as the source of HIV transmission can be associated with a significant increase in stigma. This can affect livelihoods, social standing, mental health and/or increase HIV transmission risks.1Stigma can affect very large groups of individuals, even comprising the population of nations or regions. For example, the widely criticised closure of international travel from sub-Saharan African countries on the discovery of the omicron variant of COVID-19 by local phylogenetics expertsOne concern regarding the use of HIV phylogenetics in public health practice is that some uses might normalise certain infringements of individual liberties and human rights , and/or result in a wider erosion of protections for people living with HIV.Violations of trust due to molecular public health surveillance might, therefore, worsen inequities in health and/or undermine efforts to reduce HIV transmission. Such concerns might arise when phylogenetic analyses accurately identify sources of transmission but also in cases where such attributions are erroneous. Researchers and public health agencies must, therefore, strive to maintain and increase trust, including by engaging with relevant communities and taking care to ensure ethically appropriate use of HIV phylogenetic data.Highly focused interventions involving small numbers of individuals  potentially involve significant infringements of privacy and/or other liberties. Interventions focused on small numbers of people mean that these individuals can be more easily identified, which may result in stigma and/or reduced trust in public health.23Infringements of privacy may also arise because phylogenetic relationships between viruses reveal information about, and relationships between, multiple people. For example, phylogenetic analysis of a new case might suggest that the person who was the likely source of transmission  is no longer receiving highly active anti-retroviral treatment (HAART) or has developed resistance to treatment. It might also suggest direct  contact between two people resulting in HIV transmission.Molecular analysis of HIV transmission might also infringe privacy by, for example, revealing infidelity and/or transmission between people of the same sex. This may result in particularly significant consequences if data are shared with law enforcement in jurisdictions where homosexuality is criminalised. In research contexts, many of these risks can be mitigated by appropriate data protections, including storage of data in jurisdictions without such laws . In contrast, public health agencies who hold HIV genomic data may be less able to mitigate such risks, for example, where there is an expectation of data sharing between public healt and other government agencies, including law enforcement.In principle, phylogenetic data showing multiple transmissions from a particular individual could be used to enrol such individuals in directly observed therapy, where a health worker checks individual medication use on a regular basisWhere HIV transmission or homosexuality is criminalised, phylogenetic analyses may be used to inform legal judgements about whether a particular individual was the source of transmission or whether two individuals of the same sex were involved in a transmission event.Although some low-income and middle-income countries, including in sub-Saharan Africa, have laws that explicitly criminalise HIV, criminal convictions are more common (per diagnosed cases of HIV) in high-income countries than in low-income countries.Similarly, there is a widespread consensus within public health ethics that public health agencies should not share data for any purpose  other than for interventions aiming to produce public health benefits.35clusters of transmission appear to play a relatively minor role in generalised HIV epidemics. However, they have also shown patterns of transmission that might have (other) implications for HIV public health programme design. Below, we provide a preliminary ethical analysis of molecular public health responses, with the goal of stimulating further discussion and consultation that could form the basis of ethical frameworks for best practice.Most work on the ethics of phylogenetics has focused on high-income settings,There is widespread agreement that the benefits of research and/or public health policy should outweigh associated risks  and/or liberty infringements.Phylogenetic data can be used to inform (1) public health priority setting, (2) the design of specific HIV programmes and/or (3) estimates of the benefits or cost-effectiveness of HIV treatment interventions .Given phylogenetic data in sub-Saharan Africa showing that men aged in their 30s are more likely to be the source of transmission of HIV in generalised epidemics ,Similarly, insofar as phylogenetic data from sub-Saharan African epidemics shows that transmission is more evenly spread across the population (compared with highly clustered transmission in ‘concentrated’ high-income country epidemics) one response might be to reallocate HIV programme resources from certain groups to other segments of the population. However, it might be argued on grounds of justice or fairness that certain groups warrant greater resources, whether or not they are over-represented as sources of HIV transmission. For example, sex workers or men who have sex with men might warrant greater resources insofar as they are socially or economically marginalised, regardless of whether such groups are disproportionately represented in transmission data. Alternatively, it might be argued that it is the very success of HIV programmes tailored for these groups that prevents them from being disproportionately involved in transmission. The latter claim could be tested in molecular epidemiological research.In contrast, there might be cases where justice-based claims and data from molecular epidemiology are aligned, for example, where a marginalised group is shown to be disproportionately involved in HIV transmission (as in ‘key’ populations in high-income countries). In such cases, there would be an especially strong ethical rationale (on multiple grounds) to improve the design of, or access to, HIV public health programmes for these groups.Personal data in clinical and research contexts are governed by well-established ethics norms and protected by multiple safeguards. More recently, phylogenetic data have increasingly been used in public health responses to HIV in high-income countries.34Among other differences from research settings, public health uses of data are typically not subject to individual informed consent requirements .34 41 ThUnlike phylogenetic research, which typically uses de-identified data, public health programmes may sometimes link phylogenetic data with identifying metadata . This might in principle help to increase public health benefits by enhancing existing contact tracing and/or CDR activities, however, such uses represent a significant risk to privacy, raising questions about the conditions under which the benefits outweigh privacy infringements and related risks. Such questions should also be evaluated in different local contexts, including in sub-Saharan African communities.Privacy infringements can be reduced by setting appropriate limits on data sharing. For example, it is often unnecessary for clinicians or public health agencies to have access to detailed viral genetic sequences to help patients and protect public health. Likewise, it is often unnecessary for researchers to have access to highly identifiable information to study viral evolution. Therefore, there will rarely, if ever, be a justification for clinical, research and public health databases to be (fully) linked. Similarly, data protection policies should also prevent the sharing of data collected for health purposes with police and other agencies involved in criminal prosecution.34HIV CDR requires active surveillance and contact tracing by public health authorities. While it does not necessarily require molecular surveillance, phylogenetic analysis might nevertheless make contact tracing more efficient by providing additional evidence of genetic linkage of cases within a specific transmission network. Conversely, analyses might show that a case with epidemiological links to a cluster nevertheless acquired infection elsewhere. In any case, these are resource-intensive activities used primarily in high-income settings and the benefits of CDR informed by phylogenetic analysis have not been quantified.44Cluster responses are unlikely to be a high priority in most sub-Saharan African settings given that (1) data suggest that clusters currently play at most a minor role in generalised HIV epidemics, (2) public health resources are limited and (3) CDR might erode trust among key subpopulationsPhylogenetic analysis of HIV has revealed important transmission dynamics that may help to inform public health practice and, in some cases, increase the benefits and/or cost-effectiveness of HIV diagnosis and treatment programmes. Given increasing availability of HIV sequencing data phylogenetic expertise in sub-Saharan Africa, such data will likely inform future public health policy and practice.This project is intended as to inform future consultations aimed at developing frameworks for ethical best practice for HIV phylogenetics in sub-Saharan Africa. Such frameworks should also be informed by evolving evidence regarding transmission patterns which, as we have highlighted here, may not always resemble those in high-income countries. Such frameworks may draw on existing ethical frameworks for public health or human genetics and/or on African philosophical traditions.


Although it has been reported that oxygen vacancies tend to promote Zn(II) ion migration in the STO layer and thereby effectively suppress Zn dendrite growth, there is still a lack of a basic understanding of the quantitative effects of oxygen vacancies on the diffusion characteristics of Zn(II) ions. In this regard, we comprehensively studied the structural features of charge imbalances caused by oxygen vacancies and how these charge imbalances affect the diffusion dynamics of Zn(II) ions by utilizing density functional theory and molecular dynamics simulations. It was found that the charge imbalances are typically localized close to vacancy sites and those Ti atoms that are closest to them, whereas differential charge densities close to Sr atoms are essentially non-existent. We also demonstrated that there is virtually no difference in structural stability between the different locations of oxygen vacancies by analyzing the electronic total energies of STO crystals with the different vacancy locations. As a result, although the structural aspects of charge distribution strongly rely on the relative vacancy locations within the STO crystal, Zn(II) diffusion characteristics stay almost consistent with changing vacancy locations. No preference for vacancy locations causes isotropic Zn(II) ion transport inside the STO layer, which subsequently inhibits the formation of Zn dendrites. Due to the promoted dynamics of Zn(II) ions induced by charge imbalance near the oxygen vacancies, the Zn(II) ion diffusivity in the STO layer monotonously increases with the increasing vacancy concentration ranging from 0% to 16%. However, the growth rate of Zn(II) ion diffusivity tends to slow down at relatively high vacancy concentrations as the imbalance points become saturated across the entire STO domain. The atomic-level understanding of the characteristics of Zn(II) ion diffusion demonstrated in this study is expected to contribute to developing new long-life anode systems for AZIBs.A highly polar perovskite SrTiO Due to their high energy density, extended lifespan, and dependable performance, lithium-ion batteries (LIBs) have dominated the secondary energy storage industry over the past few decades. However, there are significant concerns, especially for large-scale energy storage systems, arising from the high flammability and toxicity of organic electrolytes, insufficient Li sources, and cell production complexity ,3,4,5,6.3), abundant natural resources, low cost, and ease of production [Aqueous rechargeable batteries have a significantly higher competitive potential for energy storage devices compared to batteries that use organic electrolytes because of their exceptional benefits, including (i) high safety due to the absence of hazardous solvents with high volatility, (ii) low cost and environmental friendliness, and (iii) high ionic conductivity of aqueous electrolytes compared to that of organic electrolytes ,15,16,17oduction ,26,27. Doduction ,29. One oduction .3 solution [3 (STO) as the protective layer on Zn metal [Since Zn dendrites grow at electrode–electrolyte interfaces, forming an artificial protective layer on Zn metal with materials such as metals ,32, inorsolution . Accordisolution . RecentlZn metal . Along w3 (LAO) films were deposited on STO substrates, Kalabukhov et al. found that the oxygen vacancies created in the STO substrates as the LAO films grow induce high electrical conductivity and mobility values at the LAO/STO interfaces [Since oxygen vacancies play a crucial role in numerous features of perovskite materials, the effects of oxygen vacancies on various physical properties such as atomic structure, electrical properties, and diffusion characteristics have been extensively investigated ,43,44,45In this regard, we systematically investigated how the oxygen vacancies in the STO layer affect the characteristics of Zn(II) ion dynamics at the atomic level. Based on an earlier study that found that the charge imbalance caused by the oxygen vacancies encourages Zn(II) ion diffusivity , the pre−5 eV and 0.02 eV/Å, respectively. First-principles calculations were utilized to find the electronic total energies and charge densities  of the cThe diffusion characteristics of Zn(II) ions in the considered perovskite structures were investigated by utilizing MD simulations. From the atomic trajectories of the MD simulations, the mean squared displacement (MSD) of a Zn(II) ion can be calculated as: 3. During all MD simulations, the temperature was kept constant at 1400 K using a Nose–Hoover thermostat [The initial MD configuration of the system for Zn(II) ion diffusion was prepared by putting a Zn atom into an arbitrary interstitial site of a perovskite structure whose size is 8 × 8 × 4 nmermostat ,52 to efermostat ,54. All ermostat ,56 with ermostat . IndividZn(II) ions diffuse through the STO layer after being absorbed by the electrolyte on the outer STO surface, eventually depositing on the Zn anode surface. It was shown in an earlier study  that oxy3 (CTO) system, the observed differentiable effects of each element in STO on the charge imbalance are further validated. The variations in electron density brought on by oxygen vacancies in CTO are shown in By examining the differential electron density distribution brought on by oxygen vacancies in the CaTiO2/ns and 14.52 Å2/ns in STO and CTO, respectively). This finding further demonstrates that the charge imbalance brought on by oxygen vacancies is a major determinant of the Zn(II) ion transport properties.Because both STO and CTO have the same charge imbalance, it follows that the impact of oxygen vacancies on Zn(II) ion diffusivity will be nearly equivalent in both systems. By using MD simulations, the MSD of Zn(II) ions in the two systems with the same oxygen concentration is determined in order to compare the diffusivity of Zn(II) ions in the STO and CTO systems. The concentration of oxygen vacancies for the simulations is set at 16% in accordance with the experimental findings in a previous study . As seenSince The minimal energy reliance on the position of the vacancy is further confirmed by performing a straightforward MD simulation. The simulation starts with the structure denoted by STR1, which has the lowest energy among the five structures shown in Since the oxygen vacancies in STO have no preference for location, this indicates that the Zn(II) ion diffusion caused by the charge imbalance from the oxygen vacancies has no preference for direction too. To determine whether Zn(II) ions have a predilection for diffusion in any particular direction, the MSDs of Zn(II) ions in the x-, y-, and z-directions were individually calculated. The measured MSDs in each direction are nearly comparable to one another as seen in Since oxygen vacancies effectively promote Zn(II) ion diffusivity in the STO system, it is anticipated that Zn(II) ion diffusivity in STO can be successfully regulated by modifying the concentration of oxygen vacancies. In order to achieve this, it is critical to look at the quantitative relationship between Zn(II) ion diffusivity and oxygen vacancy concentration. Five STO structures with vacancy concentrations ranging from 0% to 16% were built in order to investigate diffusion characteristics of the Zn(II) ion at various oxygen vacancy concentrations. The slopes of MSDs computed during MD simulations were then used to estimate the Zn(II) ion diffusion coefficients in the five prepared STO structures.The calculated diffusion coefficients monotonically grow with increasing oxygen vacancies in STO, as seen in 2/ns) even at a 0% vacancy concentration in the STO layer. This can be explained by tracking the Zn(II) ion coordination. We note that the Zn(II) ion has a non-zero value of diffusion coefficient  ions at the atomic level. It has been found that changes in electron density brought on by oxygen vacancies only affect the nearby Ti atoms and the vacancies themselves, with changes occurring nearly nowhere else. According to this discovery, charge imbalances created by oxygen vacancies are confined, and as a result, the augmentation of Zn(II) ion diffusivity caused by this charge imbalance only manifests itself in the vicinity of the vacancies. Through examination of differential electron density and Zn(II) ion diffusivity in CTO systems, this localized charge imbalance was further validated. The Zn(II) ion diffusion affected by the charge imbalances exhibits essentially isotropic mobility in all directions regardless of the vacancy sites, despite the charge imbalances clustered around oxygen vacancies suggesting that their distribution features depend substantially on the vacancy locations. The isotropic diffusion of Zn(II) ions occurs in the STO system as a result of dynamic changes in vacancy locations because the energy difference between various vacancy positions can be easily overcome by thermal energy, even at room temperature. Due to the localization of charge imbalance around oxygen vacancies, the number of imbalance spots is proportional to the vacancy concentration. As a result, the Zn(II) ion diffusivity elevates with increasing vacancy concentration. However, as the imbalance spots become saturated throughout the entire STO domain, the growth rate tends to slow down at relatively large vacancy concentrations.(i)3 and BaTiO3 or even in mixed perovskites such as BaxSr1-xTiO3, due to the fact that the oxygen vacancies do not influence the electron density near Sr atoms. As a result, depending on the individual circumstance, researchers may have options for selecting a suitable perovskite.The effects of oxygen vacancies on Zn(II) ion diffusivity may stay the same in other perovskite materials such as CaTiO(ii)It has been demonstrated that isotropic diffusion is induced by oxygen vacancies in the STO coating layer. Therefore, modulating oxygen concentration during the fabrication process of the coating layer may be an effective strategy to inhibit Zn dendrite growth because homogenous ion flux caused by this isotropic diffusion prevents perpendicular Zn protuberance growth.(iii)While Zn(II) ion diffusivity in the STO layer increases with an increase in the oxygen vacancy concentration, the vacancies also decrease the structural stability of the STO layer. Therefore, to achieve increased Zn(II) ion diffusivity as well as the structural stability of the STO layer, the oxygen vacancy concentration in the STO layer needs to be optimized.Effective control of Zn(II) ion diffusion by coating materials on an anode surface is crucial to prevent the formation of Zn dendrites. The key findings regarding the impact of oxygen vacancies on Zn(II) ion diffusivity in the STO coating layer presented in this study can offer some suggestions for the fabrication of novel coating materials on anode surfaces for developing advanced AZIBs. Specifically:We believe that a comprehensive understanding of the characteristics of charge imbalances brought on by oxygen vacancies and their effects on Zn(II) ion diffusivity in STO systems is expected to provide insight into the design of new coating layers for anode surfaces with improved Zn(II) ion diffusion properties.


Homocysteine is a toxic, sulphur-containing intermediate of methionine metabolism. Hyperhomocysteinemia has been proposed as an important risk factor for ischemic stroke. We present the case of a 39-year-old male who sustained a cerebrovascular accident with left hemiparesis two years back; the patient was not compliant with his medications, and now presented with complaints of giddiness, reduced vision, and double vision. Vision disturbances were bilateral, acute in onset, progressive over time, and predominantly affected the peripheral vision. On ophthalmic examination, homonymous hemianopia was noted, and finger counting was absent in both eyes. Confrontation test revealed a bilateral reduced field of vision more so in the left eye. Baseline investigations were unremarkable except for mildly elevated serum. Homocysteine and neuroimaging showed acute infarct with hemorrhagic transformation in the right occipito-parietal region and small acute non-hemorrhagic infarcts in the right thalamus and right side of the splfingerenium of the corpus callosum. Given the visual disturbance, Humphrey visual field (HVF) perimetry was done and it revealed left homonymous congruous hemianopia, likely due to right parietal lobe infarct. The patient had recurrent infarcts previously involving anterior and posterior circulation. Stroke, which is defined as the sudden onset of a neurological deficit lasting over 24 hours, is a significant cause of morbidity and mortality worldwide, presenting a considerable socioeconomic challenge in terms of stroke survivors' occupational and neuro-rehabilitation programmes . While tA 39-year-old male who suffered from a cerebrovascular accident two years ago and was not on regular medications presented with complaints of giddiness, gradually progressing diminution of vision for four days, and double vision in both eyes for two days. The patient did not have any other significant medical history. His vision disturbance was bilateral, with predominant peripheral vision being affected. His clinical examination revealed residual weakness in the left upper and lower limbs with mild slurring of speech. On ophthalmic examination, homozygous hemianopia was present and finger counting was absent in both eyes; the confrontation visual field test revealed that the field of vision had decreased more in the left eye. Baseline investigations revealed haemoglobin (Hb) of 9.5 gm/dL, total leukocyte count (TLC) of 10100 cells/mm3, platelet count of 6.11 cells/mm3, INR of 1.3, and glycosylated haemoglobin (HbA1c) of 7.2%. Renal and liver functions were also normal. MRI of the brain was performed which revealed an acute infarct with small areas of hemorrhagic transformation involving the right occipital and a small part of the adjacent parietal lobe, as well as small acute infarcts in the right side of the splenium of the corpus callosum and small acute infarcts in the dorso-medial aspect of the right thalamus, chronic infarct with gliosis and hemosiderin residue in the inferior aspect of right cerebellar hemisphere, chronic infarcts with gliosis in the bilateral ganglio-capsular regions and corona radiata, and severe occlusion involving P2 and P3 segments of bilateral posterior cerebral arteries (PCA)  perimetry revealed left homonymous congruous hemianopia, which was most likely due to a right parietal lobe infarct Figure . In view of recurrence of stroke previously involving the anterior circulation and presently the posterior circulation, the patient was restarted on dual anti-platelets (tab clopidogrel 75 mg and tab aspirin 75 mg) and statin (tab atorvastatin 40 mg) and was also started on homochek  due to elevated serum homocysteine levels. The patient was counselled about the poor prognosis of his vision and advised to continue the medications for life without any non-compliance. The patient is currently on regular follow-up showing mild improvement in the quality of vision but no improvement in his fields of vision.With an annual mortality rate of 5.5 million people and chronic morbidity among 50% of survivors, stroke is a significant contributor to both death and long-term disability on a global scale. While bleeding in the brain or the subarachnoid space can sometimes be the cause of stroke (haemorrhagic stroke), in most cases, stroke is caused by an abrupt blockage of a blood vessel, resulting in decreased perfusion to the brain tissues (ischemic stroke) . In addiThe systemic elevation of the thiol amino acid homocysteine, which is a potentially toxic metabolite formed as an intermediate of the methionine and cystine metabolisms, is the defining feature of hyperhomocysteinemia . In indiA prolonged rise in homocysteine levels triggers complex processes such as oxidative stress, calcium dysregulation, and protein homocysteinylation . The occThe mechanisms involved in the association between plasma homocysteine levels and the risk of stroke include the following:i. Elevated levels of homocysteine can cause oxidative damage to endothelial cells, resulting in reduced production of nitric oxide and increased adhesion of platelets to the endothelial cells. These effects can contribute to the development of thrombotic vascular disease ,8.ii. Elevated homocysteine levels are associated with increased platelet aggregation which occurs due to increased thromboxane A2 synthesis and decreased prostacyclin production .iii. It is also associated with clotting cascade abnormalities which result in the inhibition of natural anticoagulants such as protein C and antithrombin III and the activation of factors V, X, and XII .Lowering homocysteine levels below 10 mol/L is associated with a substantial reduction in the risk of stroke and decreasing levels to below 9 mol/L has been linked to a significant decrease in mortality from elevated homocysteine levels . AdminisIn conclusion, regular screening for homocysteine levels in patients with stroke is essential for identifying those at risk for stroke recurrence. With the appropriate use of vitamin B12, pyridoxine, and folic acid, the levels of homocysteine in the blood can be reduced, thereby mitigating the risk of stroke recurrence. This review emphasises the significance of regular screening for homocysteine levels in all patients with stroke to help improve their quality of life and reduce the risk of further stroke-related complications.


Faecalibacterium prauznitzii, Akkermancia muciniphila, Roseburia species, and Bifidobacterium species. An important net effect is an increase in the levels of luminal SCFAs  that provide energy carbon sources for the intestinal microbiome in cross-feeding activities, with concomitant improvement in intestinal dysbiosis with attenuation of inflammatory sequalae and improved intestinal gut barrier integrity, which alleviates the morbidity of T2DM. Oligosaccharides administered adjunctively with pharmacotherapy to ameliorate T2DM represent current plausible treatment modalities.Hypoglycemic medications that could be co-administered with prebiotics and functional foods can potentially reduce the burden of metabolic diseases such as Type 2 Diabetes Mellitus (T2DM). The efficacy of drugs such as metformin and sulfonylureas can be enhanced by the activity of the intestinal microbiome elaborated metabolites. Functional foods such as prebiotics  and dietary fibers can treat a dysbiotic gut microbiome by enhancing the diversity of microbial niches in the gut. These beneficial shifts in intestinal microbiome profiles include an increased abundance of bacteria such as  The intestinal microbiota presents a complex ecosystem consisting of bacteria, enteric viruses, archaea, fungi, and protozoa ,2. The sAny subsequent alterations in the composition of the gut bacterial profile (dysbiosis) have been associated with the pathogenesis of numerous inflammatory diseases and infections . MoreoveThe current scientific literature suggests that as the intestinal microbiota composition is observed to differ between individuals and is contingent on a variety of factors such as genetics and diet, a percentage of individuals may harbour intestinal bacteria that have been reported to be associated with pro-inflammatory effects, while others may harbour intestinal bacteria with anti-inflammatory effects . BiochemThe administration of oral probiotic bacteria has been demonstrated to interact with numerous intestinal structures, including intestinal epithelial cells and immune cells associated with the lamina propria, through Toll-like receptors that then induce the production of a plethora of cytokines/chemokines ,7,8. MacFurthermore, probiotics have been reported to activate regulatory T cells that release an anti-inflammatory interleukin . What has been reported is that probiotics have multiple effects that reinforce the intestinal epithelial barrier integrity, coupled with increases in mucins, tight junction proteins, and Goblet and Paneth cells ,7. AdditOf interest is the role that probiotics may have in activating the microbicidal actions of peritoneal and spleen macrophages to protect against the action of different pathogens . FurtherA recent review reports that intestinal microbiota dysbiosis has been shown to have adverse health effects that will lead to a variety of chronic disease progressions . The sub9 CFU/dose) given intragastrically once a day to investigate the healing effect of acetic acid-induced colitis ..28].The disruption of the epigenome poise may be causal for several pathologies and is a contributing factor to obesity and T2DM . It is kIn a sequence of important studies with T2DM patients and intestinal microbiota, researchers have reported the characterization of the intestinal microbiota with this metabolic disease . ModeratClostridium perfringens) [T2DM and obesity are strongly linked with adiposopathy, along with adipose tissue dysfunction, which has been reported as a major factor in the etiology of metabolic dysfunction conditions . Metabolringens) . This siringens) .A recent systematic review analysed studies that had assessed the serum concentrations of the endotoxin lipopolysaccharide (LPS) or that of the lipopolysaccharide-binding protein (LBP) in diabetic patients and compared them to the serum of healthy individuals . The revAn early review  reportedThere is subsequent activation of pro-inflammatory activity that can alter several stages of insulin signaling. Furthermore, the review reports that chronic exposure to the LPS endotoxin may contribute to weight gain and the progression of T2DM .Obese and diabetic individuals have an increased risk of presenting with plasmatic LPS levels . The incIn a recent study linked to endotoxemia, Cox and colleagues  investigC), homeostatic model assessment for insulin resistance (HOMA-IR), and alanine aminotransferase (ALT) levels. The authors suggested that the findings could promote zonulin as a non-invasive biomarker involved in the pathogenesis of gestational diabetes [The primary outcome data demonstrated that there were differences in the measures of intestinal epithelial cell barrier permeability between individuals with and without T2DM . The autdiabetes .Butyrate, a 4-carbon SCFA produced by intestinal bacteria  via glycFurthermore, butyrate can decrease excessive inflammation through the modulation of immune cells, e.g., by increasing the functionalities of M2 macrophages and regulatory T cells and inhibiting infiltration by neutrophils . TherefoIn this narrative review, we have focused on the adjuvant role that functional foods such as prebiotics may provide to the intestinal microbiome to improve metabolic dispositions in T2DM. In addition, while the dietary approach to modulating the intestinal microbiome with the administration of probiotics has a long history, there has always been probiotic survivability and viability issues with the administration of various probiotic formulations that have been difficult to ascertain.We have previously investigated, through clinical studies, that functional foods with prebiotics and probiotics, co-administered with standard medications, were effective for the management of T2DM. These studies confirmed that the co-administration of an oligofructose prebiotic with sulfonylurea  and a muThe intestinal microbiome has been suggested to have a significant impact on transforming T2DM . The revClostridium species that mostly utilize indigestible polysaccharides by principally fermenting carbohydrates, proteins, and organic acids have shown that these bacteria produce SCFAs of acetic acid, propionic acid, and butyric acid, thereby affording numerous benefits to gut health through intestinal actions which can translate to enhanced management of T2DM [Faecalibacterium prausnitzii in the Clostridium leptum cluster  and Eubacterium rectale/Roseburia spp. in the Clostridium coccoides  cluster of Firmicutes [Bacteroides resides in their capacity to ferment carbohydrates. Members of the taxa Bacteroides and other intestinal bacteria produce a significant mixture of fatty acids, which can be utilized by the host as an energy source [Bacteroides, Bifidobacterium, Eubacterium, Lactobacillus, and Streptococci [Enterobacteria were cited as being usually found in a lesser abundance [Bacteroides, results in dominant bacterial signatures [Animal and human studies investigating  of T2DM . Consequ of T2DM ,126. Amormicutes . These grmicutes . These grmicutes .The impoy source , and thiptococci . Howeverbundance . A recengnatures .Ruminococcus and Blautia were also reported, and the significance of this is that these clusters have significant positive associations with T2DM [Blautia is widely distributed in mammalian faeces and the intestines. As a dominant genus in the intestinal microbiota, there is a significant correlation between its host physiological and metabolic dysfunctions with obesity, diabetes, and various inflammatory and metabolic diseases due to its antibacterial activity against specific commensal microorganisms [Ruminococcus also have a relevant importance to T2DM, as the members of this taxon breakdown cellulose that produces methane with the accumulation of a reserve of glucose polymers important in glucose homeostasis [Ruminococcus taxa in the intestines may constitute a significant clinical step in prescribing specific prebiotic fibers, beneficially improving the glycemic control of T2DM [Bacteroidaceae levels in sulfonylurea monotherapy patients taking adjuvant oligofructose prebiotics provides further support to the posit of a beneficial role of this family of bacteria in T2DM [Furthermore, a cluster of bacteria consisting of ith T2DM . Blautiarganisms . In addieostasis ,130. Rep of T2DM  by reduc in T2DM .Bifidobacterium [Lactobacillus species [Bifidobacterium competitiveness and butyrate production [Lactobacillus and Bifidobacterium species, which ferment these compounds into SCFAs [Bifidobacterium, Bacteroides, Faecalibacterium, Akkermansia, and Roseburia that have been reported to be significantly and negatively associated with T2DM [Faecalibacterium consists of abundant butyric acid-producing bacteria that colonize the human intestines and display an overall anti-inflammatory effect with the potential of re-regulating adverse inflammatory responses in the gut [Roseburia also shows stable and relatively abundant levels in the gut that show favourable sequelae in glucose metabolism in T2DM. Members of the Roseburia genus likely play a major role in maintaining gut health and immune defence by maintaining regulatory T-cell homeostasis, predominantly through the production of butyrate [Flavonifractor  was associated with lower insulin sensitivity and disposition index and a higher prevalence of dysglycemia [Patients without metabolic diseases, in contrast to studies that have described the effects that prebiotic fibers may have on the composition of the intestinal microbiota, show consistently reported increases in the abundance of acterium ,134,135  species . Intesti species , a recogoduction . In addito SCFAs ,138. Of ith T2DM . Specifi the gut , a prevabutyrate . Conversbutyrate . The autglycemia . Hence, glycemia .F. prauznitzii, that improve intestinal health maintenance  and immune defence by maintaining regulatory T-cell homeostasis. Moreover, this bacterium has been promoted as a new generation probiotic [The clinical use of supplemented fibers, namely oligofructose, with hypoglycemic medications such as sulfonylureas could improve health outcomes in patients diagnosed with pre-T2DM and early-stage T2DM. The intestinal benefits have been attributed to an increased abundance of butyrate-producing intestinal microbes, including robiotic ; therefo


GRP78 is a molecular chaperone protein in the endoplasmic reticulum that is involved in protein assembly and quality control, and it participates in ER stress regulation of endoplasmic reticulum stress pathways. Studies have confirmed that GRP78 gene is highly expressed in a variety of tumors and is involved in different biological functions.The present review highlights the involvement of the GRP78 gene in regulating the development of cervical cancer by promoting the proliferation and invasion of cervical cancer cells as well as by inhibiting apoptosis and promoting the Warburg effect. High expression of GRP78 is positively correlated with chemotherapy resistance in cervical cancer. GRP78 plays an anticancer role in cervical cancer by regulating autophagy and apoptosis. Mediated immune CD8 + T cells regulate tumor cell immunity and play a role in the application of the HPV vaccine.GRP78 plays a multifunctional role in cervical cancer and has important therapeutic and diagnostic value. Cervical cancer is a growing global burden, especially in developing and industrialized countries. In 2020, there were 604,127 new cases of cervical cancer and 341,831 deaths worldwide [At present, surgery is the main treatment for early cervical cancer . AccordiIn recent years, there has been continuous research on endoplasmic reticulum stress- and GRP78-regulated unfolded protein response (UPR) in cancer cells. GPRP78 gene database showed that significantly high expression was reported in highly malignant and aggressive glioblastoma, lung cancer, breast cancer, colon cancer, and liver cancer –12. ThesIn this paper, the mechanism of GRP78 involved in the regulation of cervical cancer behavior is reviewed, and the current application of GRP78 in the treatment, diagnosis and immunology of cervical cancer is discussed. The function of GRP78 gene involved in cervical cancer is summarized, and the exploration of GRP78 in cervical cancer is promoted. GRP78 gene is expected to become a potential new target for cervical cancer diagnosis and treatment, and may eventually improve the prognosis of patients with cervical cancer. The flow chart of this study is shown in Fig. The endoplasmic reticulum (ER) is the largest compartment in eukaryotic cells. It has been reported that ER plays an important role in antibody and hormone secretion, protein folding and protein quality control, among which molecular chaperone plays an important role in protein quality control and protein folding , 17, 18,Glucose-regulating protein 78 (GRP78) is an executor of the unfolded response in the endoplasmic reticulum lumen and a chaperone in the heat shock protein family 70 that regulates cellular responses to unfolded and misfolded proteins , 21. GRPAs a resident protein of the ER, GRP78 functions as a molecular chaperone that binds to misfolded proteins and unassembled complexes, and it initiates ER-associated degradation responsible (ERAD) for UPR regulation. GRP78 binds to unfolded peptides via a SBD and gains energy through ATP hydrolysis via the NBD to prevent aggregation. GRP78 binds in an inactive form to activated transcription factor 6 (ATF6), protein kinase RNA-like endoplasmic reticulum kinase (PERK) and inositol kinase-1 (IRE1) under standard conditions of cellular homeostasis (homeostasis), and it is a transmembrane stress sensor for UPR. When cells are exposed to accumulated unfolded proteins in the ER, the release of GRP78 from the UPR sensor activates the UPR , and theGRP78 has traditionally been considered an endoplasmic regulating cavity protein. However, there is increasing evidence that GRP78 is also detected at other cellular sites, including the cell surface, cytoplasm, mitochondria and nucleus, and it participates in signal transduction, proliferation, invasion, apoptosis, inflammation and immunity  ImportanGRP78, as a chaperone protein in the endoplasmic reticulum, is involved in the main regulation of UPR and is highly expressed in a variety of tumor cells. Previous studies have reported that GRP78 is involved in multiple aspects of tumor biology, such as proliferation, apoptosis, autophagy , invasioDefects in apoptosis are one of the mechanisms of drug resistance in tumor cells . The ultIn terms of chemotherapy, a variety of anticancer drugs can induce resistance of GRP78 to cancer chemotherapy drugs and promote tumorigenesis –38. ReseCancer cells reestablish endoplasmic reticulum homeostasis through UPR, which contributes to cell survival and leads to drug resistance. The regulation between UPR signal and microRNAs (miRNAs) is involved in the development and drug resistance of cervical cancer. It was found that miR-211 contains a sequence targeting CHOP promoter region, which inhibits the expression of CHOP and thus inhibits the pro-apoptotic signaling pathway, contributing to cell survival and the occurrence of drug resistance. miR-214 can reduce the expression of ATF4, thereby increasing the transcription of pro-survival genes and promoting the occurrence of drug resistance –42. JDP Recent studies have demonstrated that the unfolded protein response (UPR) triggered by GRP78 contributes to cell transformation, the inflammatory response, tumor angiogenesis, tumor cell invasiveness and tumor cell metastasis, increasing our understanding of the relationship between ER stress and cancer biology . ProteinResearchers have investigated how GRP78 promotes tumor development. Studies have confirmed that GRP78 is involved in a variety of cellular biological processes, including translocation of newly synthesized peptides across the ER membrane, promotion of proteasomal degradation of misfolded proteins, maintenance of intracellular calcium homeostasis and function as an ER baroreceptor , 46. HowDefects in apoptosis are an important cause of tumor development. A previous study has found that GRP78 has an anti-apoptotic function. GRP78 knockout in HeLa cells activates the UPR pathway and increases the expression of CHOP, ERdj4 and P5 proteins, ultimately leading to cell apoptosis.Human papillomavirus (HPV) is the main promoter of cervical cancer. The E6 protein is a nonstructural protein of HPV and is responsible for cell differentiation by targeting the tumor suppressor genes, p105Rb and p53. Studies have confirmed that the E6 protein is stabilized by the GRP78 protein to promote the development of cervical cancer. GRP78 knockout destroys the stability of E6, thus leading to faster degradation of E6 in vivo and inhibiting the development of cervical cancer . The traCancer cells use a large amount of nutrients to maintain unlimited proliferation and growth. This requires a reprogramming of energy metabolism, which is considered one of the hallmarks of cancer . In the GRP78 induces cancer cell proliferation and migration by disrupting the normal cell apoptosis process through abnormal glucose metabolism behavior . StudiesIt is currently believed that tumor cells interfere with the protein folding process of the endoplasmic reticulum (ER) under stress conditions, leading to ER stress (ERS). ERS can activate the UPR of cells . During Apoptosis is an actively regulated type of programmed cell death that plays an important role in antitumor research. In recent years, several studies have evaluated the role of GRP78 in apoptosis. This is shown in Fig. . Meng WaUnder intense and sustained ER stress, GRP78 is activated, which induces the expression of downstream CHOP, thereby inducing cell apoptosis. The accumulation of calcium ions in the endoplasmic reticulum promotes the upregulation of the Bax/BcL-2 ratio and activates the mitochondrial pathway to induce apoptosis. In addition, Ca2 + released into the cytoplasm also activates calpain, which promotes the cleavage of Caspase-12 and mediates apoptosis. JNK is also activated by dimerized IRE1 to induce apoptosis through TRAF2–ASK1 signaling . SustainA previous study has confirmed that quercetin has the following effects: induces endoplasmic reticulum stress in cervical cancer HeLa cells; induces the expression of GRP78; activates the increased expression of caspase-3, CHOP, IRE1, p-PERK and c-ATF6; reduces the expression of Bcl-2; induces cell apoptosis; and inhibits the viability of cervical cancer cells . It has Autophagy plays a dual role in tumor species, but the mechanism by which autophagy determines cell death lies in the regulation of tumor suppressor genes and oncogenes in cells . Beclin1Brefeldin is a lactone antibiotic that induces UPR activation in cervical cancer cells through endoplasmic reticulum stress, with increased IRE1α and GRP-78 protein levels and ER swelling. At the same time, endoplasmic reticular stress induced LC3 expression through activation of NF-κB and induced autophagy of cervical cancer cells. NF-κB pathway inhibitor QNZ could reverse Brefeldin-induced autophagy and reduce the death of cervical cancer cells, suggesting that GRP78/NF-κB/LC3 was involved in the autophagy death of cervical cancer cells  PropofolRecent studies have found that AGG-mediated Akt dephosphorylation leads to ER stress, inducing autophagy-dependent cell death in cervical cancer cells, and ER inhibitors reverse AGG-induced autophagic death . TobaccoIn recent years, the clinical value of serum tumor markers in the early diagnosis, efficacy evaluation, prognosis and follow-up of cervical cancer has become increasingly prominent, providing new ideas for the clinical improvement of the diagnosis and treatment of cervical cancer. The development of precancerous lesions to cervical cancer is a relatively long process. Because the early stage does not have specific symptoms, many patients are diagnosed at the late stage of the cancer. Therefore, cervical cancer diagnostic markers are valuable in the diagnosis of cervical cancer.As a member of the Hsp70 family, overexpression of GRP78 in cancer cells and human tumors leads to malignant tumors and increases the survival of cancer cells due to drug resistance , 78. HigImmune checkpoint inhibitors and other therapies have shown powerful therapeutic effects in the treatment of a variety of cancers. Other immunotherapies have gradually attracted more attention in cancer treatment . ImmunotStudies have confirmed that assembly and presentation of Major histocompatibility Complex-I (MHC-I) epitopes occur in the endoplasmic reticulum  Fig. 8)8). ThereIn cancer, ER stress activates cells of the adaptive immune system . ER streIn recent years, tumor treatment mechanisms based on ER stress have attracted extensive attention . When miProtodioscin is a steroid compound derived from the rhizome of Chinese yam that has anticancer activity in a variety of tumors. It has been verified that endoplasmic reticulum stress is induced through activation of the MAPK signaling pathway, which is accompanied by high expression of GRP78 protein, thereby inducing apoptosis of cervical cancer HeLa cells. Mulberry yellow is a traditional medicinal mushroom. According to Shennong Materia Medica, “Mulberry Yellow” is used in medicine to solve the symptoms of gynecological tumors in the form of abdominal masses, including vaginal bleeding, leucorrhea, abdominal pain and abdominal masses. Studies have confirmed that the antitumor effect of Poria cocos extract on human cervical cancer SiHa cells occurs through inducing endoplasmic reticulum stress, which promotes high expression of GRP78 and CHOP, resulting in apoptosis induction in cervical cancer SiHa cells . TanshinGRP78, as a molecular chaperone protein, is expressed in cervical cancer and affects the growth of tumor cells, the tumor microenvironment and tumor immunity. In response to changes in the external environment of cervical cancer cells, such as inflammation, hypoxia, nutrient deficiency and acidosis, GRP78 is overexpressed and migrates to the surface of tumor cells, thereby generating a stress protective response by supporting the promotion of tumor growth and inducing drug resistance of tumor cells and playing an important role in the growth, development and diagnosis of cervical cancer.Apoptosis and autophagy determine the survival of tumor cells. In tumor cells, the interaction between autophagy and apoptosis is of great significance for the regulation of intracellular environment and clinical treatment. In cervical cancer, GRP78 plays a dual role of apoptosis and autophagy. On one hand, it plays an apoptotic role in cervical cancer cells, thus inhibiting the development of cervical cancer; on the other hand, it plays an autophagy role. GRP78 induces autophagy through endoplasmic reticulum induced UPR response, mild endoplasmic reticulum stress produces protective response, while sustained and strong endoplasmic reticulum stress induces a protective response. Malignant tumors constantly activate UPR under environmental stress, and ER response remains serious. GRP78 regulates tumor cell death signaling pathway and promotes tumor cell death. In recent years, further studies on the anti-tumor mechanism of endoplasmic reticulum stress also suggest that GRP78 plays an important role in the anti-tumor activity of natural plants, and GRP78 is involved in the synergistic effect of tumor immune response and HPV vaccine.In terms of diagnostic significance, high expression of GRP78 is involved in the development of cervical cancer, and the differential expression of GRP78 in cervical cancer and adjacent tissues is correlated with the clinicopathological stage of cervical cancer patients and the differentiation of tumor cells, indicating that GRP78 is of great value as a diagnostic marker for cervical cancer.How does GRP78 regulate cervical cancer in multiple intracellular sites? Does GRP78 regulate cervical cancer metastasis through EMT metastasis? It is necessary to establish GRP78 specific conditional knockout model and cervical cancer specific metastasis model, which will help to further reveal the function of GRP78 in cervical cancer and can be translated into the development of new cervical cancer treatment strategies in the future.


This longitudinal cohort study investigates whether cumulative impact exposure is associated with oculomotor functioning in motorsport drivers from the INDYCAR professional open-wheel automobile racing series. Is cumulative impact exposure associated with oculomotor performance in professional motorsport drivers?In this longitudinal cohort study of 13 INDYCAR series drivers, there were no statistically significant associations between cumulative impact exposure and oculomotor performance.These findings reflect the relative stability of oculomotor performance despite exposure to the highest levels of cumulative impact conferred through multiple crashes over a 3-year period. Professional motorsport drivers are regularly exposed to biomechanical forces comparable with those experienced by contact and collision sport athletes, and little is known about the potential short-term and long-term neurologic sequelae.To determine whether cumulative impact exposure is associated with oculomotor functioning in motorsport drivers from the INDYCAR professional open-wheel automobile racing series.This is a longitudinal retrospective cohort study conducted across 3 racing seasons (2017-2019). Statistical analyses were conducted in November 2021. Data were retrieved from a secondary care setting associated with the INDYCAR series. INDYCAR series drivers who participated in 3 professional level racing seasons and were involved in at least 1 contact incident  in 2 of the 3 seasons were included in the study.Cumulative acceleration and deceleration forces and total contact incidents  measured via accident data recorder third generation chassis and ear accelerometers.Postseries oculomotor performance, including predictive saccades, vergence smooth pursuit, and optokinetic nystagmus, was measured annually with a head-mounted, clinical eye tracking system (Neurolign Dx 100).g  across 81 crashes. A 2-way multivariate analysis of variance did not reveal a statistically significant association between ear and chassis average resultant g forces, total number of contact incidents, and racing season assessed .Thirteen drivers  sustained median resultant acceleration forces of 38.15 In this cohort study of professional drivers from the INDYCAR series, there were no statistically significant associations among cumulative impact exposure, racing season assessed, and oculomotor performance. Longitudinal studies across racing seasons using multidimensional examination modalities  are critical to understand potential neurological and neurobehavioral sequelae and long-term consequences of cumulative impact exposure. This effort has been aided by medical and engineering innovations to improve driver safety.10 Compared with athletes engaged in contact and collision sports, motorsport drivers are exposed to high longitudinal and rotational forces as a function of event demands, even in the absence of a crash.13 Force exposure varies as a function of motorsport type, event class or series, terrain and race conditions , and/or crash event characteristics, including changes in velocity, peak acceleration, number of impacts, and vehicle dynamics.14 The combination of these factors results in a unique biomechanical force signature translated to drivers in a crash and is accumulated over time.10Efforts are under way to characterize neurobehavioral sequelae and long-term consequences of impact-related acceleration and deceleration and rotational force exposure in athletes across all levels and sports.15 Now with nearly 40 years of data since prevalence rates were first published, these early data from 1981 to 1984 have restricted generalizability and do not reflect current diagnostic criteria or innovations in engineering technology. Advances in vehicle safety mandated by the Fédération Internationale de l’Automobile (FIA), including the head and neck support device introduced by the INDYCAR series in 2003, safety harnesses, airbags, and improvements to track safety such as the energy-absorbing steel and foam energy reduction barrier developed by the INDYCAR series in 2002, have substantially reduced force translation to the driver and decreased impact-related injuries across the severity spectrum.19 Despite significant improvements in driver safety and the frequency of reported concussions in recent years, drivers are regularly exposed to unique biomechanical forces vs contact and collision sport athletes, and little is known about the potential short-term and long-term consequences of this exposure.Very few studies have examined the prevalence rate of concussion in professional motorsport. Limited data from the INDYCAR series from 1981 to 1984 indicated 13 reported concussions, defined as hospital admission for loss of consciousness.3 from the International Consensus Conference on Concussion in Sport emphasizes the importance of a multidimensional screening examination comprising symptom report, neurocognitive evaluation, physical examination, and vestibular assessment.20 Concussion protocols20 consistent with this international consensus statement3 have been adopted by all major governing sporting organizations, including the FIA. Leading the development and implementation of the motorsport concussion protocol, the INDYCAR series has developed policies and procedures for preseason baseline testing, trackside assessment, and return to racing. The INDYCAR protocol mandates that drivers are medically evaluated if head accelerations sustained during a contact incident exceed 80 g, with return to racing decisions informed by a range of objective and subjective measures comparing driver functioning to preseason baseline measures. Even with formalized procedures for concussion, concussion education, symptom recognition, and injury management, concussion symptoms are often underreported or unrecognized in athletes of all levels and across sports, including motorsport drivers, necessitating the use of objective tools to assess symptoms in the acute phase postinjury and to document cumulative exposure over the course of the racing season.24In the event of suspected concussion, the most recent statement26 Afferent and efferent visual pathways are widely distributed throughout the brain and appear to be particularly vulnerable to disruptions in neurotransmission arising from diffuse shear injury associated with concussive and subconcussive impacts.28 Postinjury visual dysfunction may include abnormalities in accommodation and convergence, saccadic and/or pursuit eye movements, pupillary light reflex, extraocular motility, and stereoacuity and may contribute to blurred vision, eye fatigue, and difficulty focusing.29 Characterizing postinjury visual disturbance has proven to be a challenge due to measurement limitations of many available tools. Vestibular oculomotor screening for vestibular ocular dysfunction via eye movement tracking and associated symptom provocation has demonstrated validity in distinguishing patients with and without concussion and is increasingly used by health care professionals in baseline and postinjury testing.33 Oculomotor devices may additionally provide enhanced sensitivity and specificity in identifying acute and chronic impairment through enhanced measurement and recording technology.37 Despite the importance of visual functioning in balancing safety and performance in the high stakes motorsport environment, to our knowledge, no published studies have explored the utility of oculomotor tracking devices with professional motorsport drivers.Oculomotor assessment has been indicated as an objective measure of concussion as part of a multidimensional evaluation. The purposes of this study were to (1) characterize cumulative impact exposure and (2) investigate the association between cumulative impact exposure and oculomotor functioning in a longitudinal cohort of professional INDYCAR series drivers. We hypothesized that greater impact exposure would be associated with less efficient oculomotor functioning over time.STROBE) reporting guideline for cohort studies. This study used a longitudinal retrospective cohort design with data retrieved from a secondary care setting associated with the INDYCAR professional open-wheel automobile racing series. Participants included professional drivers who participated in 3 professional racing seasons and were involved in at least 1 contact incident  in 2 of the 3 seasons between 2017 and 2019.This cohort study was reviewed and approved by INDYCAR Medical and was determined to be exempt from institutional review board or ethics committee review. All drivers provided broad consent to the data collection, data analysis, and data use. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology  at a sampling rate of 1000 Hz. Season-specific ADR-3 chassis and ear recordings and total contact incidents  from practice sessions, qualifying events, and races were used as indicators of cumulative impact exposure. Contact incidents were monitored in real time by INDYCAR Race Control and confirmed by review of ADR-3 data, crash damage inspection, and video by INDYCAR Accident Investigation personnel.All drivers in the INDYCAR series cohort were equipped with FIA homologated 8860 helmet from 2015 or newer as required by season-specific rules, a custom-fitted accelerometer placed in the ear canal with a 6-axis measurement, and a separate chassis accelerometer uniformly fixed to the floor of the chassis near the center of its mass. Each car in the series was outfitted with the same chassis and aerodynamic package. The INDYCAR series has used the Accident Data Recorder, third generation (ADR-3) data collection system for ear and chassis accelerometers since 2010. The ADR-3 was sourced from Delphi Motorsports and maintained in house by INDYCAR Safety Engineering. Events were recorded when sensors were triggered by a 5-39 To our knowledge, no studies have been published exploring the utility of the Neurolign Dx 100 device in a motorsport population. For this study, oculomotor performance data was extracted from subtests administered as part of the Neurolign Dx 100 battery, including predictive saccades , vergence smooth pursuit (eye correlation inward and outward), and optokinetic nystagmus (percentage of gain asymmetry).In preparation for the INDYCAR series annual opening each March, each driver in the INDYCAR series is required to undergo a preseason baseline physical and neurocognitive examination during scheduled dates in the preceding months (December or January). Since 2017, examination has included assessment of oculomotor functioning, vestibular functioning, and reaction time functioning using the Neurolign Dx 100 device, a portable, head-mounted display and eye-tracking system that is certified as a Nonsignificant Risk Device by the US Food and Drug Administration and approved for clinical use (21 CFR 882.1460). This device has demonstrated clinical utility in differentiating adults with concussion from healthy controls immediately after injury, with normalization of performance associated with symptom resolution and recovery in the subacute injury period.F tests, and statistical analyses were conducted using R statistical software version 4.1.2  and SPSS Statistics software version 27 (IBM). Statistical analyses were completed in November 2021.We first engaged in a detailed data examination of the distributions of ear and chassis accelerometer recordings. We then eliminated data points exceeding 2 SD from the mean to screen out potential noise at the higher end of the spectrum to avoid undue influence of statistical outliers on the results. To establish distinct grouping variables based on the distribution of extracted cumulative impact exposure, 2 cluster analyses were conducted to categorize (1) ear and chassis mean resultant acceleration or deceleration forces and (2) the total number of contact incidents. Finally, we conducted a 2-way multivariate analysis of variance to examine the association of cumulative impact exposure with changes in oculomotor performance over time. A total of 3 independent variables were included: the 2 grouping variables derived from the cluster analyses, the racing season assessed, and the interaction among the 3 variables. A total of 6 dependent variables were used to indicate changes in oculomotor performance, including relative differences on examination in 2018 and 2019 in comparison to 2017 baseline examination of predictive saccades, vergence smooth pursuit, and optokinetic nystagmus  across 81 crashes. Separate cluster analyses of cumulative impact exposure identified the following: (1) a 3-group solution for ear or chassis accelerometer recordings of mean resultant acceleration or deceleration forces  and (2) a 2-group solution for number of contact incidents . Cumulative impact exposure by driver is illustrated in the The initial data extraction included 19 drivers who were involved in a contact incident in 2 of the 3 seasons included in this study (2017-2019). After outliers based on series participation and accelerometer recordings were removed, a cohort of 13 male drivers was included in final analyses . Results indicated that drivers sustained median resultant acceleration forces of 38.15 F9,12 = 0.955; P = .54; Wilks Λ = 0.44). Simple analyses showed that no independent variables, including ear and chassis mean resultant acceleration and deceleration forces, total number of contact incidents, or racing season assessed, had statistically significant associations with changes in oculomotor performance in the 3-year study period.A 2-way multivariate analysis of variance did not reveal a statistically significant interaction between ear or chassis mean resultant acceleration or deceleration forces, total number of contact incidents, and racing season assessed  is critical to reduce the potential for catastrophic consequences and to prioritize driver safety for the entire racing field. Oculomotor examination may serve as an additional objective measure of neurological functioning sensitive to disruptions in neurotransmission in the event of an acute crash and could also be used when monitoring the cumulative impact of acceleration and deceleration force exposure over time. Just as engineering advances within the INDYCAR series and across the FIA have contributed to fewer catastrophic injuries, multidimensional examination of driver health in the acute, subacute, and long-term time points are critical components to maintaining driver safety.Given the high stakes associated with professional motorsport competition and the important role of oculomotor functioning in driver safety, objective evaluation with serial monitoring should remain a priority in the multidimensional examination of driver health. For drivers involved in crashes exceeding the specified gravitational force threshold, evaluation with reliable and valid multidimensional tools  to understand potential neurobehavioral sequelae and long-term consequences associated with cumulative impact exposure.Although the current study has several methodological strengths and is the first, to our knowledge, to explore sequelae associated with impact exposure in INDYCAR series drivers, it does have limitations. First, this study used longitudinal assessment of oculomotor functioning as the primary outcome. Focus on any 1 domain in the assessment of brain health will substantially limit sensitivity to the full range of potential sequelae associated with acute or cumulative impact exposure. The INDYCAR series protocol aligns with current international consensus statements and includes expert-informed multidimensional examination with reliable and valid tools composed of symptom report, neurocognitive evaluation, physical examination, vestibular assessment, and oculomotor functioning established each year during preseason baseline assessment and used in the trackside medical center in the event of a crash.48 Future studies should examine trends in oculomotor functioning in the acute, subacute, and long-term periods to determine whether professional motorsport drivers demonstrate comparable performance patterns. Third, consistent with limitations associated with a longitudinal design, this study is limited by driver attrition across racing seasons. We are currently conducting a companion study across 6 seasons that will address aspects of this limitation, because drivers not meeting current inclusion criteria  will be included in follow-up analyses within the expanded time frame.A second limitation of this study is the reliance on postseason testing, limiting sensitivity to possible acute and subacute vestibular ocular dysfunction that normalized over time, consistent with other studies in athlete populations from other sports.The findings of this cohort study of INDYCAR series drivers reflect the relative stability of oculomotor performance despite exposure to the highest levels of cumulative impact conferred through multiple crashes over a 3-year period. To our knowledge, this study is the first to explore neurological outcomes of impact exposure in a professional motorsport cohort. Longitudinal studies across racing seasons that combine multiple measurement modalities  are critical to characterize neurobehavioral sequelae and long-term consequences associated with the impact exposure unique to professional motorsport.