Conclusion: The findings underscore the importance of considering maternal cardiovascular health as a potential determinant of neonatal outcomes. Further research is needed to elucidate the underlying mechanisms and develop strategies for optimizing neonatal outcomes in high-risk pregnancies.Background: Cardiovascular diseases are a leading cause of mortality and morbidity worldwide. Pregnancy imposes unique physiological changes on a woman’s cardiovascular system. Materials and Methods: A cohort of 68 participants, comprising 30 pregnant women with cardiovascular risk and 38 without cardiovascular risk, was recruited for this study. These participants were prospectively followed during their pregnancies from 2020 to 2022 at the Obstetrics and Gynecology Department of the “Pius Brînzeu” Emergency County Clinical Hospital in Timişoara, Romania. All women included in this study underwent cesarean section deliveries at the same medical facility. Data regarding the gestational weeks at delivery, birth weight, and Apgar scores assessed by neonatologists were collected for each participant. Statistical analyses were performed to compare the neonatal effects between the two groups. Results: The results of this study revealed significant differences between the groups in terms of Apgar scores ( Women worldwide experience cardiovascular diseases as the primary reasons for illness and death, highlighting their significance in terms of morbidity and mortality. The physiological foundation of cardiovascular well-being differs between men and women, resulting in diverse cardiovascular reactions to stimuli and the manifestation of symptoms related to cardiovascular diseases. These variations directly impact the effectiveness of treatments and outcomes . PregnanThe neonatal period is a critical time for assessing the well-being and overall health of newborns. The Apgar score, developed by Dr. Virginia Apgar in the 1950s , is a wiWhile the Apgar score is routinely used to assess neonatal health, its association with maternal cardiovascular risk factors during pregnancy remains an area of active research . UnderstTherefore, this study aims to conduct a comparative analysis of neonatal effects in pregnant women with cardiovascular risk factors versus low-risk pregnant women. By evaluating the Apgar scores of newborns from both groups, we can gain insights into the potential impact of maternal cardiovascular risk factors on neonatal well-being.We hypothesize that pregnant women with cardiovascular risk factors will have infants with lower Apgar scores compared to low-risk pregnant women. This hypothesis is based on the premise that compromised maternal cardiovascular health may lead to suboptimal fetal development and neonatal outcomes .Maternal cardiovascular health plays a crucial role in fetal development and can influence the growth and overall health of the baby . SeveralHypertensive disorders of pregnancy, such as preeclampsia, can also impact birth weight . PreeclaMaternal cardiovascular health can also influence the duration of gestation and the risk of preterm birth . PretermIt is important to note that while there is a link between maternal cardiovascular risk and the number of gestational weeks, many other factors can also contribute to the length of a pregnancy. Proper management of cardiovascular health during pregnancy is crucial to minimize the risk of complications and ensure optimal gestational duration for the well-being of both the mother and the baby.This study aimed to compare neonatal effects in pregnant women with cardiovascular risk factors to those of low-risk pregnant women, focusing on Apgar score, birth weight, and delivery gestational weeks. The findings of this comparative analysis shed light on the potential impact of cardiovascular risk factors on neonatal outcomes, providing valuable insights for prenatal care and management.This study’s findings have the potential to contribute valuable information to clinical practice, assisting healthcare providers in identifying and managing high-risk pregnancies more effectively. Additionally, it may highlight the importance of addressing maternal cardiovascular risk factors to improve neonatal health outcomes.This study was conducted at the Department of Obstetrics and Gynecology in the ‘Pius Brinzeu’ County Emergency Clinical Hospital in Timisoara, Romania, spanning from 1 January 2020 to 31 December 2022. The research population and their relevant characteristics were identified using a population-based administrative database of patients who received outpatient care at the same hospital throughout the study period. The medical records of the patients were securely stored in a database that adhered to privacy laws; access to these records was obtained with the patients’ consent.The database contained comprehensive information, including demographic data, medical history, and the in-hospital procedures of the patients. The baseline characteristics and procedures of all patients were recorded both in the hospital database and in paper patient records, which were thoroughly reviewed by certified clinicians involved in this study. The implementation of an interconnected database that maintains patient information regardless of their location is of the utmost importance.For this study, we obtained ethical approval (No. 265/22 September 2022) from the management of the “Pius Brînzeu” County Emergency Hospital in Timișoara. This approval serves as a testament to our commitment to conducting the research in an ethical manner and ensures the protection of the participants’ rights and well-being throughout this study.By comparing the neonatal effects between these two groups, this study aims to shed light on the potential impact of cardiovascular risk factors on the well-being of newborns. The findings from this research may have significant implications for clinical practice and contribute to improving the care and management of pregnant women with cardiovascular risk factors, ultimately leading to better neonatal outcomes.○Women who have given birth in the second or third trimester of pregnancy;○Pregnant women over the age of 18;○Women who have received prenatal care and had regular check-ups throughout their pregnancy;○Women who have given their informed consent to be included in this study;○Having no record of a positive COVID-19 diagnosis within the past year.Inclusion criteria for this study:○Women with a previous history of substance abuse or alcohol dependency;○Women with a prior history of psychiatric disorders or mental health conditions;○Women with a previous medical history of thromboembolic disease or disorders affecting blood clotting;○Women who have been involved in alternative clinical trials or studies in the preceding 3 months;○Women who have experienced negative responses to blood collection or phlebotomy procedures in the past;○Women who are incapable or uninterested in providing informed consent to take part in this study;○Patients who have been diagnosed with infectious conditions, such as hepatitis B or C virus  and human immunodeficiency virus (HIV), as well as those who have acquired immunodeficiency syndrome (AIDS);○Patients with inadequately managed metabolic disorders;○Patients with inadequately managed endocrine disorders.This study excluded participants who met the following exclusion criteria:○Smoking history exceeding 5 years;○Presence of cardiovascular disease in the family;○Limited engagement in physical activity or leading a predominantly sedentary lifestyle;○Dietary pattern characterized by excessive consumption of saturated and trans fats, sodium, and added sugars, contributing to an overall unhealthy nutritional profile;○Sleep apnea/other sleep disorders;○Preexisting hypertension in pregnancy;○Pregnancy-induced hypertension;○Preeclampsia;○Eclampsia;○Low-density lipoprotein cholesterol over 190 mg/dL;○Total cholesterol over 280 mg/dL;○Triglycerides over 200 mg/dL.In the group of patients with cardiovascular risk or cardiovascular disease, the patients who met at least one of the following criteria were included:In Sleep disorders are an inclusive classification encompassing a range of irregularities that occur during sleep, such as snoring, obstructive sleep apnea (OSA), central sleep apnea (CSA), respiratory-related arousals, and hypoventilation .For each participant, we recorded the gestational weeks at the time of delivery, birth weight, and Apgar scores, as evaluated by the neonatologist.Based on gestational age, we identified patients who delivered preterm. According to the World Health Organization (WHO), preterm birth is defined as the delivery of a baby before completing 37 weeks of gestation or fewer than 259 days from the first date of a woman’s last menstrual period (LMP) . Based oThe data collected in this study were analyzed using GraphPad Prism (version 5). Prior to analysis, the data underwent screening for outliers, missing values, and normality. If necessary, variables were transformed or normalized to meet the assumptions of the statistical tests.t-tests. The t-test is a statistical technique commonly applied when dealing with small sample sizes to determine whether there is a significant difference between the means of two groups. By comparing the means of the two groups, the t-test determines whether the observed difference is statistically significant or simply a result of random chance.Descriptive statistics were utilized to provide an overview of the data, while group differences were evaluated using p-values lower than 0.05 were considered statistically significant. The results are reported as mean ± standard deviation (SD). The mean, also referred to as the average, is a statistical measure representing the central tendency of a dataset. It is calculated by summing all the values in the dataset and dividing the total by the number of values. The standard deviation is a statistical measure indicating the extent of variability or dispersion in a dataset. It provides information on the spread or variation of data points around the mean or average value. Graphs were generated using GraphPad Prism, with appropriate labeling and formatting to ensure a clear presentation.All statistical tests conducted were two-tailed and This study included a total of sixty-eight pregnant women who underwent delivery through cesarean section (C-section) at the same medical institution. A cesarean section is a surgical procedure in which a baby is delivered through an incision made in the mother’s abdomen and uterus. It is typically performed when a vaginal birth is not feasible or safe for either the mother or the baby.The participants were divided into two groups: Group 1 consisted of thirty-eight pregnant women without cardiovascular risk or cardiovascular disease; meanwhile, Group 2 included thirty pregnant women with cardiovascular risk or cardiovascular disease. In the context of this study, cardiovascular risk refers to the presence of risk factors or pre-existing conditions that increase the likelihood of developing cardiovascular disease during or after pregnancy.Since the age differences are not statistically significant, this study results are not influenced by age categories.For each variable, the following statistical measures are provided: minimum , 25th percentile , median , 75th percentile , maximum , mean , and standard deviation .p-value t-test: For the variable “Gestational weeks,” the p-value indicates the statistical significance of any observed differences between groups.In terms of those from Group 1, five patients gave birth prematurely and just two patients gave birth to infants with IUGR. Regarding those from Group 2, ten patients gave birth prematurely and six patients gave birth to infants with IUGR. These results are presented in The comparative analysis of neonatal effects in pregnant women with cardiovascular risk versus low-risk pregnant women provides valuable insights into the potential impact of cardiovascular health on neonatal outcomes. Our study aimed to evaluate and compare various neonatal parameters between these two groups.Offspring born to pregnant women with cardiovascular diseases or cardiovascular risks had elevated rates of neonatal complications. Increased risks of NACE  were independently linked to preeclampsia, significant adverse cardiac events, obstetric complications, and preexisting diabetes mellitus .The findings of this study demonstrated significant differences in neonatal outcomes between the two groups. Pregnant women with cardiovascular risk factors were more likely to experience adverse neonatal effects compared to low-risk pregnant women .In this study, we conducted a comparative analysis of the neonatal effects between pregnant women with cardiovascular risk factors and low-risk pregnant women. Our analysis focused on evaluating the Apgar scores, infant birth weight, and gestational weeks at delivery as important indicators of neonatal well-being.The Apgar score is a widely used tool to assess the overall health and well-being of newborns immediately after birth. It provides a quick assessment of the infant’s heart rate, respiratory effort, muscle tone, reflex irritability, and color . Our resAnother important aspect we investigated was infant birth weight. Birth weight is a critical factor in assessing the overall health and development of newborns. A higher incidence of neonatal mortality and negative outcomes among infants who survive is linked to lower birth weight . We obseFurthermore, we examined gestational weeks at delivery as a measure of fetal development and maturity. Premature birth can also be a contributing factor to hypertensive disorders during pregnancy. Preterm birth is associated with various adverse outcomes; understanding the potential influence of cardiovascular risk factors on gestational age is crucial. Approximately 75% of perinatal mortality is attributed to preterm births and these premature infants also experience more than half of the long-term morbidity. While the majority of preterm babies survive, they face higher risks of neurodevelopmental impairments, as well as respiratory and gastrointestinal complications .The association between cardiovascular risk factors and adverse neonatal outcomes can be attributed to various factors. Poor cardiovascular health in pregnant women may lead to compromised placental function , inadequOur study highlights the importance of early identification and management of cardiovascular risk factors during pregnancy. Healthcare providers should prioritize regular monitoring and appropriate interventions for pregnant women with pre-existing cardiovascular conditions or those at risk for developing cardiovascular complications. This may involve close collaboration between obstetricians, cardiologists, and other specialists to optimize maternal cardiovascular health and improve neonatal outcomes.The rationale for including only patients who underwent cesarean delivery in this article can be attributed to several factors.Firstly, cesarean delivery is a surgical procedure that allows for controlled and standardized conditions during childbirth. This ensures consistency in data collection and reduces potential confounding variables that may arise from the variability in vaginal deliveries.Secondly, the focus of this study appears to be on comparing the neonatal effects between pregnant women with cardiovascular risk and low-risk pregnant women. By restricting the sample to cesarean deliveries, the researchers can more effectively analyze and attribute any observed differences in neonatal outcomes to the underlying cardiovascular risk factor, independent of the mode of delivery.Furthermore, cesarean deliveries are often recommended or preferred in certain high-risk pregnancies, such as those with maternal cardiovascular conditions, to mitigate potential complications or risks associated with vaginal delivery. Thus, by including only cesarean deliveries, this study can specifically investigate the impact of cardiovascular risk on neonatal outcomes while minimizing confounding factors related to the mode of delivery.However, it is important to acknowledge that this selection criterion may limit the generalizability of the findings to populations where vaginal deliveries are more prevalent. Transparency regarding the rationale for the selection of cesarean deliveries in this study should be provided, along with a discussion of the potential implications and limitations of this approach in the interpretation of the results.One of the major strengths is that this study has a well-defined design, focusing on two distinct groups based on cardiovascular risk status. This allows for a direct comparison between the two groups and facilitates the examination of potential differences in neonatal outcomes.Another strength is that this study examines crucial neonatal outcomes, including Apgar scores, birth weight, and gestational weeks at delivery. These outcomes are widely recognized as essential indicators of neonatal health and well-being, ensuring this study’s relevance and clinical significance.By comparing neonatal outcomes between pregnant patients with and without cardiovascular risk factors, this study has the potential to provide valuable insights into the impact of cardiovascular risk on neonatal health. This information can contribute to improving prenatal care and management of pregnant women with cardiovascular risk.One of the limitations is that this study’s findings may not be generalizable to the entire population of pregnant women due to the potential for selection bias. This study was conducted in a single hospital, which may limit the diversity of the patient population and introduce biases related to the specific characteristics of the hospital’s patient population.Another limitation is that, despite efforts to match the two groups based on cardiovascular risk, there may be other confounding factors that were not adequately controlled for. Factors, such as socioeconomic status, ethnicity, or comorbidities, could impact neonatal outcomes but were not addressed in this study design.This study’s focus on immediate neonatal outcomes, such as Apgar scores, birth weight, and gestational weeks at delivery, may provide limited insights into the long-term effects of cardiovascular risk on neonatal health and development. Long-term follow-up studies would be necessary to comprehensively evaluate the impact of cardiovascular risk on outcomes beyond the immediate postnatal period.Further research is needed to explore the underlying mechanisms linking cardiovascular risk factors and adverse neonatal outcomes. Prospective studies with larger sample sizes and diverse populations would help confirm and expand upon our findings. Additionally, investigating the long-term implications of neonatal effects in these populations is warranted.The comparative analysis of neonatal effects in pregnant women with cardiovascular risk versus low-risk pregnant women reveals important implications for clinical practice and patient care. Our study demonstrates that pregnant women with cardiovascular risk factors are at a higher risk of adverse neonatal outcomes compared to low-risk pregnant women. These outcomes include preterm birth, lower Apgar scores, and increased rates of neonatal complications.The findings emphasize the need for proactive identification and the management of cardiovascular risk factors during pregnancy. Healthcare providers should prioritize regular monitoring and appropriate interventions to optimize maternal cardiovascular health and improve neonatal outcomes. This may involve multidisciplinary collaboration between obstetricians, cardiologists, and other specialists to ensure comprehensive care for high-risk pregnant women.It is important to mention that the presence of cardiovascular risk factors with a negative impact on pregnancy can also affect the mother’s physical well-being. Therefore, it is crucial to identify and properly treat these factors for optimal maternal health. The perinatal period, which encompasses pregnancy and the postpartum period, is a vulnerable time for women’s mental health. While postpartum depression has received significant attention, the association between personality dimensions, trait anxiety, and suicide ideation during the perinatal period remains relatively unexplored. Understanding the psychological factors contributing to suicide ideation in this specific population is crucial for identifying at-risk individuals and developing effective interventions .Further research is warranted to delve into the underlying mechanisms linking cardiovascular risk factors and adverse neonatal outcomes. Prospective studies with larger sample sizes and diverse populations will provide more robust evidence and enable the development of targeted interventions.In conclusion, this study underscores the importance of addressing cardiovascular risk factors in pregnant women to minimize adverse neonatal effects. By focusing on risk identification, monitoring, and intervention, healthcare professionals can improve the well-being and long-term outcomes of both mothers and their newborns.


The conventional methodology for appraising medical students has some limitations like inherent subjectivity, unstructured nature, and bias. Implementing the Objective Structured Clinical Examination (OSCE) can mitigate these shortcomings. However, the OSCE presents challenges, including substantial financial costs and time-intensive processes, particularly when assessing a large cohort of students. Consequently, an alternative assessment was needed to keep the advantages of OSCE and mask its limitations, especially in resource-constrained settings. In addition, many scholars have expressed concern over medical students' and interns' inadequate interviewing and physical examination competencies in recent years. Due to easy availability, videotaping is a convenient method for objectively observing students for aggregate review by faculty in order to ascertain what exactly faculty are assessing during medical student evaluations. This technique allows for aggregate faculty group improvement in the ability of educators to assess students' technical proficiency, data collection capabilities, standardized patient interaction demeanor, and strategies for fostering standardized patient comfort. Nonetheless, aggregate evaluation of videotape recordings for faculty assessment development or reliance on verbal feedback from medical students about faculty's ability to assess student skill is a matter of debate. Due to increased subspecialization, the subspecialist or specialist examiners face difficulties in assessing students' skills in specific and/or generalized domains. Despite these challenges, assessing the ability of faculty members' observation and subsequent evaluation of medical trainees remains a vital aspect of assessment throughout various specialties. This paper presents the concept of faculty members individually observing and rating premade recordings of standardized students performing clinical skills for evaluation so that when the individual faculty members' ratings are aggregated and summarized collectively for evaluation by the faculty members as a group, both the group and the individual faculty members will gain a greater understanding of what are appropriate ratings versus outlier ratings. The general concept of the traditional system of evaluating medical students could be criticized as being subjective, non-structured, and biased. These drawbacks would be avoided if the objective structured clinical examination (OSCE) was used. The OSCE, on the other hand, is expensive and time-consuming when examining a large number of students. Numerous authors have expressed concern regarding medical students' and interns' subpar interviewing and physical examination skills in recent years -5. EdelsIn a study by Fenton and O' Gorman, 60 final-year medical students were evaluated in psychiatry “using three methods: a multiple-choice questionnaire based on a series of short videotaped interviews with psychiatric patients, an examination of a traditional long 'case' with the presentation of the history, mental state findings, and formulation about diagnosis and management to a panel of three examiners; and a traditional oral examination about the principles and practice of psychiatry” . In anotThe most effective use of videotaped interviews is to show a variety of clinical situations that allow applicants to engage in debate and educated conjecture regarding the mental states being portrayed . “ObservThe Department of Radiodiagnosis and the Television Service at the University of Leeds  worked tIn a case study by Mitchell et al., which aimed to improve OSCE feedback through an analysis of student reflection on their recorded video performances, students were significantly better at self-assessing their clinical performance after viewing their videos of their OSCE stations in comparison to their self-assessment right after their performance -10. FurtWith the current focus on building an outcomes-based medical education system that increases trainee growth and patient safety, robust work-based evaluation systems are in considerable demand. Among the vast array of diagnostic tools, OSCE is one viable option. However, while objective structured clinical examinations have become the standard for evaluating clinical competence in a training setting, they are not applicable in all situations .Although OSCE is a widely used measure to assess the clinical skills of medical students, highlighting the importance of why educators should continue to research and develop enhancement methods for its grading, it also has many fundamental limitations. According to the international multi-center qualitative study conducted by Hyde et al., there are many concerns regarding the feasibility and accuracy of the OSCE from both the examiner and the examinee perspectives . Both paOn the other hand, the OSCE is an excellent tool for validating professional competence. It can also assess collective participants in the activity. Evaluating and assessing students' abilities and faculty members' abilities to evaluate and assess is critical to ensure fairness among all medical institutions. The OSCE can be a valuable tool for conducting these evaluations to guide their development and create a plan for improvements based on their weaknesses.As part of the educational relationship that responsible institutions must strive to achieve with their students, ensuring that passing requirements are fundamentally fair amongst medical schools is essential. Individually, evaluators are susceptible to “biases such as leniency, inconsistency, and the halo effect,” contributing to variability . For exaIdeally, there should be a unique, unbiased, and objective method of examination to assess the clinical skills of medical students. Student clinical examinations should be based on transparent, comparable criteria throughout medical institutions; however, examiner conduct, instruction, and other regional characteristics significantly contribute to differences in school performance . AssessoFor large-scale performance assessments in clinical education, it is crucial to ensure that examiners' judgments are consistent among groups of examiners to improve fairness and reassure the public. Standardization ensures the public that all graduates have met predetermined assessment requirements, a crucial element of the educational contract between students and institutions. Video-based Examiner Score Comparison and Adjustment (VESCA) employs video scoring to connect previously unconnected groups of examiners. This link allows for comparing the influence of various examiner groups within a shared frame of reference and the provision of modified "fair" results to students. Despite reliability, the examiner cohort experienced by students significantly influenced their scores, underlining the importance of adequate sampling and examiner training. VESCA's creation and validation may provide a method for measuring and adjusting for potential systematic disparities in scoring patterns between locations in dispersed or countrywide OSCE tests, ensuring comparability and fairness .A growing body of research demonstrates video technology's usage and efficacy in education. For example, the Best Foot Forward Project, a recent Harvard University Center for Education Policy Research study, investigated the use of video classroom observation technologies in the feedback process. According to their preliminary findings, there are various advantages to adopting video technology in the classroom . First, Second, videos improve classroom observation, self-efficacy, and agency. Educators have greater control over classroom observation when employing videos as a tool. Faculty member instructors would be unable to provide real-time in-person guidance without biasing or adversely affecting the assessment of a medical student's clinical skills performance. However, utilizing premade video recordings allows for faculty member instruction to avoid any possibility of biasing or adversely affecting an actual student's clinical skills performance in person.Third, video technology fosters reflective practice and self-assessment among educators. By providing an opportunity to review their own teaching methods and interactions with students, teachers can identify areas for improvement and implement necessary changes in their instructional approach. This self-assessment process fosters professional growth and encourages educators to become more deliberate and thoughtful practitioners.In the context of medical education and OSCE evaluations, video technology has the potential to significantly enhance the assessment process. Utilizing video recordings of student performances during OSCEs can help minimize examiner biases and increase inter-rater reliability. Furthermore, video-based assessments provide an opportunity for a more in-depth analysis of student performance, enabling evaluators to identify specific strengths and weaknesses that may not be apparent in traditional OSCE settings. This can lead to targeted feedback and individualized learning plans for medical students, ultimately improving their clinical competence and patient care.Additionally, incorporating video technology in OSCE evaluations can contribute to standardizing assessment criteria across institutions. By facilitating the exchange of videos between different medical schools, it is possible to establish a shared understanding of the expected performance levels and create a more equitable assessment system. This standardization ensures fairness for medical students and reassures the public and healthcare institutions that all graduates have demonstrated the clinical skills to provide high-quality patient care.In conclusion, the OSCE is a valuable tool for assessing medical students' clinical competence. However, recognizing its limitations and striving for continuous improvement by incorporating innovative methods and technologies, such as video-based assessments, is vital. These enhancements can help mitigate biases, increase inter-rater reliability, and promote standardization of assessment criteria across institutions, ultimately improving the quality of medical education and patient care outcomes. Furthermore, as the field of medical education evolves, it is essential to continue researching and developing best practices to ensure that future physicians are well-equipped to meet the challenges of an ever-changing healthcare landscape.The OSCE scores of students from various medical schools should not be directly compared without considering systematic differences. VESCA is a promising method for improving the validity and fairness of distributed OSCEs or national exams. Additionally, internet-based scoring could improve VESCA's viability. The development and validation of VESCA may provide a method for measuring and adjusting for potential systematic disparities in scoring patterns between locations in dispersed or national OSCE tests, hence maintaining parity. VESCA is a slowly growing tool that can enhance medical students' educational experience and training while providing a practical and easily controlled platform and allowing routine measurement of examiner-cohort effects in large-scale OSCE grading systems. Nonetheless, the medical community should continue discussing the quality of the scoring system to establish an equitable and standardized grading system to enhance medical education.


Directing our focus of attention appropriately during task execution can benefit outcome performance, cognitive efficiency, and physiological efficiency. For instance, individuals may benefit from adopting an external focus of attention  over an internal focus of attention . However, accounts concerning the theoretical functioning of such effects have primarily relied on hierarchical information processing perspectives; far less consideration has been given to potentially alternative explanations based on ecological dynamics, instances where an internal focus may be desirable over an external focus, and the associated applied implications. Within the present review, we: (a) outline the most recent developments in attentional focus research; (b) evaluate similarities and differences between information processing and ecological dynamics explanations of the focus of attention effect; (c) provide practical recommendations; and (d) discuss future research avenues. In doing so, a case is made for an “Ecological Dynamics Account of Attentional Focus” to act as an alternative to information processing-based hypotheses. Verbal instruction is one of the most common methods of conveying information to individuals when learning and performing motor skills. However, it is now well established that the language we use when providing instruction can influence the skill acquisition process, particularly in relation to whether it directs an individual's attention internally towards the body or externally towards the effect of one's movements on the environment . This phHowever, accounts concerning the theoretical mechanisms underpinning such effects have primarily relied on hierarchical information processing perspectives, whilst far less consideration has been given to alternative explanations based on ecological dynamics and the applied implications thereof. There remains debate in the skill acquisition field with regards to the extent to which end-uses of theory  should comprehend the theoretical underpinnings of skill learning so that they may best align practice decisions with their chosen perspective. Philosophically, if we adopt a “shed-building metaphor”: one belief is that if you build a shed in your garden, whether you believe the earth is flat or spherical, has little influence on the way in which the shed is built. However, there should be little doubt that for the best practice conditions to occur, coaches must be able to justify their decision making and articulate the rationale underpinning applied practice decisions. This has implications on coach education, where adequate skill acquisition and pedagogical training is arguably sporadic on a global scale .The present review aims to address these issues by providing greater clarity in relation to the fundamental theoretical principles underpinning differing perspectives that account for the focus of attention effect within skill learning/performance, and aim to address implications for applied practice. More specifically, the review will: (a) outline the most pertinent developments in the attentional focus literature; (b) evaluate similarities and differences between information processing and ecological dynamics explanations of the focus of attention effect; (c) provide practical recommendations and suggestions for coach education; and (d) discuss future research avenues. In doing so, a case is made for an Ecological Dynamics Account of Attentional Focus to act as an alternative to information processing-based hypotheses.When selecting appropriate external foci, some contexts require practitioners to decide between multiple alternatives. For example, a hockey coach choosing to direct attention towards the club vs. the ball, or a medical doctor choosing to attend to their scalpel vs. the target epidermis. This conundrum has led researchers to investigate “the distance effect”, whereby benefits of distal external foci  over proximal external foci  were first identified by McNevin et al. , on the Interestingly, the distance effect has also been considered in the context of an internal focus. Pelleck and Passmore  investigFindings from Pelleck and Passmore  suggest With focus relevance intricacies in mind, recent research has emphasized the complexities of selecting appropriate external foci for learning and performance. Mechanistic explanations underpinning the attentional focus phenomenon have tended to emphasize the role of an external focus to augment congruence between planning and action, and ultimately enhance automaticity of motor programming  or movement amplitude, somewhat removed from interactive psychological functioning (see 1 for a review). These linear methodologies have justifiably been adopted in the name of conserving methodological integrity and rigour. However, a more recent research direction has begun to embrace more holistic and non-linear methodologies, arguably more consistent with skill acquisition in practice. In this manner, Wulf and Lewthwaite's , 25 OPTIThe shift in research direction to investigate the attentional focus phenomenon more holistically, has also cemented a need to test in in more ecologically valid environments. Despite an extensive literature-base supporting the robustness of an external focus of attention to enhance a breadth of movement outcomes , the field has arguably failed to bridge the gulf between theory and practice. There remain significant discrepancies between what is advocated by empirical research and the language being observed from coaches and practitioners in the field . ResearcWhen investigated in more ecologically valid settings with athletes, Anderson et al.'s  findingsSimilarly to the complexities associated with ecological settings, the purpose of focus of attention prescription also appears to play an important role in determining optimal attentional foci. Toner and Moran  propose This notion of a facilitative somaesthetic awareness is also supported by Moore et al. , who invAccounts concerning the theoretical functioning of the attentional focus effect have arguably been skewed towards hierarchical information processing perspectives, wherein movement plans are purportedly stored in memory and transmitted to the limbs for execution . CognitiWulf et al.'s seminal  series oWulf and colleagues  tested tWulf and Lewthwaite , 25 haveEcological dynamics is underpinned by the interlinking of dynamical systems theory and ecological dynamics, focusing on the individual-environment relationship mediated through perception-action coupling –72. RathIndividuals' direct perception of the situational opportunities for action  in relation to their organismic, environmental, and task constraints, enables them to dynamically self-organise movement coordination into stable states , which achieve the desired goal. Consequently, an ecological dynamics framework features greater explanatory power than information processing accounts, with regards to individuals' functional adaptability within a world high in degrees of freedom , 73. ForFirstly, the action-effect principle of common coding  and the Secondly, the constrained action hypothesis  suggestsLastly, OPTIMAL theory of motor learning posits that adopting an external focus of attention in conjunction with an appropriate motivational climate  augments the “goal-action coupling” , 25. WitTo summarise the aforementioned sections, the Ecological Dynamics Account of Attentional Focus has three core tenets. Firstly, to facilitate optimal perception for action, the direction of the attentional focus needs to be congruent with task demands and their most relevant specifying information. Tasks guided by external environmental specifying information may exhibit superior self-organisation via an external focus on relevant aspects in the environment, while tasks guided by internal bodily specifying information may exhibit superior self-organisation via an internal focus on relevant aspects concerning the body. Secondly, utilisation of foci incongruent with task demands may result in the use of less relevant specifying information for natural self-organisation processes; this may result in reduced accuracy and physiological efficiency via misinformed attractor states, as well as reduced cognitive capacity via inefficient use of attention which needs to evaluate task-essential specifying information while also consciously monitoring less relevant specifying information derived from the adopted focus. Thirdly, it is possible to reinterpret the central “goal-action coupling” of OPTIMAL theory as the identification of appropriate specifying information from the structured energy comprising the world, to facilitate perception of detailed and relevant interactions between environmental, organismic, and task constraints. This reaffirms the impetus to select an attentional focus (organism constraint) in relation to environment and task constraints. Overall, the Ecological Dynamics Account of Attentional Focus assumes that attentional focus is not one size fits all, but dependent on its suitability when combined with the interacting constraints which influence perception for action; even intra-individually as performers continuously attune to perceptual information that specifies action. This links to the ecological mantra for coaching, helping the individual to define “where to look, not what to see” .per se, as suggested by Herrebroden  and then consider the context in relation to the motor skill , the relevance and proximity of possible foci (where appropriate) and the appropriateness of instructions altogether see .Whilst these practice decisions may well be underpinned by competing theoretical approaches, an applied solution can still be found. For example, the benefits of a proximal attentional focus for novices can be underpinned by theoretical components of constrained action hypothesis  as well The principles of a constraints-led approach can be used to guide practice design that supports an education of focus of attention toward task-relevant information. These principles being: (a) goal orientated practice with clear session intentions; (b) manipulation of constraints to afford exploration of opportunities for action; (c) representative learning design that includes perceptual information that will be available in performance; and (d) repetition without repetition, encouraging the development of adaptable and effective movement solutions.Although the fundamental principle of adopting an internal or external focus of attention is simple, there remain ample avenues for future research. Above all else, the presently proposed ecological dynamics-based mechanisms for focus of attention effects are conjecture. However, so are information processing-based explanations until it is understood whether underlying neurophysiological mechanisms resemble information processing or ecological dynamics , 99. OutAnother benefit of an ecological dynamics standpoint is its ability to account for results that are ill explained by common coding , constraWith regards to applied nuances, the ecological dynamics-based framework has demonstrated itself popular within talent development research for its pertinent emphasis of multivariable effects . It is Lastly, given doubts raised by recent research concerning an external focus’ ubiquitous superiority over an internal focus e.g., , 38, 43], 4338, 4Literature surrounding focus of attention has come a long way since the original conception of internal and external labels by Wulf et al. . This in


This report describes a novel adverse outcome pathway (AOP) on uncoupling of oxidative phosphorylation (OXPHOS) leading to growth inhibition via decreased adenosine triphosphate (ATP) pool and cell proliferation . Oxidative phosphorylation is a major metabolic process that produces the primary form of energy (ATP) supporting various biological functions. Uncoupling of OXPHOS is a widely recognized mode of action of many chemicals and is known to affect growth via different biological processes. Capturing these events in an AOP can greatly facilitate mechanistic understanding and hazard assessment of OXPHOS uncouplers and growth regulators in eukaryotes. The four proposed key events in this AOP are intentionally generalized to cover a wide range of organisms and stressors. Three out of four events can be measured using in vitro high-throughput bioassays, whereas for most organisms, growth inhibition can also be measured in a high-throughput format using standard in vivo toxicity test protocols. The key events and key event relationships in this AOP are further assessed for weight of evidence using evolved Bradford-Hill considerations. The overall confidence levels range from moderate to high with only a few uncertainties and inconsistencies. The chemical applicability domain of the AOP mainly contains protonophores uncouplers, which can be predicated using the quantitative structure-activity relationship (QSAR) approach and validated using in vitro high-throughput bioassays. The biological domain of the AOP basically covers all eukaryotes. The AOP described in this report is part of a larger AOP network linking uncoupling of OXPHOS to growth inhibition, and is considered highly relevant and applicable to both human health and ecological risk assessments. Oxidative phosphorylation mainly takes place in mitochondria, where a chain of redox reactions using reduced nicotinamide adenine dinucleotide (NADH) or flavin adenine dinucleotide  test guidelines, as well as in adverse outcome pathways AOPs; . Tissue,On the basis of the current knowledge, it is evident that a series of events mediated by OXPHOS uncouplers can be causally connected in an AOP network. In the present study, we elaborate on one of the AOPs in the network linking uncoupling of OXPHOS, ATP depletion, impaired cell proliferation, and growth inhibition.The motivation for developing this AOP originates from frequent observations of reduced mitochondrial membrane potential and ATP synthesis as common effects of environmental stressors . Capturing these events in an AOP can greatly facilitate mechanistic understanding and hazard assessment of relevant stressors. Several recent publications have also pointed out the need for including mitochondrial dysfunctions in the AOP framework see . AlthougWith the motivations and project support in place, a set of conceptual AOPs linking uncoupling of OXPHOS to growth inhibition was assembled and submitted to the AOP-Wiki (AOPs 263–268). These AOPs are considered highly relevant and applicable to both human health and ecological risk assessments. Whereas the AOP we present (AOP 263) represents an important part of a broader network, it is understood that other, intermediate, key events may also contribute to growth inhibition. For example, generation of mitochondrial reactive oxygen species (mtROS) and subsequent oxidative stress due to abnormal redox reactions, impaired lipid metabolism due to loss of energy homeostasis, and programmed cell death due to oxidative damage can all occur as a result of OXPHOS uncoupling. The proposed AOP network therefore considers various consequences of mitochondrial uncoupling as key events such as mtROS formation, DNA damage, protein oxidation, lipid peroxidation, and cell death. Detailed descriptions of the likely concurrent key events and their relationships to OXPHOS uncoupling and/or growth inhibition will be addressed elsewhere.Environ Toxicol Chem 2021;00:1–9.It should also be noted that growth inhibition is likely not the only adverse outcome following uncoupling of OXPHOS. Other types of uncoupler-mediated adverse effects, such as teratogenesis, reduced fertility, neurodegeneration, and cardiac diseases may also be considered when one is assembling information into a larger AOP network for mitochondrial dysfunction. Although the present study focuses on growth inhibition, that is just one of several potential adverse outcomes that may be linked to uncoupling of OXPHOS. Moreover, it is biologically plausible that population decline is a potential higher level adverse outcome linked to growth inhibition, but the relationship warrants further development for empirical support and is not included in the AOP we describe in the present study. The proposed AOP  links deThe four proposed key events were intentionally generalized to cover a wide range of organisms and stressors. The MIE “decrease, coupling of OXPHOS” is a lumped term representative of the main outcome of three initial actions of an uncoupler: binding of protons in the intermembrane space, transportation of protons across the inner mitochondrial membrane (uncoupling action), and dissipation of proton motive force. The first two actions are considered difficult to measure, whereas the third can be proportionally indicated by mitochondrial membrane potential, proton leak, and/or oxygen consumption rate. The three intermediate events are therefore considered as Key Event Components  to suppoThe first key event, “decrease, ATP pool,” represents the combined outcome of reduced mitochondrial ATP biosynthesis and increased ATP depletion due to various ATP-consuming processes. The available ATP pool can be easily quantified. In contrast, the ATP synthetic process is highly dynamic and thus more difficult to measure, even though it mechanistically serves as the bridge between uncoupling and decreased total ATP. The second key event, “decrease, cell proliferation,” is the outcome of a dynamic process integrating cell division, cell growth, and cell death. These processes taken together determine the rate of tissue and organismal growth. It is recognized that multiple biological events exist between KE1 and KE2 to regulate both cellular energy homeostasis and proliferation, with the AMPK–TOR cascade being key. However, the underlying pathways linking ATP abundance to cell proliferation have a high level of cross-talk with other pathways, and their responses may be difficult to measure and/or predict. In addition, there is a lack of understanding and supporting evidence for the more detailed molecular and biochemical events underpinning energetic control of cell proliferation in invertebrates and plants that are intended to be covered by this AOP. Thus, cell proliferation itself was viewed as the next practical check-point to include in the causal chain of biological events. The MIE, KE1, and KE2 can be measured using in vitro high-throughput screening bioassays . The advAs a whole, weight of evidence supporting an AOP is intended to provide scientific support that the sequence of key events outlined is causally related to one another. Evidence supporting causality was evaluated based on the evolved Bradford–Hill considerations . The strEvent 1446: Decrease, Coupling of OXPHOS) is considered high, because direct evidence was collected from multiple specifically designed studies showing simultaneous recovery of OXPHOS coupling  and ATP pool due to removal of the uncouplers  is considered high, as supported by direct evidence from a typical inhibition–rescue study showing restimulation of cell proliferation by ATP  is considered moderate, due to a lack of specifically designed studies to provide direct evidence. Several studies, however, have shown positive correlations between cell proliferation and growth  is considered high. The cellular ATP pool represents a balance between ATP synthesis and ATP consumption , the biological plausibility is considered high. Because ATP is essential for cell division and macromolecule biosynthesis . Because eukaryotic growth is mainly achieved by increasing the total cell number and volume  and a downstream key event (Event B) are: (1) Event A is impacted at a concentration/dose of stressor that is less than or equal to that which impacts Event B (dose–response concordance); (2) Event A occurs before Event B is observed ; and (3) Event A is observed in a proportion of the sample population equal to or greater than that in which Event B is observed  is considered high, because good incidence . Temporal and incidence concordance have been shown by several studies . There is, however, one study partially showing temporal concordance between reduced cell proliferation and zebrafish embryo growth  is considered high, because multiple mathematical models describing the quantitative relationships between uncoupling of OXPHOS and ATP synthesis in vertebrates have been developed  was considered moderate. The quantitative relationships between total ATP and cell proliferation have been extensively investigated  is also considered moderate. Multiple mathematical models describing the quantitative relationships between cell proliferation and tissue growth exist for both animals  that is common for almost all living organisms (including humans). Although the reported effect concentrations/doses to trigger the key events are relatively high , these were mostly derived from acute tests. It has been suggested by Danio rerio), human (Homo sapiens), rat (Rattus norvegicus), mouse (Mus musculus), and common duckweed (Lemna minor). Because the key events are highly generalized and linked to common biological processes in eukaryotes, the taxonomic applicability domain can likely cover most animals, plants, and algae. The AOP is in general considered sex-unspecific, because the key events are equally relevant for both males and females. The response patterns of the key events, however, can vary dramatically between males and females (see The empirical evidence  suggestsales see . AlthougA variety of in silico and in vitro methods have been used to identify chemicals likely to act as uncouplers of oxidative phosphorylation (see SI1SI2


Working memory (WM), a core cognitive function, enables the temporary holding and manipulation of information in mind to support ongoing behavior. Neurophysiological recordings conducted in nonhuman primates have revealed neural correlates of this process in a network of higher-order cortical regions, particularly the prefrontal cortex (PFC). Here, we review the circuit mechanisms and functional importance of WM-related activity in these areas. Recent neurophysiological data indicates that the absence of these neural correlates at different stages of WM is accompanied by distinct behavioral deficits, which are characteristic of various disease states/normal aging and which we review here. Finally, we discuss emerging evidence of electrical stimulation ameliorating these WM deficits in both humans and non-human primates. These results are important for a basic understanding of the neural mechanisms supporting WM, as well as for translational efforts to developing therapies capable of enhancing healthy WM ability or restoring WM from dysfunction. This faImpairments of this critical ability, frequently observed in nervous system diseases and during aging, are behaviorally debilitating. WM deficits affect various cognitive functions, including learning , planninFor clarity, we begin with an explicit definition of WM: when we use the term WM, we refer to a system that actively maintains or manipulates internally held representations of information and uses them to support ongoing behavior , 2020. IThe neuroscience of WM began with studies of functional localization—identifying which regions of the brain are important for maintaining and manipulating information in mind. Central to these efforts was the development of the delayed-response task paradigm, a behavioral assay of WM in which subjects are presented briefly with a stimulus and, after a short delay, required to generate a response contingent on the memory of that stimulus. Much of the evidence obtained by early studies using these delayed-response tasks implicated the prefrontal cortex as a critical node for WM: lesions to the PFC impaired humans’ and monkeys’ ability to successfully execute appropriate responses after the delay , and sinThese paradigms for studying WM benefited further from importing approaches from sensory neurophysiology–systematic manipulation of sensory features of the stimuli to be held in mind. Goldman-Rakic and others applied this methodology to the study of WM by manipulating the spatial locations of task stimuli; their results confirmed and extended earlier findings supporting PFC as a critical node for WM because they found that some PFC neurons’ activity was not just elevated during the delay, but elevated in a manner specific to the spatial location of the remembered stimulus . Follow-Despite the observation of memory-specific delay activity localized to PFC and posterior parietal cortex (PPC), interpreting such activity as the substrate of WM information contents suffers from a uniqueness problem: the converse implication (that other areas are not the substrate of information maintenance in WM) is difficult to adjudicate in the absence of whole-brain activity measurements and cannot accommodate a role for subthreshold, non-spiking, mechanisms in information maintenance. These concerns have prompted the development of new theoretical models of WM as a process distributed across several brain regions rather than one localized to the frontal or parietal lobes in particular. Although they differ in their details, these models tend to feature PFC as maintaining and broadcasting executive signals that bias activity in other brain regions, which function approximately as buffers for fine-grained representations of mnemonic content . OverallWhether elevated delay activity in PFC serves to maintain or to control information held in mind, understanding how it arises remains an open challenge in the neuroscience of WM. A combination of theory and experimentation has identified several key elements of the mechanism: biological processes with relatively long-time constants decouple PFC activity from the offset of sensory stimuli by driving reverberant spiking in recurrently connected neuronal circuits of the PFC. This class of long-time-constant processes includes the activation of NMDA receptors by prolonged elevated presynaptic activity , activitThese molecular mechanisms are complemented by circuit interactions, both within and outside the PFC, that sustain delay activity. The basic conceptual model holds that the presentation of a stimulus to be remembered triggers an initial excitatory drive that kindles activity in a subnetwork of PFC neurons, where the identity of the subnetwork reflects the identity of the stimulus . After tEarly neurophysiological research on nonhuman primates demonstrated that neurons in the PFC not only responded to sensory stimuli, but also remained active after the stimuli were no longer present. This research provided evidence that a neural correlate of WM was “persistent activity” . SubsequSpatial information representation in WM is a longstanding topic of study in systems and cognitive neuroscience. Visuospatial WM has been the focus of pioneering research because the spatial locations of sensory stimuli can be parametrically manipulated and thus allow for systematic measurement of corresponding neural activity. Classic visuospatial WM tasks, such as the oculomotor delayed-response task (ODR), provide an excellent platform for investigating WM’s neural mechanism . NeurophComputational studies considering mechanisms of persistent activity have played a significant role in advancing our understanding of the neural mechanisms underlying spatial WM. Biophysically realistic models have been developed to simulate persistent activity through a population of neurons with similar spatial tuning properties, in which activity reverberates . Such neEarlier WM studies primarily focused on the representation of spatial information, while more recent research has expanded to include a broader range of information, such as stimulus features and internal state variables. Several reports find persistent activity in PFC that represents various sensory features during WM, including objects and natural images , luminanHowever, whether persistent activity encoding the information held in mind is sufficient for WM representations remains unresolved. A recent debate  has suggThe same kind of experimental paradigm and measurement that identified persistent activity as neural substrate of WM also yielded an important addition to the understanding of WM mechanism: oscillations in the local field potential (LFP) in PFC . The encOur understanding of LFP oscillations’ role in controlling WM is still in its infancy and there are several concerns regarding the current understanding of how LFP rhythms underlies and modulates WM. Rhythmic models often focus on oscillatory activity which is postulated to gate access to WM and clear out WM information after use , but theAnother observation is that the frequency range associated with gamma bursting has varied in different studies, with reported ranges including 50–120 Hz , 30–80 aImportantly, persistent spiking activity and LFP oscillations may reflect similar aspects of WM. For instance, the magnitude of persistent activity during the delay period of a WM task increased monotonically as a function of number of remembered stimuli during the delay period . CorrespMechanisms that do not rely on sustained encoding via spiking, in particular short-term synaptic plasticity (STP), have also begun to emerge as complementary mechanisms for maintaining information in short term memory. STP belongs to a class of activity-inducible processes that modify synaptic, and by extension, neural circuits’ I/O properties over timescales of several seconds. During STP, this is thought to reflect presynaptic calcium accumulation due to vigorous spiking activity, which can lead to a temporary but slowly-decaying facilitation or depression of release. The post-synaptic effect of spiking in a pre-synaptic cell undergoing STP is therefore history-dependent, reflecting both ongoing membrane potential changes and the recent history of presynaptic calcium entry. In cells with stimulus-specific spiking during WM encoding, this buffering will be stimulus-specific, as will the eventual post-synaptic effect. Through this basic logic, laid out initially by Information maintenance has also been shown to correspond with neural codes that are dynamic and do not involve changes in mean firing rate, in addition to more traditional sustained codes —particulWorking memory performance can be influenced by a multitude of factors such as aging , side efThere is ample evidence that WM performance declines with age . CompareAlthough there is evidence that WM performance declines with age, studies in nonhuman primates have shown that the number of neurons in area 46 does not significantly change with age . TherefoSeveral electrophysiological and pharmacological studies have shown that aging alters the physiological properties of PFC neurons during WM tasks in aged monkeys . NeurophWM can be adversely affected by certain medications commonly prescribed to treat behavioral disorders or used as dissociative anesthetics. Benzodiazepines, one of the most widely prescribed medications for anxiety disorders, can lead to various negative effects, including impairments in WM . SimilarBenzodiazepines, gamma-aminobutyric acid (GABA) receptor agonists, are a class of psychoactive drugs that are commonly prescribed to treat anxiety, insomnia, and other related disorders . While bKetamine, a dissociative anesthetic that has been used for decades in clinical settings to induce anesthesia and sedation, has also gained interest as a rapid-acting antidepressant for treatment-resistant depression . While kIn addition to acute effects, chronic ketamine use has also been associated with WM deficits. A study in rats found that chronic ketamine administration reduced the number of NMDA receptors in the prefrontal cortex . This reWorking memory impairments are also prevalent in clinical cases of multiple neurodegenerative disorders. Common neurodegenerative diseases such as Alzheimer’s disease (AD) and Parkinson’s disease (PD) are shown to result in WM deficits, and the related symptoms of WM deficits are crucial for early diagnosis of these disorders. Studies relating these diseases’ pathology to this executive dysfunction have also shed light on how mechanisms like oscillatory patterns or persistent activity are involved in WM processes.Memory loss is a key feature of Alzheimer’s disease, and deficits in working memory can be presented in the preclinical or early stages of AD . LongituMoreover, a multimodal study that tracked AD biomarkers with PET imaging while recording MEG signals from patients found that increased tau accumulation and global cognitive deficits were correlated with reduced resting-state synchrony in the alpha band . SynchroIn Parkinson’s disease, patients also exhibit cognitive impairments in addition to its widely known motor symptoms. Individuals with PD show deficits across visuospatial working memory tests that manifest even in early disease states . Since PAs discussed so far, research from multiple domains has given important insight into the neural mechanisms underlying WM, and has identified factors that can contribute to impairment of WM. Recent work has also started to identify approaches for enhancing, and potentially restoring, WM through both invasive and non-invasive means .In recent years, functional neuromodulation has offered therapeutic benefits through deep brain stimulation (DBS) for a variety of neurological and psychiatric disorders. DBS offers the potential to stimulate or suppress the functioning of neural populations within a radius of a stimulating electrode. Electrode leads are implanted in the target neuronal structure, electrical pulses are applied to modulate neural responses near the lead and alter the neuronal activity to rectify abnormal neural function. DBS has been accepted as an invasive procedure for alleviating cognitive deficits in patients with Parkinson’s disease  and AlzhSimilar results have been reported in DBS research in non-human primates, where a series of studies targeted the nucleus basalis (NB) of Meynert, a key structure associated with attention control and arousal—two key functions for learning and memory . The resEmerging non-invasive stimulation techniques provide a safer and more adaptable tool than invasive stimulation in both research and clinical settings. Non-invasive brain stimulation refers to a group of techniques that can modulate brain activity without the need for invasive procedures such as surgery and they are becoming an increasingly common tool to study and treat a range of neurological and psychiatric disorders. These techniques include transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), and transcranial alternating current stimulation (tACS), and they have been shown to be effective tools to enhance cognitive functions . For insThese promising findings suggest the potential for non-pharmacological and non-invasive interventions to effectively treat cognitive decline affecting WM. However, it is important to note that specific location and frequency combinations of the stimulation are critical for achieving optimal effects on WM improvement. Previous studies have shown that both theta and gamma frequency rhythms contribute to WM function , but gamThis review provides a summary of recent research, debates, and insights into mechanisms underlying the maintenance and manipulation of information in WM. Together, this recent work suggests that although WM relies on a broad, distributed brain network, the unique cellular and circuit organization of the prefrontal cortex is crucial for WM. Current theories of persistent activity models, rhythmic models, and activity silent models offer potential mechanistic explanations of WM, with each model replicating some of the neurophysiological findings from research in humans and animal models. While WM is essential for many cognitive functions, several factors can impair WM performance. However, advancements in brain stimulation techniques have shown promise in improving WM performance in patients with cognitive decline. Brain stimulation interventions not only improve WM performance during the intervention period or a short period after the intervention, but also show promise for providing long-lasting WM improvement for days or even weeks after the intervention.Many questions remain unanswered regarding the mechanisms underlying WM, and regarding the effectiveness of brain stimulation techniques in improving WM. Firstly, there is ample neurophysiological evidence supporting the role of persistent neural activity as a key component for mediating WM in range of behavioral tasks—particular tasks involving spatial memory and manipulation of remembered information. However, it is necessary to more thoroughly test for the generality of persistent activity in different subtypes of WM . Secondly, the rhythmic model suggests that gamma bursts are coupled with the representation of WM, and beta bursts are associated with the suppression of informative spiking. However, it still lacks evidence of how modulation of different frequencies of WM-related oscillations affects behavioral outputs in a WM task. Moreover, there are conflicting results of what frequency ranges these different phases of oscillations cover across various studies, emphasizing the need for a deeper understanding of the roles of different oscillations in WM, rather than in a specific WM task. Thirdly, the activity silent model proposes that the representation of WM information can be maintained even without elevated populational activity through transient changes in synaptic weights or neuronal excitability, rather than actively maintaining WM information with persistently elevated spiking. While these models may appear to conflict with one-other, they actually provide complementary insights into different aspects of WM function. Recent studies have even shown that both persistent activity and activity-silent dynamics can coexist and switch actively during the same WM task, highlighting the need for a better understanding of how these different dynamics contribute to overall WM functionality . Lastly,SL conceived of and organized the article. SL, MR, SC, and SD wrote the initial draft. All authors contributed to the article and approved the submitted version.


Editorial on the Research TopicAortopathy in congenital heart diseaseAortopathies may be syndromic like in Marfan syndrome (MFS), non-syndromic or associated with congenital heart diseases (CHD) such as coarctation of the aorta (CoA) or bicuspid aortic valve (BAV) , 2. The 1.Soto-Navarrete et al. demonstrated in a hamster model, that the genetic background may be a better predictor of aortopathy than the presence or absence of a BAV itself. The authors found that aortic diameter, smooth muscle apoptosis, elastic waviness, and Tgf-β and Fbn-2 expression were significantly increased in T strain animals  compared to controls—irrespective of whether the aortic valve was bicuspid or tricuspid. The authors conclude that patients with the same genetic defect but differing valve morphology may carry the same risk for developing bicuspid aortopathy.2.Robertson et al. found that patients with Loeys-Dietz syndrome and non-syndromal heritable aortopathies are often diagnosed late and have a higher risk of initial presentation with aortic dissection, when compared to MFS. At 10 years follow-up though, actuarial mean survival was not significantly different between different types of congenital aortopathies, highlighting the importance of structured aortopathy follow-up programs and preventive measures.3.Grewal et al. described important similarities in the pathogenesis of thoracic aortic aneurysms in BAV and MFS, e.g., the intima was thinner in both BAV and MFS patients compared to controls. The authors suggest that common mechanisms should be further investigated in an effort to personalize treatment strategies.4.Dolmaci et al. evaluated coronary arteries of a total of 90 patients with MFS, BAV and controls. They found that MFS had fewer typical cardiovascular risk factors than BAV and controls. Importantly, the prevalence of obstructive coronary sclerosis was significantly lower in MFS and BAV patients compared to controls. These findings provide a clinical correlation to above described molecular biologic findings by Grewal et al.5.Verheijen et al. presented an example of successful percutaneous management of an adult with an unusual presentation of CoA.Lastly, The articles in this research topic illustrate that understanding aortopathies at various levels is an important first step to personalized medicine, leading ultimately to improved outcome. Aortopathies should be viewed in the context of traditional cardiovascular risk factors and their effect on outcome in this patient population. The data so far is scarce though, which is why we are taking this opportunity to briefly review data on arterial stiffness and acquired cardiovascular risk factors in congenital aortopathies and CHD—and how these are related to outcome. We hope that this may stimulate further research in this area:The articles included in this research topic cover a wide range of specialties within the area, ranging from molecular genetics and immunohistochemistry to clinical analyses of outcome and a case report. Briefly, the following key findings are presented in this issue:In young and healthy people, the aorta has a well-functioning Windkessel effect. Thereby, pulsatile blood flow is transformed into a steady flow supplying peripheral tissues, which enables a steady blood supply of the organs (esp. coronary arteries), reduces cardiac afterload and reduces pulsatile stress on the distal vasculature , 4. ArteArterial stiffness is a well-known predictor of cardiovascular morbidity and mortality in the general population . It has The most well studied congenital lesions in the field of arterial stiffness are BAV, CoA, and MFS—all of which are associated with intrinsic aortic wall abnormalities that extend beyond the actual anatomic lesion of aortic dilation vs. narrowing , 9. OverGrewal et al.). However, other features of cardiovascular ageing differed between the BAV and MFS in this study . Interestingly, there is also evidence that the risk for obstructive coronary atherosclerosis is decreased rather than increased in both MFS and BAV patients alike, supporting the above functional, structural and histologic findings .Aortic stiffening (and often dilation) in these groups starts during childhood and progresses with age. While MFS patients have general aortic stiffening together with thinning of the common carotid intima-media, this is not seen in BAV patients who have proximally increased aortic stiffness and pulse wave reflection –16. SimiLinking outcome to micro- and macro scalar arterial characteristics in CHD patients with aortopathies would be an important step to personalized medicine. Ultimately, longitudinal follow-up will be crucial in determining changes in arterial stiffness, central blood pressure and diastolic function over time and in response to changes in medical management.Survival of patients with MFS has increased throughout the last few decades , 18. LikAmong CoA patients, e.g., the risk for acquired cardiovascular risk factors appears particularly high , 22. MorTo date, many aortopathy patients are still restriced from exercise, even though the European Society of Cardiology (ESC) has published exercise recommendations specific for the type of underlying aortopathy and degree of aortic dilation . In factThus, over the last 50 years, the focus has shifted from improving early survival to optimizing long term outcome. Minimizing acquired cardiovascular risk factors plays an increasing role in the counseling of patients with CHD associated aortopathies.Aortopathies in CHD and genetic aortopathies are heterogeneous with variable mechanisms for increased arterial stiffness and varying risks for aortic complications. What all aortopathy patients have in common though is that they are exposed to increased arterial stiffness for a life-time—as opposed to the typical patient with acquired cardiovascular disease. The combination of a congenital aortopathy and acquired cardiovascular risk factors may be a particularly risky combination. Further research is needed to identify personalized treatment strategies for patients with aortopathies, taking into account their individual risk factors. Perhaps most importantly, we as medical professionals need to focus more on minimizing additional cardiovascular risk factors from an early age by encouraging a healthy lifestyle and exercise.


Cryopreservation is a popular and crucial method for long-term storage of cells, tissues, and other biological samples at low temperatures. During this process, the cells are in a state of “suspended animation” to inhibit biological and chemical reactions . RecentlBesides the toxicity of DMSO, commonly used convective rewarming can lead to ice recrystallization and devitrification because of its slow rewarming rates . Also, uTo solve the problems discussed above, advanced cryopreservation technologies must be employed. Initially, impermeable CPA is widely used in cryopreserving biological samples such as oocytes and red blood cells due to its non-toxicity, high efficiency, and stability . HoweverOn the one hand, trehalose has the ability to form hydrogen bonds with biomacromolecules and promote hydration, enabling cell components to maintain functional conformations. It can also slow metabolic activity by forming glassy substrates with extremely low molecular mobility . On the T) was synthesized as a natural antifreezing glycopolypeptide (AFGP). It can be used as a carrier for trehalose delivery while also mimicking a CPA to inhibit ice recrystallization and protecting cells (Endocytosis is one of the mechanisms by which nanoparticles (NPs) can deliver trehalose into cells . For insng cells .Membrane perturbation is another method to deliver impermeable CPAs into cells. The effectiveness of this approach has been demonstrated by the delivery of AFPIII via the location of cell-penetrating peptide pep-1 . In non-Convective rewarming, which means immersing biological samples in a water bath heated to 37°C, is still considered the gold standard for rewarming . HoweverNéel and Brownian relaxations caused by magnetic moment oscillation can induce the thermal effect of magnetic nanoparticle under an alternating magnetic field (AMF) . TherefoGold nanorods and carbon black micron-sized particles have also been utilized in rewarming methods to achieve photoresponsive inducing heating . Laser vCurrently, the removal of DMSO from biological samples still relies on manual centrifugation, which requires skilled operators to remove the supernatant and replace it with a washing solution . HoweverThe hollow fiber module with semi-permeable membrane uses the pressure and concentration difference between the cell membrane and the fiber membrane to remove CPA from cells. This technique can also be scaled up for large cryopreserved cell suspensions . Dual-flWith the advancement of modern biotechnology, conventional cryopreservation obviously failed to keep pace with current needs. This review generalized the recent advances of delivery, warming and washing methods used in cryopreservation. Delivery methods helped to overcome the major limitation of the ultra-low permeability of impermeable CPAs, enabling their intracellular and extracellular cryopreservation. The use of novel warming methods can achieve rapid and even rewarming while avoiding the adverse effects of devitrification on biological samples. The emergence of various washing methods created a novel platform for convenient and efficient CPA removal. It must be noted that all the novel methods for cryopreservation have not been widely used neither in laboratory nor in clinic due to the high cost and complex operation protocol. Future studies need to focus on making new methods less difficult to perform without reducing their effectiveness, so that they can be applied by more researchers.


The gut microbiome provides the host access to otherwise indigestible nutrients, which are often further metabolized by the microbiome into bioactive components. The gut microbiome can also shift the balance of host-produced compounds, which may alter host health. One precursor to bioactive metabolites is the essential aromatic amino acid tryptophan. Tryptophan is mostly shunted into the kynurenine pathway but is also the primary metabolite for serotonin production and the bacterial indole pathway. Balance between tryptophan-derived bioactive metabolites is crucial for neurological homeostasis and metabolic imbalance can trigger or exacerbate neurological diseases. Alzheimer’s, depression, and schizophrenia have been linked to diverging levels of tryptophan-derived anthranilic, kynurenic, and quinolinic acid. Anthranilic acid from collective microbiome metabolism plays a complex but important role in systemic host health. Although anthranilic acid and its metabolic products are of great importance for host–microbe interaction in neurological health, literature examining the mechanistic relationships between microbial production, host regulation, and neurological diseases is scarce and at times conflicting. This narrative review provides an overview of the current understanding of anthranilic acid’s role in neurological health and disease, with particular focus on the contribution of the gut microbiome, the gut–brain axis, and the involvement of the three major tryptophan pathways. The metabolome, small molecules produced by the collective metabolism of an organism and its microbiome, is difficult to comprehensively examine, in large part due to the sheer complexity of the interaction between the microbiome and the host metabolic state. This difficulty is especially pronounced in the human gut, where extensive overlap between small molecule metabolism of the host and microbiome exists . DespiteBacteroides and Prevotella, that aid in the synthesis of micronutrients, like vitamin K2 and B12 . TStudies that focus on the production of anthranilic acid by gut microbiota many times rely on a more universal approach to this analysis, highlighting the production in the gut by broad functional groupings and not by a specific taxon. The difficulty of teasing apart microbes and their metabolic products in the gut is in large part due to the complex interactions between microbes and the present diversity , which iPsuedomonas can produce multiple components of the kynurenine pathway [P. aeruginosa produces anthranilate and then uses it as a precursor to several virulence factors [Burkholderia fungorum, Bacillus cereus, Ralstonia solanacearum, and Ralstonia metallidurans were found to encode for all three anthranilate-related enzymes [Prevotella UCG-003 was revealed to be the most strongly correlated microbe with this cold stress-induced increase in anthranilic acid [The ability to produce anthranilic acid or other Trp-related neuroactive metabolites may be species specific. Metabolic production is also context specific, as the host dietary intake and the resulting concentrations of these shared metabolic products shifts the equilibrium for both microbe and host. Human pathogen  pathway . More re factors . Kurnaso factors . Among o enzymes . Another enzymes . Prevotelic acid . It is wResearch on the mechanistic role of anthranilic acid in neurological diseases has been limited up until now. Many studies focus primarily on the use of anthranilic acid and its derivatives as biomarkers , but do E. coli, some Bacillus species, Klebsiella pneuomoniae, and Staphylococcus aureus, have been reported to produce dopamine from tyrosine [Anthranilic acid is often seen as part of the neurotoxic branch of the kynurenine pathway, a branch that includes quinolinic acid and hydroxykynurenine ,188. Eletyrosine . Though tyrosine . The intBeyond schizophrenia, other neurological conditions  have been correlated to the levels of circulating anthranilic acid. A study on chronic migraines in humans tracked the serum levels of multiple kynurenine metabolites and found a 339% increase in the concentration of anthranilic acid in those suffering from chronic migraines . In tandEvaluation of depression’s metabolic roots has indicated that there are correlating Trp metabolite concentrations. In one study on circulating anthranilic acid in patients diagnosed with depression, anthranilic acid was found to be inversely correlated to the severity of depression, though this finding was dependent on sex . As was Contrasting to predicted neurotoxic properties, studies have suggested that anthranilic acid derivatives may have neuroprotective bioactivity ,185. DecResearch on Trp metabolites and their relation to neurological outcomes is ongoing and has resulted in an abundance of broad descriptive studies for Trp compound relationships in patients with neurological symptoms. Though examples have been identified for strong correlations between anthranilic acid and multiple disease states, not all neurological conditions are showing the same trend. Studies on multiple sclerosis in children and Huntington’s disease showed no or weak correlations with anthranilic acid ,205. A rThe key to understanding this apparent paradox between neuroprotective and neurotoxic activity may be in part due to those metabolic pathways which are not linear. These pathways are dynamic networks with many forces directing the movement of metabolism between the arms of complex interconnecting routes and shunts. Anthranilic acid alters the availability of its own primary precursor, kynurenine, and in so doing changes the compound equilibrium. Anthranilic acid is an inhibitor of 3-hydroxyanthranilic acid oxidase (3-HAO) enzymatic activity, the inhibition of which results in decreased production of quinolinic and picolinic acid from 3-hydroxyantranilic acid . Iron isIn pharmaceutical applications, anthranilic acid and related compounds have exhibited anti-inflammatory properties ,207. In Anthranilic acid, along with its related compounds, cannot be considered singularly neuroprotective or neurotoxic. Perhaps these Trp-related metabolites should be considered more broadly as neuroactive, leaving space for the host context as a driver of ultimate effect relative to the local niche conditions. In the context of human studies, the directionality of metabolic levels cannot be fully assessed. One study reported that increased 3-hydroxyanthranilic acid levels, along with decreased anthranilic acid, were correlated with more beneficial clinic outcomes in stroke patients . MeasureMetabolic activity is a balancing act between different metabolic routes rather than a singular linear continuation to a compound in a static situation. Much of the current literature discussing bioactive compounds within the same metabolic network nods to this complexity by using ratios rather than absolute concentrations. The concentration of a single compound within a complex metabolic cascade does not often provide the necessary holistic perspective to determine potential health outcomes. Likewise, a singular focus on microorganisms via taxonomic analysis in this metabolic context is likely inadequate to describe a complete picture of such complex microbial interactions and relative abundance changes, even within the gut. Utilizing metabolic ratios, which highlight the push and pull nature of metabolism, in place of static concentrations is one key component for an improved study design. This change enables many complexities to be captured in a dynamic niche that leads considering functional rather than taxonomic location to analyzing microbial consortia. This approach could also be very helpful when considering the microbiome changes to understand what microbes, but also what pathways, are enriching or depleting within the community of metabolism. These combined approaches also enable a quantitative assessment to determine the ranked importance of metabolic routes as well as taxonomic groups as they change in the population relative abundance.Firmicutes and Proteobacteria, both contain species with genes encoding KYNU, TPH1, AFMID. Some Proteobacteria also encode IDO1 but no Firmicutes exhibit this ability. A deeper look at Firmicutes reveals the distribution of these genes is skewed towards the Psuedomonadales order and, interestingly, Escherichia lack these four genes. The five Proteobacteria orders display a more even distribution of kynurenine enzyme-encoding genes, with Betaproteobacteria the only order lacking species encoding IDO1. Though the analysis here covers only a small piece of the larger Trp metabolic network, the broad distribution shown here of kynurenine metabolism genes amongst common gut phyla both highlights the complexity of metabolic-related research but also the necessity of a functional approach to such work.One part of a functional approach to host–microbe–metabolite interactions is looking at the population distribution of Trp-related metabolic genes in bacteria. Considering the push–pull method to regulate this pathway, it is very likely that specific steps in the pathway will be increased or decreased to change the intermediate concentrations as a flux balance. For example, when shunted towards the kynurenine pathway, Trp is first converted to kynurenine via tryptophan indoleamine 2,3-dioxygenase 1 or 2  or via the liver enzyme tryptophan 2,3-dioxygenase (TDO) . KynurenHost neurology and microbial activity can work in union or conflict with each other, and thus the tight regulation of both is essential for optimal host health. A symbiotic partnership between the gut microbiota and host is a beneficial exchange of substrates that results in increased access to nutrients for the host and readily accessible dietary precursors for the microbes. When the balance shifts, however, the host can experience detrimental neurological effects that are either a result of or exacerbated by microbially produced metabolic products.Trp is one metabolite whose balance must be carefully regulated. Trp is funneled into the indole, kynurenine, or serotonin pathway, all of which contain other bioactive molecules in their ranks. Some Trp-derived compounds can have positive effects on systemic host functions, like serotonin and the immune and circulatory systems. Other Trp-derived compounds, like quinolinic acid, have detrimental effects on host function and have connections to neurological disorders such as dementia. Another kynurenine-derived bioactive compound produced by both the host and microbe is anthranilic acid. As detailed above, anthranilic acid can be useful as a biomarker for disorders like Alzheimer’s but anthranilic acid may also have a promising future use as a potential therapeutic target for the treatment of devastating and currently incurable neurological diseases. The gut microbiome has the functional capacity to shift the balance of anthranilic acid and subsequent metabolites to the point of disease exacerbation or onset. Controlling this finely tuned metabolic network, especially in the context of the human microbiome, is a challenge that needs additional investigation before being used more practically as biomarkers or therapeutic targets.


Ageing is an inevitable aspect of life and thus successful ageing is an important focus of recent scientific efforts. The biological process of ageing is mediated through the interaction of genes with environmental factors, increasing the body’s susceptibility to insults. Elucidating this process will increase our ability to prevent and treat age-related disease and consequently extend life expectancy. Notably, centenarians offer a unique perspective on the phenomenon of ageing. Current research highlights several age-associated alterations on the genetic, epigenetic and proteomic level. Consequently, nutrient sensing and mitochondrial function are altered, resulting in inflammation and exhaustion of regenerative ability.Oral health, an important contributor to overall health, remains underexplored in the context of extreme longevity. Good masticatory function ensures sufficient nutrient uptake, reducing morbidity and mortality in old age. The relationship between periodontal disease and systemic inflammatory pathologies is well established. Diabetes, rheumatoid arthritis and cardiovascular disease are among the most significant disease burdens influenced by inflammatory oral health conditions. Evidence suggests that the interaction is bi-directional, impacting progression, severity and mortality. Current models of ageing and longevity neglect an important factor in overall health and well-being, a gap that this review intends to illustrate and inspire avenues for future research. The attainment of very old age and accumulation of life experiences has always been fascinating to humankind. Throughout history humans have revered longevity. Elevated status of elders and ancestors in the late neolithic period or the pronounced role in culture Xiao , religioResearch continues to examine the question: How do people achieve exceptional longevity and age successfully? Although many questions remain to be answered, metabolic dysregulation  biological age < chronological age, (2) slowed or delayed decline in functional status , semi-super centenarians (> 105) and supercentenarians (> 110), showing that the greatest delay in the onset of disease appeared in the oldest sub-cohorts. In this study, researchers postulated that supercentenarians sustain a health span that approximates their life span  supercentenarians , flies (Drosophila melanogaster) and mice (Mus musculus) demonstrate that a disruption of the IGF1 signaling pathway results in an increased lifespan among several species  compared to healthy individuals  and Japan (TOOTH) to illuminate the connection between oral and overall health. In the It must be noted that these studies were performed in people under 100 years and therefore the results may not necessarily apply to centenarians or (semi-)supercentenarians. More research is needed to understand the dental and periodontal health of the oldest people in our societies. Currently oral health and illness aren´t integrated into the complex construct of successful ageing.To attain extreme longevity, maintenance of homeostasis appears to be a prerequisite. The ageing process can be approached as web of complex interactions between several factors see Fig. . These mConsidering the strong link between inflammatory processes  could provide a better understanding of the relationship between oral disease and ageing.Centenarians are a very exclusive cohort and the main challenge lies in the recruitment process. In previous studies the recruitment rate ranged between 13 and 97% (Frese et al. This review illustrates that oral health plays a significant role in reaching exceptional longevity, especially considering its influence on nutrient uptake (Wolfe et al.