In this review, we discuss the role of transforming growth factor-beta (TGF-β) in the development of pulmonary vascular disease (PVD), both pulmonary arteriovenous malformations (AVM) and pulmonary hypertension (PH), in hereditary hemorrhagic telangiectasia (HHT). HHT or Rendu-Osler-Weber disease is an autosomal dominant genetic disorder with an estimated prevalence of 1 in 5000 persons and characterized by epistaxis, telangiectasia and AVMs in more than 80% of cases, HHT is caused by a mutation in the ENG gene on chromosome 9 encoding for the protein endoglin or activin receptor-like kinase 1 (ACVRL1) gene on chromosome 12 encoding for the protein ALK-1, resulting in HHT type 1 or HHT type 2, respectively. A third disease-causing mutation has been found in the SMAD-4 gene, causing a combination of HHT and juvenile polyposis coli. All three genes play a role in the TGF-β signaling pathway that is essential in angiogenesis where it plays a pivotal role in neoangiogenesis, vessel maturation and stabilization. PH is characterized by elevated mean pulmonary arterial pressure caused by a variety of different underlying pathologies. HHT carries an additional increased risk of PH because of high cardiac output as a result of anemia and shunting through hepatic AVMs, or development of pulmonary arterial hypertension due to interference of the TGF-β pathway. HHT in combination with PH is associated with a worse prognosis due to right-sided cardiac failure. The treatment of PVD in HHT includes medical or interventional therapy. Hereditary hemorrhagic telangiectasia (HHT), additionally known as Rendu-Osler-Weber disease, is an autosomal-dominant inherited disease with an estimated prevalence of 1 in 5000 individuals and higher in certain regions . UnfortuFrequent and recurrent epistaxis, which may be mild to severeMultiple telangiectases on characteristic sites: lips, oral cavity, fingers, and noseAVMs or telangiectases in one or more of the internal organs A 1st-degree relative with HHTDiagnosing HHT can be done through genetic testing or by the use of the clinical Curaçao Criteria framework. The Curaçao diagnostic criteria for HHT consist of the following : FrequenA diagnosis of HHT is considered confirmed if at least three criteria are present, and possible with two criteria, as listed above .Currently, there are five different mutations known to cause HHT; this has led to the subdivision of HHT into five subtypes . These mHHT1 is caused by mutations in the ENG gene . HHT type 1 is characterized by a higher prevalence of pulmonary and cerebral AVMs, mucocutaneous telangiectasia, and epistaxis compared to HHT type 2 .HHT type 2 is caused by a mutation in the ACVRL1-gene  and has a higher prevalence of hepatic AVMs compared to HHT type 1 ,11.HHT type 3 and HHT type 4 are linked with mutations in, respectively, chromosome 5 and 7; however, the exact genes remain unknown ,13,14.HHT type 5 is caused by a mutation in the Growth Differentiation Factor 2 gene (GDF-2) that codes for the Bone Morphogenetic Protein 9 (BMP9) OMIM615506) which expresses an HHT-like phenotype and is therefore classified as HHT type 5 ,15.506 whichMutations in the SMAD4 gene  can cause a rare syndrome that is a combination of juvenile polyposis and HHT. This mutation is only found in 1–2% of HHT patients ,16.The various types of HHT can be subdivided based on the genetic mutation in the TGF-β signaling pathway :HHT1 is Approximately 80% of HHT patients have mutations in the ENG and ACVRL1-gene .Excessive TGF-β activation contributes to the development of a variety of diseases, including cancer, autoimmune disease, vascular disease, and progressive multi-organ fibrosis. The TGF-β signaling pathway is involved in many cellular processes, including cell growth, cell differentiation, apoptosis, cellular homeostasis, and others ,18 Figu. In endothelial cells (ECs), TGF-β can signal through two type-1 receptors: the ALK-5 pathway in which SMAD 2 and 3 are activated and the ALK-1 pathway in which SMAD 1, 5, and 8 are activated  Figure . All theSeveral studies show biphasic effect of TGF-β in ECs ,20. In lEndoglin is upregulated by ALK-1 and is an accessory receptor in the TGF-β signaling pathway that is specifically expressed in the proliferation of ECs and has an opposite effect on ALK-5 ,22,27,28BMP-9 is a ligand involved in the TGF-β/ALK-1 complex, high concentrations of BMP-9 in vitro and ex vivo inhibit proliferation and migration of ECs ,33. In vECs deficient in endoglin cannot mature because the balance between the ALK-1 pathway and the ALK-5 pathway is disrupted and ALK-5 predominates . Since eMutations in the ENG and ACRVL-1 genes alter the ligand–receptor interaction, creating an imbalance between Vascular Endothelial Growth Factor (VEGF). VEGF is stimulated by the ALK-5 pathway and inhibited by the ALK-1 pathway ,40. AlthThis allows for the creation of a thin-walled arteriovenous complex that is exposed to increased arterial blood flow and increased pressure . VEGF apAlthough ENG and ACRVL-1 mutations cause HHT-1 and HHT-2, it is noteworthy that HHT vascular lesions only occur in certain organs and are not expressed throughout the body ,48. One In resting EC, endoglin is present at low concentrations, but when cells are actively proliferating or during angiogenesis and embryogenesis, the endoglin concentration is increased ,50,51,52Thus, in the haploinsufficient HHT setting where a second hit occurs, endoglin and ALK1 do not reach the minimum concentration necessary to perform their roles in vascular damage ,54,55,56Further genome analysis of HHT families with phenotype variability as well as families with HHT whose genetic causes are unknown may be useful to identify new genes that may explain the heterogenic spectrum . Pulmonary AVMs (PAVMs) are a direct connection between a pulmonary artery and pulmonary vein without the interference of the pulmonary capillary bed. This results in an intrapulmonary right-to-left shunt with no gas exchange and a reduced filtering capacity of the pulmonary capillary bed. PAVMs are frequently underdiagnosed and asymptomatic . PAVMs cThe estimated prevalence of PAVMs is 38 in 100,000 individuals . ApproxiThe gold standard for screening PAVM is transthoracic contrast echography (TTCE) using agitated saline. TTCE has a sensitivity of 95–100% and can therefore be used to exclude a PAVM ,63,69,70The degree of pulmonary shunt can be classified by the number of microbubbles found in the left heart. The presence of a moderate or large shunt is an independent predictor of cerebrovascular events and brain abscesses . In caseScreening for PAVMs in (asymptomatic) HHT patients is justified due to good treatment options and non-invasive examination, reducing the risk of serious complications ,73. It rGroup 1—Pulmonary arterial hypertension (PAH)Group 2—PH caused by left heart diseaseGroup 3—PH caused by lung diseases and hypoxiaGroup 4—Chronic thrombo-embolic PH and other pulmonary arterial obstructionsGroup 5—PH with unclear or multifactorial mechanismsPH is a condition of increased blood pressure within the pulmonary arteries. PH has been defined as a mean pulmonary arterial pressure (PAP) ≥25 mmHg at rest as assessed by right-heart catheterization . In the There are no data describing the prevalence of PH per group. In an echocardiographic study, the prevalence of PH (estimated pulmonary artery systolic pressure >40 mmHg) was 11%, with 79% of patients suffering from left heart disease and 10% suffering from lung diseases, respectively . A studyDiagnosing PH in HHT can be challenging. Symptoms of HHT, such as fatigue, dyspnea and exercise intolerance, resemble those of PH due to anemia, hypoxemia associated with PAVMs, inadequate sleep due to epistaxis, and the psychological burden of a chronic illness ,6,75. A transthoracic ultrasound (TTE) should always be performed when PH is suspected. TTE provides different echocardiographic variables, such as an estimation of the PAP and secondary signs, to assess the probability of PH . A rightOne of the subgroups of PAH, a disease with a pre-capillary hemodynamic profile and an increased pulmonary vascular resistance (PVR > 3 Woods Units), is heritable PAH (HPAH) . SeveralLess than 1% of patients with HHT suffered HPAH caused by a mutation in the ACVRL1 gene . Up to 2Research by Vorselaars et al. showed that very few cases are known in the literature with the combination PAH-HHT. Ref.  in totalHowever, a majority of family members of patients with HPAH in combination with HHT do not develop HPAH, indicating that other genetic or environmental factors are required to develop an HPAH phenotype .Symptomatic HPAH patients with ACVRL1 mutations, frequently without HHT, are more likely to present with symptoms than patients with a BMPR2 mutation or idiopathic PAH . DespitePost-capillary PH arises from a hyperdynamic state caused by an increased cardiac output (CO), which can cause heart failure in the long term . Within Treatment of PAVMs in HHT is recommended to prevent severe complications—in particular, the development of brain abscesses and cerebral ischemic events—and is therefore justified for asymptomatic patients. In addition, symptoms of hypoxia and dyspnea can be reduced by PAVM treatment . EmbolizSometimes, the PAVM are complex and diffuse involving pulmonary arteries from different segments. This group is difficult to treat; surgery might be an alternative for percutaneous treatment. However, lung transplantation might be the only option left , 91]..91].Despite the fact that local treatment of telangiectases and PAVMs continues to improve, no ideal systemic therapy is available to date. Various studies and trials have attempted to find new drugs and have investigated the possibilities for repurposing existing drugs ,93.Currently, anti-angiogenic drugs used in cancer treatment (anti-VEGF antibodies and thyrosine kinase inhibitors) are under investigation with the aim of inhibiting the pro-angiogenic processes in HHT .VEGF plays a role in the development of AVMs and anti-VEGF therapy has shown to be effective in the treatment of other AVMs. Several case reports described treatment of diffuse PAVM with bevacizumab in which respiratory symptoms improved and epistaxis was decreased, without the formation of new AVMs on chest-CT during follow-up . BevacizTreatment differs for the different types of PH in HHT. There have not yet been randomized control trials to contribute to a guideline for PAH-specific therapy in HHT . StandarTreatment of PAH consists of lifestyle advice and drug therapy. Lifestyle advice includes avoiding pregnancy and infections, having elective surgery performed in specialized centers with experience in PH, genetic testing of family members, oxygen, psychological assistance, and water and salt reduction ,6. Drug Different drugs are currently under investigation for the treatment of PAH. Tacrolimus is a drug used to prevent rejection after allogenic organ transplantation . The preA few case reports describe the use of tacrolimus in PAH with promising results . A phaseA recent case report has shown that low-dose tacrolimus treatment improved HHT-related epistaxis but had no effect on PH progression in HHT patients . HoweverPH due to left heart disease can be treated by means of salt reduction and diuretics. Embolization of liver AVMs can cause serious complications, such as biliary ischemia. Treatment of choice might be the use of intravenous bevacizumab, recently recommended in the international guideline for HHT . SeveralTacrolimus has demonstrated to be a potent ALK-1 signaling mimetic, downregulating the ALK-1 loss of function transcription response, tacrolimus is therefore an interesting option for the treatment of HAVM in HHT2 with high cardiac output PH . Secondly, if anemia is present the underlying etiology should be treated to reduce the high CO.In this review, we discussed the pathophysiology, screening, and treatment of PVD, both PAVM and PH, in HHT. Research into pathophysiology of these mutations has led to potential targets for therapy like tacrolimus and bevacizumab. Although case reports show promising results, scientific evidence is still insufficient to use these therapies in daily practice. Further research is required, and it is reasonable to assume that clinical trials will follow.


The VD was significantly lower in the foveal area in choriocapillaris (p = 0.046). There were no statistically significant changes in the VD in the superior, inferior, nasal, and temporal quadrants in superficial and deep plexus, or in the choriocapillaris. The VD was not significantly lower in the foveal area in superficial or deep plexus. COVID-19 may affect the retinal vasculature, causing ischemia, enlargement of the FAZ, and lowering of the VD in the choriocapillaris area. Routine ophthalmic examination after SARS-CoV-2 infection should be considered in the course of post-infectious rehabilitation.The purpose of this study was to evaluate retinal and choroidal microvascular alterations with optical coherence tomography angiography (OCTA) in COVID-19 patients hospitalized because of bilateral pneumonia caused by SARS-CoV-2. The vessel density (VD) and foveal avascular zone (FAZ) of 63 patients with SARS-CoV-2 pneumonia who had positive polymerase chain reaction (PCR) tests and who recovered after receiving treatment and 45 healthy age- and gender-matched controls were evaluated and compared using OCTA in the superficial capillary plexus (SCP) and deep capillary plexus (DCP). The VD was also estimated in both groups in the choriocapillaris (CC). In COVID-19 patients, there was a statistically significant difference between the patients and a control group in both superficial (FAZs) and deep (FAZd) avascular zone ( Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a new beta coronavirus that was first identified in December 2019 in Wuhan, China. Since then, SARS-CoV-2 has spread as a pandemic, announced by the World Health Organization (WHO) on 11 March 2020. Transmission of the virus occurs primarily by droplets, through exposure to respiratory secretions containing the pathogen, but infection through contact with contaminated objects or surfaces was also reported [The clinical picture of the disease ranges from asymptomatic through mild and moderate respiratory infection to life-threatening viral pneumonia with acute respiratory distress syndrome, septic shock, and multiple organ dysfunction with a very high mortality rate. SARS-CoV-2 uses a spike protein that directly binds with a human angiotensin-converting enzyme 2 (ACE2) in order to infect human cells ,4. ACE2 The virus has been detected in the tears of COVID-19 symptomatic and asymptomatic patients, as well as in the retina of human cadavers, using a real-time polymerase chain reaction (PCR) . PostmorThe vascular endothelium plays a role in the control of vascular tone and the preservation of the blood–retinal barrier. Dysfunction of the endothelium can lead to microvascular ischemia due to mechanisms including vasoconstriction and inflammation ,13. It iOur study aimed to assess the macular anatomy, macular vessel density, and the foveal avascular zone in patients who recovered after hospitalization due to COVID-19.Cross-sectional, consecutive, and prospective case-control series. COVID-19 patients, confirmed with at least one PCR test, were selected from a group of cases with bilateral pneumonia. Patients were admitted at the Department of Infectious Diseases of WSZ in Kielce during March, April, May, and June 2021. This project was approved by the Bioethics Committee of Collegium Medicum of Jan Kochanowski University in Kielce (study codes 54 approved 1 July 2021). Written informed consent was obtained from all patients. All patients were examined 8 weeks after hospital discharge (group 1). This group consisted of 63 subjects who agreed to participate  with a mean age of 51.33 ± 1.45. At the moment of ocular examination, all patients were already asymptomatic. Nineteen patients (3.16%) suffered from hypertension and three patients (4.76%) suffered from dyslipidemia. Twenty-two (34.92%) patients received oxygen therapy during hospitalization.The control group (group 2) included healthy patients who attended the ophthalmology department for a routine eye examination. This group consisted of 45 subjects  with a mean age of 47.76 ± 1.38. Written informed consent was obtained from all patients. Inclusion criteria for this group were as follows: age of 30–70 years; negative laboratory tests for SARS-CoV-2 infection ; absence of COVID-19 symptoms in the past or close contact with COVID-19 patients within the 14 days before the examination; absence of concomitant eye diseases. Demographic characteristics of both groups are presented in A flow chart illustrating the consolidated standard for reporting all trials which describe included and excluded eyes is presented in Exclusion criteria related to eye diseases for both groups were myopia >3 diopters, hyperopia >3 diopters, retinal vascular disease, macular and optic nerve disease, previous ocular surgery (including cataract or glaucoma surgery), uveitis, ocular trauma, age-related macular degeneration, other retinal degenerations and media opacity affecting the OCTA’s scan or image quality, and diabetes mellitus.Both groups underwent complete ophthalmic examination, including a best corrected visual acuity (BCVA) test measured on a logMAR scale, intraocular pressure (IOP) measurement, slit lamp examination, OCT of the macula and optic nerve, and angio-OCT (OCTA).All scans were acquired with swept-source angio-OCT . OCT protocols included 3D macula 7 × 7 mm scanning protocols and 3D 6 × 6 mm disc scanning protocols. OCTA images were captured using the 4.5 × 4.5 mm and the 6 × 6 mm scanning protocols. All scans eligible for the study reached an image quality of at least 65%.Structural OCT macular parameters were measured using the early-treatment diabetic retinopathy (ETDRS) grid centered in the fovea by manual fixation. Three areas of interest were defined as the fovea, the inner ring (IR), and the outer ring (OR). The retinal stratus and parameters analyzed were the total retina (TR), the retinal nerve fiber layer (RNFL), the ganglion cell layer (GCL), and choroid thickness, delineated automatically by the built-in segmentation software. Optic nerve head RNFL thickness was measured in each of four quadrants using a radial scan centered on the optic nerve head and presented as mean RNFL.OCTA parameters evaluated were vessel density (VD) in the three different plexi: superficial capillary plexus (SCP), deep capillary plexus (DCP) and choriocapillaris (CC), using the ETDRS grid subfields to define the areas of interest. The mean vessel density (VD) was calculated as the average value obtained in the parafoveal area, defined as the area conformed by the inner superior (IS), inner nasal (IN), inner inferior (II), and inner temporal (IT) ETDRS subfields centered on the macula by fixation. The foveal avascular zone (FAZ) area was manually delineated on the SCP and the DCP by two independent graders, encompassing the central fovea where no clear vessels were seen in the image.p-value of less than 0.05 was regarded as statistically significant. All statistical analyses were performed using Statistica 13.3 . Clinical demographics and imaging data were analyzed with frequency and descriptive statistics. The description of quantitative variables was performed using the mean (M), standard error of the mean (SEM), median (Me), and quartiles (IQR). Differences between COVID-19 and control groups were tested using the Mann–Whitney U test. Clinical variables, structural OCT, and OCTA parameters were compared between cases and controls using Student’s t-test. Categorical variables were presented as percentages, and comparisons between groups were performed with the chi-square test. Pearson (r) or Spearman’s correlation coefficient, Q (rho), was used to assess associations between SCP (%), DCP (%), CC (%), RNFL retinal, GCL, BMCSI, and RNFL optic nerve. A A total of 203 eyes were included in the study: 120 COVID-19-affected patients and 83 eyes in the control group. In all, 43 men and 20 women with COVID-19 bilateral pneumonia participated in the analysis. The control group consisted of 28 men and 17 women. The mean age of the study group was 51.33 (SEM = 1.45), while the mean age of the control group was 47.76 (SEM = 1.38). p = 0.024) and inner nasal ring  (p = 0.021) and in the inferior sector  was observed in COVID-19 patients  . No stat= 0.018) . In the patients .p = 0.012), the inner nasal ring , the inner temporal ring , and the outer inferior ring   . Detailed information about retinal thickness measurements can be found in supplementary tables p = 0.000) and for the DCP   . Enlargep = 0.046) (p = 0.456). The VD was significantly lower in the foveal area of CC  , but thep = 0.620) (p = 0.706)   and in t= 0.706) . p = 0.241) (p = 0.849)   and in t= 0.849) .There were no statistically significant differences in the superior, inferior, temporal, or nasal areas in the SCP, DCP, or CC between COVID-19 patients and the control group. Detailed information can be found in p < 0.00). We observed that the FAZ area was significantly larger in female COVID-19 patients than in male COVID-19 patients in the SCP , but significantly higher in women than in men in the inferior area of the SCP . The VD in the SCP was significantly lower in women than in men in COVID-19 patients in the foveal area of the SCP , in the nasal area  and in the temporal area .The VD in the DCP was significantly lower in women than in men in COVID-19 patients in the superior area , in the inner nasal ring , in the inner inferior ring , in the inner temporal ring , and in the outer temporal ring .In the structural OCT analysis, a statistically significantly thicker RNFL retina was observed in men than in women in COVID-19 cases in the foveal area . p = 0.002), in the inner temporal ring , and in the outer temporal ring .A significantly thicker GCL was observed in men than in women in COVID-19 patients in the foveal area , in the inner superior ring , in the inner nasal ring , in the inner inferior ring (318.10 ± 1.67 vs. 309.19 ± 2.72), p = 0.002), in the inner temporal ring , in the outer inferior ring , and in the outer temporal ring .The retinal thickness was significantly thicker in men than in women in COVID-19 patients in the foveal area . The immunofluorescence microscopy confirmed two essential proteins of the SARS-CoV-2 viral particles: S protein, exposed on the virus surface, and nucleocapsid protein located within the virus. The nucleocapsid protein was visualized in the ganglion layer (GCL) . These fBelow we discuss the most important findings of our work regarding changes ongoing in the retinal microvasculature in COVID-19-affected patients. One of the most prominent features in our study was the enlargement of the FAZ area in the SCP. There are conflicting data in the literature, as some authors confirm this finding , while nEnlargement of the FAZ zone can be a consequence of retinal ischemia due to endothelial dysfunction, vasoconstriction, and procoagulant activity. It can be the perfusion deficit in the foveal area caused by general hypoxia and inflammation.Postmortem studies confirmed the presence of microvascular thrombosis, endotheliitis, viral elements, apoptotic bodies, and inflammatory cells within the endothelium of small vessels in many organs. The ischemic processes can cause enlarging of this FAZ area. It can be observed in many vascular diseases such as diabetes mellitus or retinal vascular occlusion ,29, and The ganglion cell layer (GCL) and the inner plexiform layer (IPL) are supplied with blood by the SCP, but the DCP supplies the outer plexiform layer (OPL) adjacent to the outer nuclear layer (ONL). The OPL includes oxygen-dependent synapses of photoreceptors, bipolar cells, and horizontal cells. The SCP and the DCP are the final branches of the central retinal artery. We can expect the ischemia and secondary atrophy of the inner retina due to endotheliitis and micro thrombotic processes within these small vessels.In our group, we did not find a difference between COVID-19 patients and the control group in the foveal GCL layer, but we confirmed significantly thicker GCL in the inner superior ring, the inner nasal ring, the inner temporal ring, and the outer inferior ring. Our results are in accordance with the study performed by Burgos-Blasco et al. on children between 6 and 18 years who recovered from COVID-19. They observed increased macular GCL in the nasal outer and temporal inner sectors . On the The RNFL and the GCL layers are the neuroretinal layers. John Dowling referred to the human retina as “the approachable part of the brain”, which can be clinically visualized with proper tools . Many stIn our study, the foveal RNFL was not statistically different between COVID-19 patients and the control group, but a significantly thicker RNFL retina was observed in COVID-19 cases in the inner superior ring and inner nasal ring. There were no signs of choroidal neovascularization, or any abnormalities in the RPE in these regions. It is difficult to state the origin of this change. Most authors also did not find differences in foveal RNFL ,26,35.Contrary to our analysis, Burgos-Blanco et al. confirmed decreased macular RNFL in the nasal outer and temporal inner sectors, but also an increase in global peripapillary in the temporal superior and temporal sectors . AuthorsSavastano et al. described decreased radial peripapillary capillary plexus (RPCP) perfusion density in post-COVID-19 patients. The RNFL thickness was linearly correlated with the RPCP flow index and perfusion density in this study group. The impairment in the blood supply to the optic nerve may result in the peripapillary RNFL thinning .Marinho et al. reported the presence of hyperreflective lesions at the GCL and inner plexiform layer (IPL) in adults 11-33 days after the onset of COVID-19 symptoms. Subtle cotton wool spots and microhemorrhages were present along the retinal branches . In our In our study, we observed significant thickening of the RNFL in the optic nerve head. This stays in line with Gonzalez-Zamora et al. findings, as they also noticed it in the superior and inferior sectors of the optic nerve head in COVID-19 patients .Another parameter analyzed in this study was the VD. We did not notice, either in the SCP or the DCP, statistically significant differences between groups in VD in the foveal or the parafoveal area. Our results are consistent with those reported by Dominika Szkodny et al. , but mosThese results were similar to Leyla Hazar et al’s. estimations, which confirmed significantly lower VD in the SCP and DCP one month after patients were discharged following recovery .Another parameter analyzed in this study was VD in the CC plexus. It was significantly lower in the foveal area in COVID-19 patients than in controls, but not in the parafoveal area. Most studies did not estimate VD in the CC plexus. In the study performed by Gonzales-Zamora et al., no alterations in VD in the CC plexus were observed .As all the above-mentioned studies vary significantly in the time of examination , it can probably explain the differences in results obtained. There is no consensus yet of when a reliable measurement should be taken, or which mechanisms COVID-19 can affect the vessel density.In our earlier study, we emphasized the role of the choroid in the nourishment of the outer layers of the retina, part of the optic nerve, and retinal pigment epithelium. The choroid is the only metabolic source in the avascular zone of the macula. Retinal oxygenation is also provided by the choroid, which is one of the most vascularized tissues in the human body. It plays a role in the pathophysiology of many eye and systemic diseases such as anemia or carotid artery stenosis .We suspect that reduced VD in the choriocapillaris in COVID-19 patients can affect the retina. Long-term follow-up is needed to estimate the functional and anatomical consequences on the general and local condition.Our study has several limitations. It could not be performed during the symptomatic acute phase of COVID-19 due to the emergency condition and risk of contagion. Nineteen COVID-19 patients suffered from hypertension and three from dyslipidemia, so we cannot exclude that part of our findings were related to the general condition. We have no baseline results of the OCT before disease, so we cannot compare these findings. A strong point of the study is a large group consisting of selected patients without the influence of vascular diseases such as diabetes mellitus, examined at the same time point after discharge from the hospital.Here we report significant changes in the retinal microvasculature of COVID-19 patients, especially in the most metabolically active regions of the retina. These findings confirm the microvascular involvement of SARS-CoV-2 infection and its possible vascular sequelae. We cannot yet state whether these changes are permanent or transient, but even a minor decrease in the perfusion in the macular area can result in slow degradation of its function. Long-term follow-up studies are required to further evaluate these findings. OCT can be a useful tool to assess the severity of the disease and to determine the effectiveness of the COVID-19 treatment.


The statistically significant thickening of RNFL optic disc and thinning of RNFL retina in some macular areas in patients with SpO2 ≤ 90% were reported. The size of FAZ area in SCP and vessel density were significantly greater in some areas of SCP, DCP, and CC in patients with SpO2 ≤ 90% (p = 0.025). Baseline oxygen saturation ≤90% has been found to influence the ocular parameters of OCT in COVID-19 patients. We noticed a widened FAZ zone in SCP and increased VD in some regions of the retina and choroid as a response to systemic hypoxia.The aim of the study was to evaluate changes in the retinal thickness and microvasculature based on optical coherence tomography (OCT) depending on baseline oxygen saturation (SpO2) in patients hospitalized due to COVID-19 bilateral pneumonia. The prospective study was carried out among 62 patients with COVID-19 pneumonia who underwent ophthalmic examination after hospital discharge. They were divided into three groups depending on the oxygen saturation (SpO2) on admission: ≤90% (group 1), >90% and ≤95% (group 2), and >95% (group 3). The following parameters were assessed in the ophthalmological examination and correlated with the baseline SpO2: ganglion cell layer (GCL), the retinal nerve fiber layer (RNFL) in the macular area, RNFL in the peripapillary area, the foveal avascular zone (FAZ) in superficial capillary plexus (SCP) and deep capillary plexus (DCP), vessel density (VD) in SCP, in DCP, and in the choriocapillaris plexus (CC). Baseline saturation ≤90% in COVID-19 patients caused a decrease of VD in some areas of SCP and DCP and an increase in FAZ area in SCP and DCP. In the group of patients with SpO2 ≤ 90% statistically significant thinning of the retina in the inner superior ring (ISR) ( Since the end of 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread worldwide, resulting in the pandemic announced by World Health Organization (WHO) on 11 March 2020. SARS-CoV-2 is transmitted by respiratory droplets, close contact with the infected person, or aerosols. The disease it causes, termed coronavirus disease 2019 (COVID-19), is mild or even asymptomatic in most of the patients affected, while about a fifth of them experience a severe course ,4. AccorTreatment methods for patients with COVID-19-associated pneumonia include oxygen therapy and antiviral, anti-inflammatory, and immunosuppressive drugs depending on the phase of the disease, while low molecular weight heparin is recommended regardless of the stage of the illness as prophylaxis of thromboembolism ,11,12. OThe presence of the genetic material of SARS-CoV-2 in the retinal tissue has been confirmed postmortem by PCR . The vasThe most current method to visualize macular micro vessels is by using non-invasive optical coherence tomography angiography (OCTA). The OCTA can successfully visualize the microvascular network of the retina with its blood flow in numerous eye disorders and general diseases . Both OCThe current study aimed to evaluate the microvascular changes in the retina based on OCTA in COVID-19 patients hospitalized due to bilateral pneumonia caused by SARS-CoV-2. The impact of comorbidities and the received treatment was also analyzed.A cross-sectional, consecutive, prospective case-control series analysis was carried out. Cases were selected from a population of COVID-19 patients with bilateral pneumonia hospitalized in the Department of Infectious Diseases of Municipal Hospital in Kielce during the pandemic spring wave caused by B.1.1.7 variant of SARS-CoV-2 from March to May 2021. The project was approved by the Bioethics Committee of Collegium Medicum of Jan Kochanowski University in Kielce (study code 54 approved on 1 July 2021).Exclusion criteria related to eye diseases included as follows: myopia > 3 diopters, hyperopia > 3 diopters, retinal vascular disease, macular and optic nerve disease, previous ocular surgery including cataract surgery, glaucoma surgery, and other types of eye surgery, uveitis, ocular trauma, age-related macular degeneration, and other macular degenerations and media opacity affecting OCTA’s scan or image quality, diabetes mellitus. All examinations were performed by a single non-masked investigator, with standard protocol applied to each patient.All patients signed the written informed consent to participate in the current study and underwent ophthalmological evaluation eight weeks after hospital discharge.2. Thirty-nine patients suffered from comorbidities with the most common arterial hypertension (20 patients) followed by other cardiovascular diseases, including ischemic, valvular heart disease, and cardiac rhythm disturbances, which affected six patients. Five individuals had liver steatosis, and five had a history of malignant neoplasm (inactive). Data on the course of hospitalization were obtained retrospectively from hospital records. At the time of admission to the hospital, due to COVID-19, all patients were symptomatic. In all patients, the clinical diagnosis of COVID-19 was confirmed by the positive result of the real-time reverse transcriptase-polymerase chain reaction (RT-PCR) from nasopharyngeal swabs. The diagnosis of bilateral pneumonia was supported by typical chest computed tomography scan changes described in 26 patients.The analyzed group consisted of 62 patients with male predominance , the mean (M) ± standard error of the mean (SEM) age was 51.3 ± 1.4 years, and BMI M ± SEM was 28.5 ± 0.5 kg/mTwenty-two patients were classified at baseline as stable with oxygen saturation (OS) >95%, twenty-nine were unstable with OS 91–95%, and the remaining eleven patients were assessed as unstable with OS ≤ 90%. The need for continuous low-flow oxygen therapy was documented in 23 patients. The most frequent drug used for the in-hospital treatment of COVID-19 was low-molecular-weight heparin in prophylactic dose, which was administered in fifty-nine patients; two individuals received a therapeutic dose. The antiviral agent remdesivir was used in 26 patients. Immunosuppressive treatment with dexamethasone was administered to 22 patients, while 3 received tocilizumab in a single dose of 600–800 mg, depending on the patient’s weight.The low-molecular-weight heparin in prophylactic dose was administered in 59 COVID-19 patients for an average of 9 (6.25–12) days. Dexamethasone was administered in 22 infected patients, tocilizumab was administered in 3 patients in a single dose of 600–800 mg depending on the patient’s weight. Remdesivir was administered to 26 patients. The need for continuous oxygen therapy was in 23 patients for an average of 5 (4–10) days. Twenty-three patients received oxygen therapy during hospitalization for an average of 5 (4–10) days.The COVID-19 patients  underwent complete ophthalmic examination, including a best corrected visual acuity (BCVA) test, in a LogMAR scale, intraocular pressure (IOP) measurement, a slit-lamp examination, OCT of the macula and optic disc and angio-OCT (OCTA).The mean LogMar BCVA was 0.0 and the mean LogMar Reading Vision (RV) was 0.3, the spherical equivalent (SE) was 0.13 (0.13) D, the mean axial length was 23.55 (0.08) mm .All scans were acquired with Swept Source DRI-OCT Triton SS-OCT Angio . OCT protocols included 3D macula 7 × 7 mm scanning protocols, 3D Disc- 6 × 6 mm scanning protocols, and OCTA images were captured using the 4.5 × 4.5 mm and the 6 × 6 mm scanning protocols.Structural OCT macular parameters were measured using the early treatment diabetic retinopathy (ETDRS) grid, centered in the fovea by manual fixation. Three areas of interest were defined as the fovea, inner ring (IR), and outer ring (OR). IR and OR include superior (S), inferior (I), nasal (N), and temporal (T) areas. The retinal stratus and parameters analyzed were total retina, retinal nerve fiber layer (RNFL), ganglion cell layer (GCL), and choroid thickness as delineated by the boundaries automatically defined by the built-in segmentation software. Optic nerve head RNFL thickness was measured in each quadrant using a radial scan centered on the optic nerve head and presented as mean RNFL.The evaluated OCTA parameters were: vessel density (VD) in the three different plexi: superficial capillary plexus (SCP), deep capillary plexus (DCP), and choriocapillaris (CC) using the ETDRS grid subfields to define the areas of interest. Mean vessel density (VD) was calculated as the average value obtained in the parafoveal area, defined as the area conformed by the superior (S), inner nasal (N), inner inferior (I), and inner temporal (T) ETDRS subfields centered on the macula by fixation. The foveal avascular zone (FAZ) area was manually delineated on the SCP and the DCP by two independent graders, encompassing the central fovea where no clear and demarcated vessels were seen on the OCTA.p ≤ 0.05 were considered significant. The statistical analysis was performed using the STATISTICA 13.3 statistical package .Counts (n) and percentages (%) attendance were counted for all qualitative parameters in the COVID-19 patient group. Three groups of patients with saturation were distinguished using the following cut-off values: ≤90%, ≤95%, and >95%. In the distinguished groups, the distributions of the variables were checked with the quantitative Shapiro–Wilk test. The mean .The clinical course of SARS-CoV-2 disease was assessed with the ordinal scale based on the WHO recommendation, modified to an 8-score version to fit the specificity of the Polish healthcare system and used in previous SARSTer studies ,15,16. TThe COVID-19 patients were divided in three groups depending on oxygen saturation: ≤90% (group 1), ≤95% (group 2), >95% (group 3).p = 0.029 in inner, superior ring (ISR), r = 0.49, p = 0.034 in inner, temporal ring (ITR), r = 0.56, p = 0.012 in outer superior ring (OSR), r = 0.062, p = 0.004 in outer temporal ring (OTR)] in some areas of the macula in the group of patients with SpO2 equal or lower than 90%. A statistically significant correlation was found between choroidal thickness (BMCSI) and SpO2. For SpO2 equal to or lower than 90% r = 0.52, p = 0.021 in the outer nasal ring (ONR) and for the oxygen saturation of 90–95%, r = −0.38, p = 0.007 in the outer nasal ring (ONR).There were no statistically significant differences between the different OCT parameters in COVID-19 patients according to oxygen saturation . Group 1 consisted of 10 patients, including 19 eyes, group 2 consisted of 29 patients, including 56 eyes, and group 3 consisted of 23 patients, including 44 eyes . There wp = 0.005 in superior RNFL optic disc, r = −0.60, p = 0.012 in temporal RNFL optic disc). A decrease in RNFL retinal thickness was observed in some areas of the central retina in COVID-19 patients with SpO2 ≤ 90% . As SpO2 ≤ 90% level, a decrease in macular GCL thickness was observed , r = 0.46, p = 0.047 in GCL inner inferior ring (IIR). There was a positive statistically significant correlation between GCL in the outer inferior ring (OIR) and SpO2 of 90–95% . As the SpO2 decreased, the FAZ area in the SCP statistically significantly increased .A statistically significant negative correlation was reported between SpO2 ≤ 90% and RNFL optic disc . There was a statistically significant correlation between mean VD in DCP and SpO2 ≤ 90%  and between the temporal area of VD in DCP and SpO2 ≤ 90% .There was a statistically significant correlation between foveal VD (vessel density) in SCP and SpO2   .In this study, we present the correlations between blood saturation and ocular parameters based on changes in blood flow observed in OCTA examination in COVID-19 patients. This is intended to clarify the role of hypoxia in metabolism and microvasculature of the retina and choroid.Hypoxia and inflammation are linked at the molecular, cellular, and clinical levels. Factors that induce acute hypoxemia, such as SARS-CoV-2 disease enhance various cytotoxic functions of neutrophils and may stimulate hyperinflammation. Animal models showed that exposure to low oxygen concentrations results in increased vascular permeability, accumulation of inflammatory cells, and increased serum cytokine levels. Therefore, hypoxia is not only a consequence of respiratory disease but also contributes significantly to progressive lung damage and failure of other organs ,23.OCTA has revolutionized ophthalmic clinical practice. It produces high-contrast images of the retinal blood flow, with sufficiently high resolution to show the location of individual capillaries in the retina. OCTA can differentiate the SCP from the DCP and show how each plexus is affected in retinal vascular disease . The OCTWe observed a significant thinning of retinal thickness in some macular areas in patients with SpO2 equal to or lower than 90%. A statistically significant correlation was found between choroidal thickness (BMCSI) and SpO2; we reported significant thinning of choroidal thickness in patients with SpO2 equal to or lower than 90%, but the thickness of choroid was correlated significantly negative in patients with SpO2 of 90–95%.p = 0.0002) and the baseline (p = 0.0320). The OCT features were only significant in the inner retina in the GCC (p < 0.0001) but not in the outer retina.Thinning of the GCC on OCT may reflect the selective vulnerability of the inner retina to hypoxia, and secondary peripapillary edema development, likely as a result of post hypoxic inflammation . The eleWe also observed a significant thickening of RNFL in the optic disc, and significant thinning of RNFL in some macular areas in patients with SpO2 equal to or lower than 90%.In a pig model of acute respiratory distress syndrome, RNFL thickness was increased and there was immunostaining for reactive oxygen species HIF-1 alpha and VEGF-A in retinal arterioles, suggestive of increased retinal vascular permeability and endothelial dysfunction . In our We observed a significant increase in the size of the FAZ area in patients with lower values of SpO2. This area allows the most distinct vision because of the high cone density and absence of blood vessels. The circulation is particularly vulnerable in the FAZ, as in this region retinal blood vessels are absent. Therefore, the retinal cones of the FAZ area are completely dependent upon oxygen and nutrient delivery from the underlying choriocapillaris. The FAZ is therefore highly sensitive to ischemic events, and because of this, can act as an indicator of several pathological processes ,35. EnlaIn our study, we observed significantly greater vessel density in some areas in SCP, DCP, and CC in patients with SpO2 equal to or lower than 90%. The inner retina is supplied by the central retinal artery, but the outer avascular retina, which consists entirely of photoreceptors and Muller cell processes is supplied and nourished by choroid .2  in the outer and inner retina behaves differently as well. The choroidal circulation does not seem to adapt to the metabolic needs of the outer retina and its resistance is not considered to change during hypoxia, although there are not many studies on the subject. Choroidal blood flow is likely to increase as a result of increased arterial pressure during hypoxia, but the choroidal circulation is regulated to some extent during moderate pressure changes, so this is not a major effect. As a result, when PaO2 falls, there is no mechanism to compensate and transport more blood to the choroid. In contrast to the choroid, the retinal circulation does regulate in response to metabolic demand, and blood flow goes up during hypoxia. It is sensible to ask whether hypoxia itself can result in neovascularization in the retina. In young animals, the retina shows elevated HIF-1alpha  and VEGF  before the development of the retinal vasculature, and this is most probably the main stimulating factor for the normal development of the retinal circulation. The elimination of HIF-1 alpha and VEGF in astrocytes does not change this, therefore the other cells or other compensatory processes must be involved. In the hypoxic conditions of oxygen-induced retinopathy, HIF-1 alpha and VEGF are also vital to abnormal neovascularization. Several hours of hypoxia in rats led to the upregulation of HIF-1 alpha protein and VEGF expression. Many researchers have suggested that the neovascularization in ischemic diseases such as diabetes or vein occlusion, which do not destroy the whole inner retina, may be caused by hypoxia, but the retinal disease always involves a complex mixture of events besides hypoxia, so the role of hypoxia itself is rarely certain [The influence of hypoxia on retinal and choroidal microcirculation was widely studied previously ,39. Beca certain .In an examination of the diabetic patients without clinical retinopathy (NoDR) with OCT, significantly higher perfused capillary density (PCD) and the PCD were noted compared to the healthy control group. The PCD was more sensitive than FAZ metrics for detecting a difference between diabetic patients and the healthy group. The diabetic patients with NPDR (non-proliferative diabetic retinopathy) and PDR (proliferative DR) had progressively decreased PCD . The incRelative tissue hypoxia can be an early trigger in the pathogenesis of the diabetic microvascular disease. Direct evidence of inner retinal hypoxia in diabetic cats without retinopathy has been observed using an intraretinal electrode. The tissue demand for oxygen is increased due to the need to accommodate increased levels of glucose. Relative hypoxia can occur as a result of reduced oxygen extraction from blood vessels by retinal tissues . It is kAnother mechanism was proposed for increased retinal flow in well-controlled type 1 diabetics without retinopathy, reported on the absence of retinal arterial constriction in response to a pressure stimulus, attributing it to a defect in the myogenic response of the smooth muscle cells of retinal arterioles in the setting of diabetes . A more 2, the changes in pO2 are opposite to those in hypoxia [2, which was observed in several studies in various animal models. The amount of O2 transported by the choroid does not change much beyond the point of full hemoglobin saturation, but the increase in PC is quite essential because this is the driving force for O2 diffusion into the retina. If the increase in PC is large enough, O2 will diffuse to the inner retina. The value of PC will increase still further with hyperbaric oxygen. Therefore, hyperoxia and hyperbaric treatment for vascular occlusive disease have been suggested, but there is a misconception that hyperbaric O2 would be much better than 100% O2 at atmospheric pressure. Because the influence of hyperoxia on PC is large, the PO2 in the outer retina increases dramatically. The retinal circulation vessels constrict during hyperoxia. This tends to keep inner retinal PO2 close to levels during air-breathing, but the regulation is not perfect, because the diffusion of O2 from the choroid is unavoidable. The rise in inner retinal PO2 in animal models is considerably less than the increase in PO2 in the outer retina. Hypercapnia superimposed on hyperoxia can become smaller or eliminate the hyperoxic vasoconstriction of the retinal circulation and lead to much larger increases in inner retinal PO2 [In our study, twenty-three patients were treated with continuous oxygen therapy for an average of 5 (4–10) days. The influence of hyperoxia on retinal and choroidal microvasculature was previously studied. When the arterial pO2 (oxygen tension) increases as a result of increased inspired O hypoxia . The choinal PO2 .Significantly decreased SpO2 ≤ 90% was one of the indications for the implementation of tocilizumab (TOC), apart from elevated interleukin 6 (IL-6) levels > 100 pg/mL and the need for oxygen supplementation. In these indications, the effectiveness of TOC was the best. TOC was used in three patients in our study group. This medication is aimed at blocking an IL-6 proinflammatory pathway. Despite the direct viral effect, the pathogenesis of COVID-19 includes an overproduction of cytokines . This meOur study has several limitations. It could not be performed during the symptomatic, acute phase of COVID-19 due to the emergency condition and risk of contagion. Patients were burdened with additional diseases such as hypertension or dyslipidemia, so we cannot exclude the effect of these diseases. We have no baseline results of the OCT in COVID-19 patients before the disease, so we cannot compare these findings. The number of patients with SpO2 equal to or lower than 90% was small because some patients died or had a comorbid vascular disease that excluded them from the study. Most patients in our group had SpO2 above 90%.A strong point is a group consisting of the selected patient without the influence of vascular disease such as diabetes mellitus. Only hospitalized COVID-19 patients were included in the study, forming a significant number of COVID-19 patients, examined at the same time point after discharge from the hospital.This is the first study to describe the correlations between individual OCT parameters and SpO2 and to explain the effect of general hypoxia on ocular vascularization.Our study demonstrated the effect of systemic hypoxia due to bilateral SARS-CoV-2 pneumonia on ocular parameters based on OCTA examination. Further follow-up of these patients is needed for long-term evaluation of the retina, choroid, and optic nerve for the development of degenerative changes resulting from systemic hypoxia.


In addition to being highly digestible, lupin and chickpea beverages have anti-inflammatory and anti-carcinogenic potential evaluated through the inhibition of metalloproteinase MMP-9.There is a strong demand for plant-based milk substitutes, often low in protein content (<1.5% w/v). Protein-rich pulse seeds and the right processing technologies make it possible to make relevant choices. The major objective of this study was to assess the impact of processing on the nutritional characteristics of beverages with a high impact on health, in particular on digestibility and specific bioactivities. The results suggest that pulse beverages are as high in protein content (3.24% w/v for chickpea and 4.05% w/v for lupin) as cow’s milk. The anti-nutrient level characteristics of pulses have been considerably reduced by strategic processing. However, when present in small quantities, some of these anti-nutritional factors may have health benefits. Controlling processing conditions play a crucial role in this fine balance as a tool to take advantage of their health benefits. There is evidence of protein hydrolysis by   Two batches per pulse beverage were produced and this procedure was repeated three times to verify the repeatability. Briefly, 150 g of dried seeds, previously soaked in water (1:3 w/v) for 16 h, changing the water two times in the same proportion, were cooked for 30 min in a pressure cooker  into 1.5 L of tap water. Cooked pulse seeds were drained and 1.5 L of fresh tap water was added. The milling step included the food processor at 20,500 rpm  for 4 min, followed by colloid milling simulated by a mortar grinder  at a lab scale at 70 rpm for 45 min, at room temperature. Both chickpea and lupin beverages were sieved with a strainer, and their particle diameters were marked from an analysis carried out in a previous study  and incubated for 2 min at 37°C under continuous agitation in an overhead rotator . The volume of simulated gastric fluid (SGF) with porcine pepsin  to dilute the oral bolus was 1:1 (v/v) and the pH was adjusted to 3 with 10 M HCl, when necessary. The mixture was incubated at 37°C with agitation for 2 h. The gastric chyme was diluted 1:1 (v/v) with simulated intestinal fluid (SIF), and the bile salts (10 mM) and pancreatin (100 UI/mL of trypsin activity) were added followed by adjustment to pH 7 (with 1 M NaOH). Incubation at 37°C under agitation was stopped after 2 h with Pefabloc, a serine PI (5 mM). An enzyme-blank tube was included in these trials where the 2 mL of pulse beverage was replaced by demineralized water. To obtain the soluble  and insoluble fractions after in vitro digestion, the whole digesta was centrifuged at 6,000 × g for 10 min, at 4°C.Chickpea and lupin beverages were subjected to the static n method  comprisiin vitro digestion and that presumably becomes accessible (available) for absorption through the small intestine walls. Bioaccessibility should be distinguished from the term bioavailability, which is defined as the fraction of nutrients or food components that have been efficiently digested in vivo, assimilated, and then absorbed in the body  in 17.5% (w/v) polyacrylamide gel  and the correction factor used to convert nitrogen to crude protein was 5.4 . All anaThe total starch analysis was determined according to the Megazyme Total Starch Assay Procedure (K-TSTA) based on the AOAC official method 996.11 (2005), regarding specific procedures for samples in which the starch is present in a soluble or suspended form. The analyses were carried out in duplicate and expressed in grams of starch per 100 mL of sample.D-glucose content was obtained by high-performance liquid chromatography (HPLC) (g for 10 min and 500 μL of supernatant was collected. After its dilution in H2SO4 (50 mM) (1:1 v/v), the samples were centrifuged  to discard the precipitated protein and filtered under vacuum through a 0.20 μm-pore-size filter. Glucose was quantified in an HPLC system  equipped with a refractive index detector (Waters 2414) and a Rezex™ ROA Organic Acid H+ (8%) column , at 65°C. Sulfuric acid (5 mM) was used as the mobile phase at 0.5 mL min–1. The analysis was performed in triplicate and the results are expressed in grams of glucose per 100 mL of sample.The y (HPLC) . BrieflyTotal carbohydrate content was carried out in triplicates and according to the Dubois’ method . The resThe ash content was determined gravimetrically by incineration of triplicates at 550°C in a muffle furnace  using the AOAC 923.03 method . The resDry matter was also determined gravimetrically by drying at 105°C in a forced-air oven  until the constant weight of the sample according to the AOAC 934.01 method , and solThe energy value of each pulse beverage was calculated considering the conversion factors  for prot3 (65%) were added. The digestion  occurred at 15 min/45°C, 15 min/80°C, and 60 min/105°C. After cooling, up to 50 mL of distilled water was added and the solution was left to settle. Finally, the clear supernatant was used for the ICP analysis. Eleven elements  were identified in triplicate. Results are expressed in milligrams of mineral element per 100 mL of sample.Minerals’ profile was evaluated by inductively coupled plasma optical emission spectrometry  based on the AOAC 984.27 method . Brieflyg for 20 min at 10°C in a Beckman Coulter™ Allegra™ 25R centrifuge until clear supernatants were obtained. Supernatants were collected for color development. A calibration curve was previously obtained from a 25 mg/mL phytic acid solution  varying from 0 to 3.5 mg/mL. The modified Wade reagent [0.03% (w/v) FeCl3⋅6H2O + 0.3% sulfosalicylic acid (w/v)] was added to volume samples in a proportion of 3:1 (v/v), thoroughly mixed on a vortex, and centrifuged at 1,000 × g during 10 min at 10°C in a centrifuge Himac CT15RE. The absorbance was measured at 500 nm using the Synergy HT spectrophotometer, Bio-TEK . Final results are expressed in grams of phytic acid per 100 mL of beverage and in mg/g of phytic acid per weight of the beverage.The phytic acid content of the beverages was determined in triplicate using the Gao et al.’s method . Brieflydigesta, were first desalted through PD-10 columns previously equilibrated in saline solutions (0.9% w/v NaCl), following ultrafiltration at 1,400 × g and 4°C  of all samples, in a way to wash them with saline and reduced to volumes containing 50 and 100 μg of protein. The last centrifugation was carried out with a saline solution containing 2 mM CaCl2 and 2 mM MgCl2. For the hemagglutination activity, 5 mL of rabbit erythrocytes was used and washed three times in a saline solution by centrifugation , after which they were incubated with trypsin  and shaken at 120 rpm for 1 h at 37°C, at a final concentration of 0.1% (w/v) in a saline solution. The suspension of 4% (v/v) of trypsinized erythrocytes was stored at 4°C and used for the hemagglutination activity assays. The measurements of hemagglutination activity required the protein analysis  through serially dilution (1:2) in a 96-well microplate. The erythrocyte suspension (50–70 μL) was then added and the microplate was incubated for 30 min at 37°C before visual evaluation. Both positive [Con-A lectin  at 0.5 mg/mL] and negative  controls were prepared. One H.U. (Hemagglutination Unit) is defined as the minimal protein concentration, which induces erythrocyte agglutination (n refers to dilution).Lectins activity (hemagglutination activity) of sample protein extracts was performed according to the method described by Ribeiro et al. . BrieflyThe human colon adenocarcinoma cell line, HT29 (ECACC 85061109), obtained from a 44-year-old Caucasian female, was used. HT29 cells were maintained according to Lima et al. .5 cells/well) were seeded in 24-well plates and allowed to reach 80% confluence. Each well was subsequently supplemented with a fresh medium containing the water-soluble protein extracts of both beverages at a concentration of 100 μg mL–1. The invaded area after 48 h was calculated for each treatment and compared to the initial area at 0 h.For cell migration analysis, the wound healing assay was performed according to Lima and coworkers . HT29 ce4 cells/well), and the soluble protein extracts of both beverages were added at a concentration of 100 μg mL–1 as described above, and the cells were incubated for 48 h. The extracellular medium was then collected, the wells were washed with phosphate-buffered saline (PBS) to remove the unattached cells, and the cell growth and viability were determined using the MTT  assay as described in an earlier study (HT29 cultured cells were seeded in 96-well plates (2 × 10er study .MMP-9 gelatinolytic activities in the culture media after exposure to both beverages for 48 h were determined using the DQ (dye-quenched) gelatin assay, as described by Lima et al. .digesta soluble fractions were then subjected to the DQ gelatinolytic activity assay to test their inhibitory activity upon MMP-9. Briefly, the fluorogenic substrate DQ-gelatin was acquired from Invitrogen  and dissolved in water at 1 mg/mL. All solutions and dilutions were prepared in assay buffer . A 96-well micro-assay plate  was used. Each well was loaded with 0.1 mM  MMP-9 (Sigma), to which 100 μg/mL of total protein fraction from each legume beverage and also their digesta  was added, and the plate was incubated for 1 h at 37°C. Subsequently, DQ-gelatin  was added to each well and the plate was left to incubate again for 1 h. Fluorescence levels were measured (ex. 485 nm/em. 530 nm). In each experiment, positive (no protein fraction) and negative (no enzyme) controls were included for all samples to correct for possible proteolytic activities present in the protein samples. All data were corrected by subtracting the corresponding negative controls. Triplicates were used for each sample.Lupin and chickpea beverages as well as their respective digesta were also tested for lectin activity, mineral content, bioaccessibility estimation, and inhibitory activity on MMP-9 (four levels). The replication number has at least 3.A complete randomized design (CRD) was used due to low variability in beverage production and digestion (two factors). The two pulse beverages were subjected to thirteen different analysis procedures (13 levels), resulting in nine physicochemical results, bioaccessibility value, inhibitory activity on MMP-9, and evaluation of cancer cell migration and proliferation. The two respective p < 0.05). Multiple comparisons were performed by the Tukey HSD test.All statistical processing was carried out using SPSS Statistics . An analysis of variance (one-way ANOVA) was used to assess significant differences between samples at a significance level of 95%  than chickpea beverage (3.24% w/v).Evaluation of the nutritional composition revealed that lupin and chickpea beverages are important sources of protein. Lupin beverage had a higher (4.05% w/v) significant value (The significant higher starch content of the chickpea beverage (1.391 g/100 mL), when compared to the lupin beverage 0.008 g/100 mL), was already expected from the predictable starch content of these pulses: 10 g of dried seeds (in 100 mL) contain 4.5 g of starch in chickpea and 0.7 g in lupin . The val g/100 mLp < 0.05) than the chickpea beverage  of dry seed.in vitro digestion of both beverages  for the majority of the elements  presented a broad polypeptide profile with more representative molecular weights than the chickpea beverage (C), while digesta showed polypeptides with molecular weights under 50 kDa mixed with the commercial enzymes added. Comparing the differences between digesta and the enzyme-blank profiles, the digesta exhibited some low molecular weight peptides (<10 kDa) and several polypeptides under 25 kDa that are distinct from the blank (B). This revealed the high digestibility suffered in the digesta as a result of the enzymes used.Protein digestion by the static o method  has alsoo method . Polypepdigesta, evidencing all the enzymes used during the protocol, as expected. The α-amylase used showed a molecular weight of around 58–62 kDa, the pepsin of 36 kDa, and pancreatin comprises a group of several enzymes with molecular weights from 13 to 64 kDa (The electrophoretic profile of the enzyme control (B) has a match with the beverage o 64 kDa   on MMP-9 activity, cancer HT-29 cell migration, using the wound healing assay, and cancer HT-29 cell proliferation, using the MTT assay.To understand if beverage processing conditions kept the anti-inflammatory and anti-cancer potential of both pulse seeds, particularly in relation to their inhibitory ability on gelatinase MMP-9, a matrix metalloproteinase, which is related to inflammation and cancer disease, we set out to test the p < 0.05) reduce MMP-9 activity and cancer cell migration of HT-29 cells, while not reducing HT-29 cell proliferation in a significant manner. Although both beverages present similar results on MMP-9 activity and cell proliferation, the reduction in cell migration was significantly higher with the lupin beverage when compared to the chickpea beverage (p < 0.05).The results show that both pulse-based beverages were able to significantly , which were considerably higher after in vitro digestion, particularly for the lupin beverage, with a 96% reduction in the MMP-9 activity, as opposed to the chickpea beverage, for which a 48% inhibition was obtained (p < 0.05).Overall, both beverages presented very significant inhibitory activities on commercial MMP-9  established for adults , 57 Tab was highin vitro method and mineral bioaccessibility evaluation of cow milk and soy milk should be used in further studies to compare accurately the differences between these two pulses-based beverages.Despite that, the pulse beverages obtained in this study could not have a nutrition claim for minerals, except for manganese (DRI > 7.5%) , which ain vitro method  to dairy protein intolerance. The possible nutritional claims that could be used for both pulse beverages are as follows: “with no added sugar,” “fat-free,” “very low sodium,” and “source of manganese,” but for lupin beverage itself, it is possible to have one more specific allegation as “source of protein” , taking Furthermore, the studied anti-nutritional compounds (phytic acid and lectins), naturally present in pulse seeds, are highly reduced through beverage processing and did not hinder minerals bioavailability and nonexistence of intestinal malabsorption events.Laminaria ochroleuca seaweed, and another study (However, the mineral content of these pulse beverages, especially in calcium, magnesium, and phosphorus, is much lower compared to milk as mentioned above, and to obtain a sustainable vegetable alternative to milk, using a clean label approach, algae could be added to increase its mineral content. Several studies have been carried out and confirm this approach: Fradinho et al.’s study  showed aer study  increaseer study .In addition to being highly digestible and nutritious, lupin and chickpea beverages showed specific bioactivities of MMP-9 inhibition, as well as a reduction in the migration of colon cancer cells. Furthermore, the MMP-9 inhibitory activity was resistant to the digestion process, and is significantly enhanced, thus suggesting a strong potential as a functional food, for effective preventive diets against inflammatory and cancer diseases, especially those related to the digestive system.The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.IS, ARa, and RF: conceptualization. IS, ARa, AL, and ARi: methodology. CD, MN, ARi, JM, and AL: validation. CD, JM, AL, and MN: formal analysis. CD, JM, RA, CM, and ARi: investigation. IS, RF, RA, and CM: resources. CD and AL: writing—original draft preparation. CD, ARi, AL, IS, RF, RA, CM, ARa, and MN: writing—review and editing. CD and AL: visualization. IS and RF: supervision. IS: project administration and funding acquisition. All authors have read and agreed to the published version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This Frontiers in Veterinary Science Women in Veterinary Neurology and Neurosurgery collection of scientific articles presents the innovative work of female neurologists working in the UK, Europe, and North America. The series comprises 13 articles showcasing original research and case reports in various fields of Veterinary Neurology and Neurosurgery, including advances in diagnostic imaging techniques and novel neurosurgical procedures.Boudreau et al. describes DWI MRI findings of spontaneous canine CVA in relation to the time of clinical onset, the DWI type (EPI vs. non-EPI), and the presence or absence of a haemorrhagic component of the lesion. The results of this study help to inform the appropriate clinical interpretation of these sequences by veterinary neurologists and neuroradiologists.Diffusion MRI is a specific sequence that detects and quantifies water diffusivity, which is the molecular motion (Brownian movement) of water and represents an intrinsic feature of tissues. Diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) are MRI sequences routinely used in the diagnostic investigation of suspected cerebrovascular accidents (CVA) in people . There iRemelli et al. highlights the usefulness of low and high-field MRI in complementing clinical and laboratory findings in the diagnosis of SRMA. In this retrospective study, including 70 dogs with SRMA, the MRI showed abnormalities in 98.6% of dogs, with the majority (87.1%) being MRI features suggestive of meningeal inflammation. T1W FAT-SAT sequences were particularly useful in detecting meningeal enhancement. In addition, the contrast enhancement of the synovium of the cervical articular facets and the epaxial muscles was detected in 48.6% of dogs.Steroid-responsive meningitis-arteritis (SRMA) is an inflammatory disorder of probable immune mediated origin, commonly recognized in dogs . It typiLaws et al. describes the clinical and diagnostic findings, treatment , and outcomes of dogs with SEE that were presented to five referral hospitals in the UK. This study provides detailed information on the presenting clinical signs, MRI findings, laboratory investigation results, treatment, and long-term outcomes. The results of this study inform client communication and clinical decisions on canine SSE management.Spinal epidural empyema (SEE) is characterized by the “accumulation of purulent material in the epidural space of the vertebral canal” . It can Goffart et al. shows that end-on fluoroscopy, with or without inversion, is a highly accurate technique for the intraoperative evaluation of bicortically placed Steinmann pins' position in the canine thoracolumbar vertebral column. Three-dimensionally printed patient-specific drill guides have been used to improve the accuracy of implant placement in the canine spine  of the central and peripheral nervous system.The author confirms being the sole contributor of this work and has approved it for publication.


Osteoarthritis (OA) is an immensely pervasive joint disorder—typically concerning large weight-bearing joints—affecting over 30 million people in the United States, with this number predicted to reach 67 million by 2030 . Its patRecently, various molecular targets, such as, interleukin-1 (IL-1), transforming growth factor-β (TGF-β), matrix metalloproteinases (MMPs), etc., have been reported to be linked in the etiopathogenesis of OA ,5,6; howOver the last decade, there has been a heightened interest in the use of biologics, including autologous biologics such as platelet-rich plasma (PRP), bone marrow concentrate, adipose tissue, and allogenic biologics, such as perinatal tissue for regenerative medicine applications specifically for musculoskeletal disorders . Perinathomogenized amniotic membrane suspended in physiological solution). These patients were assessed at baseline (prior to injection) and at 3, 6, and 12 months post-injection using the International Knee Documentation Committee (IKDC) and Visual Analogue Scale (VAS) scores. No severe adverse events were reported throughout the duration of the study. Statistically significant improvements (p < 0.05) were observed for both IKDC and VAS at all follow-up time points compared with the baseline. Interestingly, both IKDC and VAS scores regressed by 6 months, indicating a lack of long-lasting effect of ASA; however, at the 12-month follow-up, both scores indicated significant improvement compared to the baseline. In spite of this, the results from this study indicated that a single intra-articular injection of ASA is safe and showed positive clinical outcomes, which is in accordance with other published clinical trials utilizing ASA for the treatment of knee OA [In this Editorial, I will focus on a recently published clinical trial by Natali et al. , titled, knee OA ,22,23. Thomogenized amniotic membrane suspended in physiological solution’, whereas previously published studies [amniotic suspension allograft that contains human amniotic membrane and human amniotic fluid-derived cells’, with no description of the formulation protocol. Thus, I believe, it is essential to maintain uniformity in the composition of similarly named biologics and to describe the formulation protocol to allow the repeatability and reproducibility of the results of prospective trials assessing the safety and efficacy of these biologics throughout the world, in order to ultimately justify their clinical usage.In addition to the aforementioned limitations, one of the concerns, not limited to this study, is lack of consistency in the composition of similarly named biologics. For instance, this study used the term ASA and defined it as a ‘ studies ,22,23 declinicaltrials.gov . These trials are summarized in In summary, despite limitations, I applaud the efforts of the authors, as this study positively adds to the current literature suggesting that the administration of amniotic tissue including ASA is safe and justifies the need for a high-powered, prospective, multi-center, double-blind, randomized controlled trial with a longer follow-up duration to further establish the efficacy of ASA to alleviate symptoms associated with knee OA, thereby, possibly providing a new minimally invasive therapeutic alternative for patients suffering with knee OA. As of 13 October 2022, there are three ongoing clinical trials registered on


Although the dominant view in the literature suggests that work-related anxiety experienced by employees affects their behavior and performance, little research has focused on how and when leaders’ workplace anxiety affects their followers’ job performance. Drawing from Emotions as Social Information (EASI) theory, we propose dual mechanisms of cognitive interference and emotional exhaustion to explain the relationship between leader workplace anxiety and subordinate job performance. Specifically, cognitive interference is the mechanism that best explains the link between leader workplace anxiety and follower task performance, while emotional exhaustion is the mechanism that best explains the link between leader workplace anxiety and follower contextual performance. Additionally, we examine how follower epistemic motivation serves as a boundary condition for the effect of leader anxiety on follower performance outcomes. Results from a 2-wave study of 228 leader-follower dyads in a high-tech company mostly supported our theoretical model. We conclude the study with a discussion of the theoretical and practical implications of our findings. In the current “age of anxiety,” the dual influences of unfavorable environmental factors and individual psychological characteristics cause many people to experience varying degrees of anxiety in the workplace . WorkplaConsidering the harmful consequences of workplace anxiety on employee attitudes and behaviors, it is not surprising that a large number of articles have focused on the negative effects of workplace anxiety . DespiteSecond, prior anxiety research has focused almost exclusively on the prediction of in-role behaviors (task performance) that reflect formal job expectations. However, the effect of anxiety on extra-role behaviors beyond the job description  has been overlooked . Task peAccordingly, our study aims to better understand how and when leader workplace anxiety influences subordinates’ task and contextual performance. We draw on the Emotions as Social Information (EASI) model  to examiOur research makes three main contributions to the literature. First, we advance the anxiety literature by deriving a conceptual framework from past theory and research to describe the mechanisms by which leader workplace anxiety affects follower performance. Based on the Emotion-as-Social-Information theory, we tested how follower emotional exhaustion and cognitive interference mediate the relationship between leader anxiety and employee job outcomes. Second, we extend the anxiety literature by simultaneously considering the influence of workplace anxiety on subordinates’ task performance and contextual performance. Because previous studies have found that task and contextual performance involve different behavior patterns and have unique antecedents , consideAnxiety is defined as the tendency to experience tension and worry with regard to the appraisal of threatening situations . SpielbeIn this study, we focus on leader workplace anxiety for several reasons. First, leaders not only need to complete their work tasks but also undertake important aspects of people management such as developing the relationship with subordinates or even handling complex relationships between multiple members of the organization at different levels of the hierarchy . Second,via two distinct routes: inferential processes and emotional reactions. Inferential processes refer to an emotional observer’s inference about the emotion expressor’s true emotions and intentions  theory provides a comprehensive framework to understand how emotions are interpreted and used by those who perceive them . The EAStentions . These ptentions . In thisEmotional reactions are the processes through which emotions expressed by one individual influence the emotions of another individual who observes them . Unlike Drawing on the EASI model, the emotional expressions of others can elicit the cognitive processes of observers, which may subsequently affect the observers’ behavior . As emotWe expect that leader workplace anxiety engages followers’ cognitive processes and interferes with their ability to process immediate events, thereby reducing their job performance. High job performance requires sustained effort over extended periods, requiring employees to mobilize cognitive resources such as high levels of attention and focus. This means that any kind of cognitive interference may divert employees’ attention from their current job task, resulting in lower task performance. At the same time, cognitive interference also exhausts a number of personal resources, including time, energy, and effort . This caHypothesis 1a: Leader workplace anxiety has a negative indirect effect on followers’ (a) task performance and (b) contextual performance via follower cognitive interference. Specifically, leader workplace anxiety is positively related to follower cognitive interference, which is negatively related to task performance and contextual performance.Emotion expression can also affect the behavior patterns of observers by triggering their emotional reactions, and then exerting interpersonal influence in the organization . When leHypothesis 1b: Leader workplace anxiety has a negative indirect effect on follower (a) task performance and (b) contextual performance via follower emotional exhaustion. Leader workplace anxiety is positively related to follower emotional exhaustion, which is negatively related to task performance and contextual performance.Although the inferential processes and emotional reactions described above can lead to lower employee performance, it is important to determine when each process is likely to produce negative work outcomes. According to the EASI framework, the interpersonal effects of emotional expression in the work environment depend on the observer’s motivation and ability to process the information conveyed by these emotions, also known as epistemic motivation . EpistemSpecifically, individuals with high epistemic motivation were more likely to view their immediate emotional responses to expressed emotion as inaccurate or irrelevant . InsteadGiven these findings, when followers experience cognitive interference caused by their leader’s expression of anxiety, we expect that the effect of such cognitive interference on task performance depends on each follower’s level of epistemic motivation. Employees with high epistemic motivation will be more likely to reflect on other people’s emotions and engage in deeper analysis and information processing of the root causes of leaders’ anxiety . This wiHypothesis 2a: Follower epistemic motivation will moderate the negative relationship between cognitive interference and task performance, such that this negative relationship is weaker when epistemic motivation is higher rather than lower.We also expect that epistemic motivation will change the relationship between the emotional exhaustion felt by an employee and her contextual performance. The EASI theory posits that the interpersonal effects of emotional expressions depend on the observer’s ability to process and interpret the information conveyed by these expressions. The shallower the epistemic motivation, the stronger emotional reaction an observer will have to others’ displays of emotion .Emotional exhaustion depletes an individual’s resources such as energy, optimism, and self-efficacy . To presHypothesis 2b: Follower epistemic motivation will moderate the negative relationship between emotional exhaustion and contextual performance, such that this negative relationship is weaker when epistemic motivation is higher rather than lower.In the above sections, we have proposed that employees’ epistemic motivation serves as a moderator variable affecting two mediation processes  that link leader anxiety to subordinate job performance. Our model predicts that in leader-follower interactions, workplace anxiety displayed by leaders can reduce contextual performance and task performance through emotional responses and cognitive processes. We predict that followers’ epistemic motivation levels are a boundary condition on this indirect effect. Employees with high epistemic motivation rely less on emotional states and instead process information more deliberately and systematically to guide their behavior. When they experience cognitive interference due to the leader’s expression of workplace anxiety, they will interpret this information as a signal that leaders are dissatisfied with their work results and will work harder to improve task performance.In contrast, employees with low epistemic motivation tend to process information in a fast, relaxed, and heuristic manner. They respond to displays of emotion with their own emotions. Therefore, when they experience emotional exhaustion due to the leader’s expression of workplace anxiety, individuals with low epistemic motivation further amplify the panic and stress conveyed by their leader. This emotional exhaustion causes employees to be self-critical  and deplHypothesis 3a: Follower epistemic motivation will moderate the indirect effect of leader workplace anxiety on follower task performance via follower cognitive interference, such that this indirect effect will be weaker when epistemic motivation is high than when it is low.Hypothesis 3b: Follower epistemic motivation will moderate the indirect effect of leader workplace anxiety on follower contextual performance via follower emotional exhaustion, such that this indirect effect will be weaker when epistemic motivation is high than when it is low.We collected matched supervisor-subordinate dyadic data at two time points from several high-tech enterprises located in northern China. The authors contacted each company’s human resource (HR) director and assisted the HR department with organizing the participants. Each company’s HR department helped us randomly invite dyads with direct supervisor-subordinate relationships to participate in our research. Participants were informed that we were interested in their true feelings and behaviors at work to diagnose current issues within the company and that they could quit at any time. In total, we successfully solicited 279 supervisor-subordinate dyads to participate.Before participants filled out the questionnaire, we assured them that their answers would be kept confidential and used only for research purposes. Surveys were coded before distribution and were distributed to project team leaders and members. We collected time-lagged data at two different points to alleviate common method bias.At time 1, we asked 279 team leaders to rate their workplace anxiety and subordinates to rate their emotional exhaustion and cognitive interference. In addition, we asked supervisors and subordinates to report their demographic information including gender, age, education, and supervisor-subordinate tenure. In total, we received 256 pairs of supervisor-subordinate dyadic data at the first time point, giving a response rate of 92%.SD = 8.35), and 156 subordinates (68%) held an undergraduate or graduate university degree. The average supervisor-subordinate tenure was 1.81 years (SD = 1.60). Following the procedures recommended by At Time 2 (1 month later), the 256 subordinate members who participated in the Time 1 survey assessed their task performance, contextual performance and epistemic motivation. This time, we received a total of 234 responses, for a response rate of 91%. After matching the superior-subordinate data we obtained a final sample of 228 supervisor-subordinate pairs. In the final sample, 128 subordinates (56%) were male. Their average age was 32.46 years old (strongly disagree to 7 = strongly agree).We followed α = 0.933).We adapted the eight-item scale from α = 0.93).Using an eight-item scale from α = 0.89).Cognitive interference was assessed with the five-item subscale of the Cognitive Interference Questionnaire Items developed by α = 0.82).We employed the eleven-item scale developed by α = 0.97).We utilized the fourteen-item scale developed by α = 0.86).Task performance was assessed with the ten-item scale developed by We controlled for the gender of the participants because previous studies have found that men and women may experience different levels of workplace anxiety for several reasons. First, biological factors such as genetic predisposition and hormonal influences may predispose women to experience higher levels of anxiety in different workplace contexts . Second,2 = 1939.82, p < 0.01, Comparative Fit Index = 0.91, Root Mean Square Error of Approximation = 0.05, Standardized Root Mean Square Residual = 0.07. Alternative models that combined cognitive interference and emotional exhaustion, as well as contextual performance and task performance, did not improve the fit compared to the six-factor model. Therefore, the six-factor model was retained for hypothesis testing.To investigate the discriminant validity of focal variables, we performed a series of confirmatory factor analyses with all items as indicators. Fit indices for a six-factor model including workplace anxiety, emotional exhaustion, cognitive interference, epistemic motivation, task performance, and contextual performance were satisfactory : χ2 = 19r = 0.240, p < 0.01) and emotional exhaustion . Follower cognitive inference was significantly and negatively correlated with task performance and contextual performance . Emotional exhaustion was also negatively correlated with task performance and contextual performance .We first adopted hierarchical regression and via cognitive interference. As shown in b = 0.159, p < 0.001), which was negatively related to task performance  and contextual performance . As reflected in b = –0.064, 95% CI . However, the indirect effect of leader workplace anxiety on contextual performance through cognitive interference was not significant, b = –0.004, 95% CI . Thus, H1a was only supported for task performance.Hypothesis 1a proposes that leader workplace anxiety indirectly affects follower task and contextual performance via emotional exhaustion. In the parallel mediation model, leader workplace anxiety was positively related to follower emotional exhaustion , which was negatively related to follower task performance  and contextual performance . Similarly, the bootstrap analysis showed that the indirect effect of workplace anxiety on follower contextual performance through emotional exhaustion was significant, b = –0.056, 95% CI . However, the specific indirect effect of leader workplace anxiety on follower task performance through emotional exhaustion was not significant, b = –0.007, 95% CI . Thus, H1b was only supported for contextual performance.Hypothesis 1b predicts that leader workplace anxiety indirectly affects follower task and contextual performance b = 0.104, s.e. = 0.029, p < 0.01). Simple slope tests and the interaction plot depicted in simple slope = –0.642, p < 0.001). When epistemic motivation was low (1 SD below the mean), the negative relationship between followers’ cognitive interference and task performance was stronger . Although cognitive interference was negatively related to task performance in the case of both high and low epistemic motivation, the relationship was stronger when epistemic motivation was low.Hypotheses 2a predicts that follower epistemic motivation will moderate the relationship between cognitive interference and task performance, such that this negative relationship is weaker when follower epistemic motivation is higher rather than lower. Results in b = 0.009, s.e. = 0.029, ns). Thus, Hypothesis 2b was not supported.Hypothesis 2b proposes that epistemic motivation will moderate the relationship between follower emotional exhaustion and contextual performance, such that this negative relationship is weaker when epistemic motivation is higher rather than lower. Results presented in b = –0.023, 95% CI = ] and lower  levels of epistemic motivation. Using a directional index of moderated mediation test ] or lower  levels of epistemic motivation. Thus, our results support Hypothesis 3a, but not 3b.Hypotheses 3a and 3b propose indirect effects which are moderated by epistemic motivation. As shown in ion test , we founDrawing on the Emotion-as-Social-Information theory, our study investigated how leader workplace anxiety affects employee task performance and contextual performance through two pathways: emotional exhaustion and cognitive interference. We also found that employee epistemic motivation is a key boundary condition in this indirect relationship. Our findings offer implications about how leader anxiety can affect subordinate performance.First, we extend the job performance literature by examining the differential influence mechanisms of leader anxiety on employee performance. Previous research on the impact of anxiety on performance has mainly studied performance as a one-dimensional construct, with few studies suggesting that anxiety might have different effects on different dimensions of performance. Our research showed that anxiety affects different types of performance through different mechanisms. While cognitive interference mediated the effect of leader anxiety on task performance, emotional exhaustion mediated the effect of leader anxiety on contextual performance.Second, we respond to calls for a fine-tuned framework to explore the connection between leader anxiety and follower behaviors . PreviouThird, our study extends EASI theory in several important ways. Specifically, the EASI framework provides a mechanism to explain how leader emotions affect follower behaviors and introduces the social function view of emotions into the leadership field. We apply EASI theory to an organizational setting and show how its predictions apply to the effect of managers’ emotional displays on their subordinates. Specifically, we found that leader anxiety can affect subordinates’ job performance by triggering both their inferential processes and emotional reactions. These findings help to generalize the principles of EASI theory to the ongoing leader-follower relationships that occur in actual organizations. Furthermore, we contribute to the literature on the EASI model by examining the effect of anxiety, a discrete emotion universally experienced in the workplace, on individual behavior. Previous studies using this model have examined the effects of discrete emotions such as anger , disappoOur findings also offer insights into managerial practice. First, employee performance is not only affected by the employee’s own anxiety, but also their leader’s anxiety. Therefore, leaders need to be aware that their emotional displays may have a considerable impact on their followers’ behaviors. More specifically, we suggest leaders should learn to adjust their anxiety in the workplace and try to avoid showing excessive anxiety in front of subordinates. To alleviate the anxiety of team leaders and reduce the impact of leader anxiety on employees’ work results, organizations should reduce the work pressure of leaders and guide them to effectively use their rest time to adjust their emotions . Second,Despite the theoretical contributions and practical implications discussed above, our research is not without limitations, which provide avenues for future work. First, all variables we measured were evaluated by a survey, which may lead to a certain degree of common method variance . To alleSecond, our study only explored how subordinates’ epistemic motivations act as boundary conditions affecting the relationship between leader workplace anxiety and subordinate job performance. Therefore, future research could continue to explore other possible contextual factors, such as leaders’ emotion regulation strategies, employees’ personal traits, the quality of leader-member exchanges, and organizational climate. For example, subordinates who are more professionally adaptable and resilient are likely to be less susceptible to the severe consequences of leader workplace anxiety, and leaders who are adept at employing emotion regulation strategies can reduce the impact of their anxiety on their employees.Third, considering the widespread use of work groups in organizations, another important direction for future research is to consider the anxiety levels of groups. In work teams, individual employees may transmit their anxiety to other team members through emotional contagion .Fourth, we were only able to collect empirical data from China, a culture that features high power distance and a highly collectivistic orientation. Although the theoretical arguments discussed in our study are not culturally bound, we encourage future research to use cross-cultural data to demonstrate the generalizability of our findings.Today, workplace anxiety is more prominent than ever before, leading to noticeable consequences for employees and organizations. This study established, tested, and discovered that leader workplace anxiety affects subordinate performance through both emotional and cognitive mechanisms. Meanwhile, our study also contends that employee epistemic motivation acts as an antidote to the influence of leader anxiety on subordinate job performance. Overall, these findings provide further insights for researchers and practitioners to understand the consequences of workplace anxiety.The datasets generated for this study are available on request to the corresponding author.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent from the patients/participants or patients/participants legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.SZ contributed to the data curation, formal analysis, and original draft and revision of the manuscript. LC contributed to the conceptualization and revision of the manuscript. LZ contributed to the supervision and guidelines. AS contributed to the review and editing of the manuscript. All authors contributed to the article and approved the submitted version.