Cholangiocarcinoma (CCA) is an aggressive tumor characterized by a poor prognosis. Therapeutic options are limited in patients with advanced stage of CCA, as a result of the intrinsic or acquired resistance to currently available chemotherapeutic agents, and the lack of new drugs entering into clinical application. The challenge in translating basic research to the clinical setting, caused by preclinical models not being able to recapitulate the tumor characteristics of the patient, seems to be an important reason for the lack of effective and specific therapies for CCA. So, there seems to be two ways to improve patient outcomes. The first one is developing the combination therapies based on a better understanding of the mechanisms contributing to the resistance to currently available chemotherapeutic agents. The second one is developing novel preclinical experimental models that better recapitulate the genetic and histopathological features of the primary tumor, facilitating the screening of new drugs for CCA patients. In this review, we discussed the evidence implicating the mechanisms underlying treatment resistance to currently investigated drugs, and the development of preclinical experiment models for CCA. Cholangiocarcinoma (CCA) is a kind of “biliary tract cancer” and can be subdivided into intrahepatic CCA (iCCA), perihilar CCA (pCCA), and distal CCA (dCCA) according to the anatomic location. CCA development may be associated with several risk factors, such as opisthorchis viverrini or clonorchis sinensis infection , hepatolUnfortunately, few more compounds have been approved for CCA treatment. The shortage of therapeutic strategies in CCA might be attributed to two main reasons. The first one is that the poor preclinical models fail to represent the multiple features of the tumor of the patient, leading to the dilemma that many drugs which show well anti-tumor efficiency in preclinical research finally fail in clinical trials , 13. CCAThe second reason for the drug shortage in CCA treatment is the developed drug resistance. For these drugs going beyond clinical studies, limited benefits were observed mainly because of intrinsic or acquired treatment resistance in CCA. A better understanding of the mechanisms underlying drug resistance in CCA is meaningful for developing novel therapeutic strategies for the treatment of CCA. Great efforts have been devoted to investigating the mechanisms contributing to the drug resistance of CCAs. CCAs could downregulate pro-apoptotic regulators (caspase-3 and caspase-9) to overcome chemotherapy-induced death . DiosgenHerein, we review the current development of experimental models in the studies of drug sensitivity in CCA and evidence implicating the mechanisms underlying treatment resistance to currently investigated drugs, hoping to provide new insights into developing new therapeutic targets or treatment strategies to improve the prognosis of patients with CCA.As a result of the increasing incidence of CCA worldwide and the dismal prognosis of patients, new therapeutic strategies for CCA are urgently needed. In this regard, ideal preclinical models, which can facilitate our understanding of heterogenicity within CCA and molecular mechanisms responsible for CCA development, will pave the way for identifying new therapeutic targets and determining the effectiveness of therapies through high throughput experiments. Next, we will review the development of experimental models for CCA.CCA cell lines are the most commonly used and well-characterized experimental model. During the last three decades, more than fifty CCA cell lines have been established after the first one was established in 1985 , 19. Thein vitro culture model-organoid and patient-derived xenograft (PDX) in vivo models to break this tension , and this can be rectified by in vivo mouse models. For example, paclitaxel and nanoparticle albumin-bound paclitaxel exhibited similar anti-tumor effect in in vitro experiment; whereas only nanoparticle albumin-bound paclitaxel could inhibit tumor growth in in vivo models, for its ability to reverse CAF-mediated paclitaxel resistance, offering evidence for the advantage of in vivo model in studying the role of TME in drug resistance  mice  mice . Neoplasmmarized Table 2.mmarized , we onlyin vivo  superfamily of proteins , and theThe expression of the copper transporter (CTR1) (SLC31A1), a transporter of platinum derivatives, is significantly downregulated in CCA, which might result in reduced chemosensitivity to these drugs . It has To reduce drug uptake, the intracellular concentration of active drugs can also be influenced by increased efflux of drugs mediated by ABC family proteins, such as ABCB, ABCC and ABCG . These pMultidrug resistance-associated proteins (MRPs) are transporters belonging to the ABCC family. Upregulation of MRP1 is found in gemcitabine-resistant CCA cell lines established by stepwise exposure to increasing concentration of gemcitabine, and the sensitivity of these cells to gemcitabine was recovered after silencing MRP1 . MRP3, aABCG2, a member of the ABCG family, is another bump located at the plasma membrane and plays a significant role in chemotherapeutic resistance in various cancers through efflux of anticancer drugs, such as doxorubicin , methotrSome drugs are transported into cells in an inactivated form of prodrugs that need to be further activated by cellular enzymes, and the loss of these enzymes will cause drug resistance. For example, orotate phosphoribosyl transferase (OPRT) is associated with activation of 5-FU into FdUMP, and a reduced expression of OPRT has been found to be associated with poor response to 5-FU in CCA, suggesting that OPRT could be used as a predictor for the response to 5-FU in CCA . BesidesCCAs are characterized by high interpatient and intratumor heterogeneity, which makes it difficult to overcome the problem of Darwinian selection of most resistant subclones. Drug treatment pressure may elicit subclones that are naturally resistant to drugs after eliminating the sensitive cells. For example, drug-induced selection of tumor subclones with tyrosine kinase domain mutation is the main mechanism of resistance to BGJ398 in CCA patients carrying FGFR2 fusions . Cancer via the repair of 5-FU induced DNA lesion , DNA mismatch repair (MMR), and recombination repair. The downstream target of p53, p53R2, is a ribonucleotide reductase associated with repairing damaged DNA, and the increased expression of p53R2 has been found to be involved in gemcitabine-resistance in CCA . ExcisioA lesion . RAD51 pA lesion . Obama eA lesion .via downregulation of pro-apoptotic mediators or upregulation of anti-apoptotic factors, exhibiting resistance to these drugs. In CCAs, high expression levels of Bcl2 and low expression levels of Bax have been associated with resistance to cisplatin and 5-FU  belongs to the extrinsic pathway of apoptosis and is a promising therapeutic target for CCA . HoweverSeveral oncogenic signaling pathways, critical in tumor progression, also participate in the regulation of chemoresistance in CCA Figure 2The tumor microenvironment (TME), composed of fibroblast, endothelial cells, immune cells, and extracellular matrix, represents an important component of tumor growth and progression. CCA is characterized by rich stromal, where cancer-associated fibroblasts (CAF) and extracellular matrix play significant roles in promoting CCA progression , 151. ReDespite the progress in the development of experimental models and the great efforts devoted to developing new targeted therapies in CCA, the clinical outcomes of CCA patients remain to be poor, mainly for the challenge of translation of basic science to the clinical setting, and the intrinsic or acquired resistance to the therapeutic agents. Here, we have summarized the different experimental models available for CCA research. All these models have their advantages and drawbacks. Despite the apparent drawbacks, the 2D cell line model and cell line-based xenograft animal model are the most frequently used models for their being easy to operate and not costly. Novel technologies, such as CRISPR/CAS9 library and high-throughput drug screening, could be applied in these models to help identify critical genes implicated in drug resistance, favoring the development of combination treatment therapeutic strategies for CCA patients. Single-cell RNA-seq technology greatly enriched our knowledge of the heterogeneous property of tumors, and tumor heterogeneity was regarded as an important cause for treatment resistance . TheoretThe resistance to anticancer treatment is another reason for the dilemma in CCA treatment. A better understanding of the molecular mechanisms underlying the poor response of CCA to anticancer treatment will facilitate the identification of therapeutic targets for improving the efficiency of anticancer treatments. Several mechanisms have been associated with chemoresistance in CCA: reducing import of drugs or increasing efflux of drugs; inactivation of drugs; changes in drug molecular targets; enhanced ability to repair drug-induced DNA alterations; re-balancing anti-apoptotic and pro-apoptotic factors; overactivation of oncogenic signaling pathway; pro-survival microenvironment induced by cancer cells. Combination therapies that reverse the mechanisms underlying multidrug resistance in CCA seem to be a promising therapeutic strategy. For example, to enhance intracellular drug concentration, several strategies have been proposed: combined usage of anticancer agents with compounds that alter membrane fluidity of cancer cells to facilitate anticancer drug influx ; encapsuAll authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


Proper functioning of the digestive system is ensured by coordinated action of the central and peripheral nervous systems (PNS). Peripheral innervation of the digestive system can be viewed as intrinsic and extrinsic. The intrinsic portion is mainly composed of the neurons and glia of the enteric nervous system (ENS), while the extrinsic part is formed by sympathetic, parasympathetic, and sensory branches of the PNS. Glial cells are a crucial component of digestive tract innervation, and a great deal of research evidence highlights the important status of ENS glia in health and disease. In this review, we shift the focus a bit and discuss the functions of Schwann cells (SCs), the glial cells of the extrinsic innervation of the digestive system. For more context, we also provide information on the basic findings regarding the function of innervation in disorders of the digestive organs. We find diverse SC roles described particularly in the mouth, the pancreas, and the intestine. We note that most of the scientific evidence concerns the involvement of SCs in cancer progression and pain, but some research identifies stem cell functions and potential for regenerative medicine. The chief functions of our digestive system are to break down food, absorb nutrients, and eliminate waste products. It consists of an alimentary tract, which spans from the mouth through the esophagus, stomach, and bowel, as well as accessory organs, notably the pancreas, liver, and gall bladder . The perENS is the key for proper motility, secretion, and defence in the digestive system and, to some extent, can function independently of the central nervous system (CNS) . ExtrinsMost of the cells that make up the PNS, such as neurons and Schwann cells (SC), originate from the multipotent  neural cThe term SCP refers to a set of cell populations that form directly from NC cells or NC-derived boundary cap cells . SCPs arThe formation of mature SCs from SCPs includes an intermediate stage with a characteristic immature Schwann cell (iSC) phenotype. The iSCs participate in axon sorting and promote nerve maturation. Some iSCs become associated with larger axons in a 1:1 ratio and mostly become myelinating SCs, while others remain associated with several smaller axons and remain non-myelinating . In the It is important to stress that, united by NC origin, PNS glia are not uniform and present a broad spectrum of cells with unique morphology and distinct phenotypes. These differences become apparent already during embryonic development . In addiPerhaps not surprisingly, this rich variety of PNS glial cells fulfil a wide repertoire of functions. In this review we focus on the functions of SCs, some of which might appear novel or non-canonical in the sense that they are not merely restricted to PNS homeostasis ,39,40. ASome of the SC functions become especially apparent in disease settings and injury. In this case, SCs switch to an activated state, meaning they become less differentiated, and start dividing and overexpressing some markers characteristic to glial precursors, for example, nerotrophin receptor p75. Wallerian degeneration that occurs after nerve injury is a classic example of glial cell plasticity, where myelinating SCs change their phenotype dramatically and become specialized repair cells . SimilarTumours are often hyperinnervated and neural signalling contributes to the dynamic tumour environment in many ways ,49. LateThese exciting findings regarding extrinsic innervation prompted us to provide a comprehensive overview of known SC functions in the digestive system. In this section, we describe the functions of SCs and SC progenitors in the main organs of the digestive system. We summarise them in TP53, a gene most commonly mutated in head and neck cancers, further promotes innervation in mouse oral epithelia, while in patients with OSCC, increased innervation correlates with worse overall survival . P. P152]. To complicate things, both CXCL-12 and IL-6 can also be secreted by SCs ,77,154. Autophagy, a process that activated SCs use in nerve repair to reduce cell membrane size and clear myelin debris , is alsoSCs can be activated or participate in PDAC tumorigenesis indirectly by communicating with other cells of the stroma. For example, by producing CCL2, SCs attract CCR2-expressing monocytes that eventually differentiate to tumour macrophages and promote nerve invasion . An axonTogether, these studies demonstrate a complex context-dependant paracrine function of SCs in the stroma of pancreatic tumours and warrant further exploration, for example, to establish whether the dispersed SCs found in the tumour stroma are associated with the axons or are independent and which exact nerves contribute SCs to the tumour microenvironment. A more thorough investigation, involving 3D imaging of normal and tumour sites in mouse and human tissue, similar to that performed in the endocrine pancreas, might answer these questions ,119. ImpThe gall bladder receives sympathetic, parasympathetic, and sensory innervation with major input provided by the vagus nerve . AccordiCholangiocarcinoma (CCA) is a rare aggressive cancer with limited response to chemotherapy that affects the bile ducts outside or within the liver . These tGall bladder cancer is another rare biliary tract malignancy with frequent PNI that has a prognostic impact and correlates with the late stage of the disease. In this case, tumour cells use the neural route to invade tissues surrounding the extrahepatic bile ducts . The rolThe parasympathetic and sympathetic nervous system provides extrinsic innervation of the liver through the portal area. Sympathetic innervation comes from the celiac and mesenteric ganglia, while parasympathetic innervation is represented by branches of the vagus nerve stemming from the dorsal motor nucleus, which can either directly reach liver tissue or synapse at the hepatic plexus . These afferent and efferent nerves gain access to liver tissue along the portal vein, hepatic artery, and bile ducts. In humans, unlike rodents, sympathetic innervation reaches deeper into the liver lobules along sinusoids and connects with the parenchymal cells . HepaticAutonomic innervation plays an important role in liver physiology and homeostasis. Parasympathetic impulses regulate nutrient sensing, bile production, regulation of homeostasis, and response to toxins. Sympathetic innervation ensures the release of noradrenaline, which is involved in glycogenolysis. Innervation also plays a critical role in liver regeneration processes, food intake, hepatic blood flow, and circadian rhythm regulation ,187. AbeHomeostasis of the liver is regulated by the interaction of cytokines, growth factors, and signal transducers secreted by Kupffer cells and other cell types. Coordination of these factors within various cells and even organs is involved in the hepatic regeneration process. Various roles of the autonomic nervous system have been described in this process. . For exaDespite the accumulating evidence on the importance of liver innervation in regeneration and disease, the role of glial cells in these processes has not been studied so far. Scarce data are limited to observations of SCs in association with unmyelinated nerve fibers in the Disse space close to perisinusoidal cells in human liver tissue specimens  and in tThe intestines are constantly exposed to large amounts of foreign material that has to be sensed and monitored . The ENSIn addition to ENS neurons, the glia are involved in virtually all basic aspects of gut homeostasis and disease, including motility disorders ,199,200,In addition to intrinsic innervation, ensured by ENS, mammalian gut function also depends on extrinsic innervation. The small intestine consists of the duodenum, jejunum, and ileum, and functions to breakdown and absorb nutrients. It is extrinsically innervated by the parasympathetic and sympathetic nervous system. Parasympathetic fibres of the vagus nerve are responsible for the control of secretions and motility, while sympathetic fibres of splanchnic nerve ganglions control blood vessels, secretions, and motility . The larDhh-Cre mice [Dhh-Cre-traced neurons causes oligoganglionosis. Similarly, ongoing post-embryonic neurogenesis by extrinsic SCPs takes place in zebrafish [ENS of the gut develops from the progenitors of vagal and sacral NC that colonise the developing bowel . HoweverCre mice ,27. SCP ebrafish . In someebrafish . Indeed,ebrafish ,218,219.ebrafish . TogetheIn Hirschprung disease (HSCR), due to impaired progenitor migration, colon segments remain underpopulated by ENS progenitors and lack ENS ganglia, eventually causing obstruction and inflammation of these areas. However, hypertrophic extrinsic innervation of aganglionic segments containing many SCs is a hallmark of HSCR . Soret aPatients with inflammatory bowel diseases (IBD), such as ulcerative colitis and Crohn’s disease, are exposed to chronic inflammation of the colon or other segments of the gastrointestinal tract. Enteric glia are actively involved in neuroimmune modulation, and many studies, sometimes with contrasting results, have linked ENS glia with IBD. In ulcerative colitis, inflammation-activated glial cells trigger neurotoxicity and cause neuronal death . On the Even with the recent development of the field, many questions remain unanswered. For example, the extent and type of innervation in organs of the digestive system is not yet completely mapped, with some contrasting reports ,134. AdvDespite a clear morphological distinction between ENS glia and myelinating SCs , they shBased on the publications we reviewed, several translational directions appear. One is clearly related to the functions of SCs in carcinomas, such as the promotion of PNI, immune modulation, and mediation of pain signals. Preventing SC activation or targeting SCs to limit paracrine stimulation of the tumour microenvironment could be one possible strategy, especially for tumours with a high prevalence of PNI, such as PDAC. This could be achieved by interrupting SC communication with neuronal, tumour or immune cells, for example, using neurotrophic factor or TRK inhibitors that could target several of such interactions ,232,233.Dhh-traced SCs, suggesting the existence of another neuron progenitor [In intestinal inflammatory disorders, the promotion of the neurogenic potential of SCs is an exciting strategy, as exemplified by the successful use of GDNF enemas in mouse models of HSCR . There aogenitor . A betteogenitor . Progeniogenitor .Another direction is to improve the islet grafts for transplantation. Here, harnessing the original glial cells in the islets for autotransplantation or incorporation of glial components into pluripotent stem cell (PSC)-derived islets could be among the possible strategies. This could potentially promote revascularisation and reinnervation of grafts and improve islet performance .In the sources we reviewed, the use of co-culture approaches and conditioned media is commonplace. SCs have strict culture requirements and rely on constant trophic support and contact with the ECM substrate. Cells of various sources, including commercial immortalized, primary and induced, can be used, but primary SCs from a cognate PNS source would be advantageous . Human SCultured glial cells acquire a different transcriptional profile , and theThis has been achieved for gut ENS by differentiation of PSCs under defined conditions that produce gut organoids with glial cells . In anotHaving researched the recent literature regarding the functions of extrinsic innervation and SCs in the organs of the digestive system, we find diverse SC roles described particularly in the mouth, the pancreas, and the intestine. We note that most of the scientific evidence concerns the involvement of SCs in cancer. Most of the research data comes from SC studies in the pancreas, where glial precursors and glia are involved in the development of the endocrine pancreas and are observed in association with the cells of healthy endocrine islets and acini and become ‘activated’ in disorders of both the endocrine and exocrine pancreas. In diabetes, the number of SCs expands and their functions have yet to be established, but they may interact with cells of the immune system. In a pancreatic tumour, SCs modulate the immune response and perception of pain, and promote tumour spread by attracting tumour cells to the nerves. Similarly, in the oral epithelium and salivary glands, SCs mediate pain and promote PNI. Taking into account the parallels between the mechanisms of carcinoma progression and propensity to invade nerves in other parts of the digestive system , similar functions of SCs could be expected there.In the gut, SCPs give rise to ENS neurons and glia. In some species, these functions persist into adulthood where, apparently, extrinsic nerve SCs can act as stem cells to replenish ENS. Several mechanisms of action of SCs were identified and could be used for therapeutic interference (summarised in


The aims of the study were to investigate the burden for health care workers (HCWs) who suffer from occupational-related adverse events (ORAEs) while working in contaminated areas in a specialized hospital for novel coronavirus pneumonia, to explore related risk factors, to evaluate the effectiveness of bundled interventions, as well as to provide scientific evidence regarding the reduction of risks concerning ORAEs and occupational exposure events.The study was completed using a special team of 138 HCWs assembled for a specialized hospital for novel coronavirus pneumonia in Wuhan, dated from February 16 to March 26, 2020. The incidence of occupational exposure was determined by data reported from the hospital, while the prevalence of ORAEs was derived from questionnaire results. The relation coefficients of ORAEs and the variable potential risk factors are analyzed by logistic regression. After the risk factors were identified, targeted organized intervention was implemented and chi-square tests were performed to compare the incidence of occupational exposure and the prevalence of ORAEs in contaminated areas before and after the interventions.P < 0.05). Among non-PPE-related factors, insomnia is associated with the majority of ORAEs in contaminated areas. Significant differences were achieved after organized interventions in the incidence of occupational exposure of HCWs  and the prevalence of ORAEs in contaminated areas .Ninety one out of 138 (65.94%) had reported ORAEs with 300 (27.96%) cases of ORAEs being recorded in a total of 1073 entries into contaminated areas. The prevalence of different ORAEs include 205 tenderness (24.73%), 182 headache/dizziness (21.95%), 138 dyspnea (16.65%), 130 blurred vision (15.68%), and 95 nausea/vomiting (11.46%). Personal protective equipment (PPE) is significantly associated with ORAEs in contaminated areas (During the epidemic period of novel severe respiratory infectious disease, the burden of the ORAEs in contaminated areas and the risk of occupational exposure of HCWs were relatively high. In time, comprehensive and multi-level bundled interventions may help decrease the risk of both ORAEs and occupational exposure. In clinical practice, the occupational exposure events during the pandemic include not only respiratory exposure, but also blood-related and other mucosal exposures. In the hospitals specializing exclusively on COVID-19 medical care in the epidemic regions, occupational exposure has become one of the most critical risks threatening the lives and health of HCWs.34 Based on the information of an unpublished report on occupational exposure from a COVID-19 hospital in Wuhan, the frequency of occupational-related adverse events (ORAEs) in contaminated areas appeared relatively high. Large scale studies on ORAEs in contaminated areas and the risk of occupational exposure for HCWs were rare before the COVID-19 pandemic. This study attempted to identify the prevalence of ORAEs in HCWs working in the contaminated areas, to explore the incidence and risk factors of various adverse events (AEs), and to determine the effectiveness of bundled interventions during the outbreak of emerging severe respiratory infectious diseases, providing evidences to establish reasonable and scientific interventions to decrease the risk of ORAEs.Occupational exposure carries significant risk of threatening the safety of health care workers (HCWs). During the severe acute respiratory syndrome (SARS) outbreak in 2003, 931 HCWs were infected, accounting for 19% of all clinically diagnosed casesA total of 143 HCWs in a special team urgently assembled for a COVID-19 specialized hospital to work in Wuhan from February 16 to March 26, 2020, were asked to join this investigation by completing a questionnaire. The inclusion criteria are having a clear awareness, the ability to understand the content of the questionnaire, and voluntarily signing an informed consent. Incomplete and obviously inappropriate questionnaires were excluded. A total of 138 (96.5%) valid questionnaires were returned.The information obtained from the questionnaire included age, gender, specialty and qualification of the HCW, weather temperature (highest and lowest) of the workday, number of times entering as well as the duration in the contaminated area, ORAEs. Self-identified causes of ORAEs were documented by the study participants, including personal protective equipment (PPE)-related factors  and non-PPE-related factors .The clinical presentations included in the ORAEs are nausea, vomiting, dizziness, headache, tenderness, palpitation, dyspnea, blurred vision, falls, epistaxis, and stick/cut injuries. Tenderness was defined as pain of skin caused by redness, blisters, or even ulcer at the site of facial bony eminence , due to wearing the mask, goggles, and protective face screen. Occupational exposure events were defined as needle stick/cut exposure, broken skin/mucosal exposure, and respiratory exposure during occupational activities.This is a self-controlled study. The participants were given bundled interventions. The differences in the incidence of occupational exposure events and prevalence of ORAEs before  and after the interventions  were compared.Based on the factors discovered from our previous experience in the infectious disease unit and at the early stage of the special team, each participant received bundled interventions  and 2.P values < 0.05 were considered to be significant.All investigations were implemented via Wenjuanxing System, a popular and largest online questionnaire platform in China. Statistical analyses were performed with SPSS statistical software version 25.0 . Quantitative data were shown with $\overline x \pm s$ according to distribution characteristics. Count data were represented by n (%). Two independent samples, t and chi-square tests, were used in group comparisons with quantitative and count data, respectively. A multivariate logistic regression analysis was conducted to analyze the risk factors. The incidence and rank of ORAEs documented in contaminated areas are shown in Relationships between ORAEs and presumed risk factors are shown in Tenderness was mainly correlated with PPE-related factors, such as mask suffocation, goggles oppression, and glasses/goggles fogging. Work time in the contaminated area may be an independent risk factor for tenderness. For every 1 hour increased working in the contaminated area, the risk of tenderness would increase by 81.8%. Meanwhile, tenderness may be associated with insomnia, as shown in Headache and dizziness were correlated with goggles oppression, the sultriness of protective suit, insomnia, and car sickness, as shown in Dyspnea was correlated with mask suffocation, sultriness of protective suit, insomnia, and work time in the contaminated areas, as shown in Blurred vision was correlated with glasses/goggles fogging, overfatigue, and car sickness. In fact, overfatigue and car sickness may increase the risk of blurred vision in the contaminated areas, as shown in Mask suffocation, goggles oppression, and glasses/goggles fogging may also be correlated with nausea/vomiting in the contaminated areas, although the main reason was recent dyspepsia. Insomnia may also increase the risk of nausea/vomiting, as shown in Insomnia, overfatigue, mask suffocation, and protective suit sultriness may increase the risk of palpitation. For each hour increase in work time in a contaminated area, the likelihood of palpitation would increase by nearly 68.3%, as shown in 2=61.49, P < 0.001). The incidence density of ORAEs in contaminated areas before interventions was 73.15%, which was significantly higher  than post-intervention (33.23%).The comparison of occupational exposure events and ORAEs pre- and post-interventions is shown in 5The COVID-19 pandemic highlighted the necessity of health agencies worldwide to be well prepared to combat large-scale emerging infectious diseases. In the context of the outbreak of a novel severe respiratory infectious disease, especially at the early stage, reliable information of the pathogenic etiology and mechanism, mode of transmission, clinical presentation characteristics, and susceptible populations is lacking – and the availability of effective vaccines can be months to years away. To prevent cross-infection in hospitals, which may represent major spreading events of the infection and a significant impact to the occupational safety of HCWs, a standard and effective protocol of occupational protection is essential. Protective clothing, masks, and other PPE for HCWs entering wards to manage patients are already well accepted in the infectious disease units. In China, the dates when the peak of COVID-19 occurred were particularly unusual. It was during the traditional Spring Festival when manufacturing work was suspended almost all over China; thus, there was a marked shortage of production and supply of the PPEs. The vital role of medical care in the event of a huge number of patients, the fear of the unknown due to lack of sufficient information on the disease itself, and the pressure of public opinion place HCWs under huge psychological pressure. We experienced a stage when ORAEs, such as nausea/vomiting, headache/dizziness, tenderness, palpitation, dyspnea, and blurred vision, frequently occur in contaminated areas, and the incidence of occupational exposure, such as respiratory exposure, syncope, and needle stick injuries, was also relatively high, causing great physical and psychological burdens on HCWs.6 Mask suffocation is a major factor of ORAES. We think the following measures can be considered to reduce AEs: First, reducing the respiratory resistance by better manufacturing; second, decreasing the work duration and intensity by increasing the number of HCWs per shift would certainly improve the subjective feeling of mask suffocation; third, as irritating smells of masks can aggregate the perception of ORAEs, increasing the purity of the materials and improving the manufacturing process may help reduce some uncomfortable smells of masks. Many studies have reported that pressure injuries on skin associated with medical devices are caused by tightly worn goggles and masks. These injuries not only cause skin damage and pain, but also increase the risk of skin infection. We found that the use of protective dressing can reduce local friction, help absorb exudation, and promote repair while still ensuring that the airtightness of the mask and goggles are adjusted properly. If any pressure injuries are found, they should be properly treated. Antifogging agents applied to goggles are the most common way to prevent blurred vision. Although many goggles and protective face screens have antifogging features, moisture-resistant coatings are frequently destroyed by disinfectants. Povidone-iodine or detergents, such as handwashing solutions, may be reasonable substitutes when antifogging agents are in shortage. Anionic surfactants in detergents can reduce surface tension effectively to achieve moisture resistance; molecular iodine formed after povidone-iodine oxidation may also achieve moisture protection. Those alternative methods can generally achieve more than 2-hour antifogging effects, reducing the occurrence of ORAEs caused by blurred vision.7 Last, but not least, overuse and misuse of PPE should also be discouraged. Overuse of PPE by overlapping/double protective clothes, goggles, and masks results in a significant waste of already limited medical resources and increased disposal burden. Among non-PPE-related factors, HCWs were found to have a higher prevalence of insomnia, and it was also associated with most ORAEs in contaminated areas. Similar results have been reported in previous studies.10 When providing diagnoses and treatments to critically ill patients, due to frequent overtime work with higher intensity and occupational safety risk, HCWs would inevitably break sleep habits, which then lead to disruption of the biological clock. Long-term and persistent stressful events not only increase the risk of newly onset insomnia, but also enhance chronic insomnia. To mitigate the burden of insomnia for this group of people, the prevailing protocol is to deploy professional psychotherapists with active individual intervention, supplemented by the use of sedative hypnotic medicines. On the other hand, Car sickness is a risk factor that arises in a particular background. During the COVID-19 outbreak in Wuhan, HCWs were gathered in dormitories located more than 40 kilometers from the hospital and commuted with specially assigned shuttle buses so as to facilitate workforce management and to avoid cross-infection. As a result, multiple cases of ORAEs in contaminated areas associated with car sickness had been observed. Therefore, measures to reduce car sickness, such as reducing commute time by moving to closer lodging, training drivers to avoid operations that might induce car sickness, and distributing prophylactic pills to HCWs vulnerable to car sickness, may decrease the risk of ORAEs. Additionally, working duration in the contaminated “red zone” was also a crucial risk factor. The increased risk was associated not only with the clinical workload, but also the lengthy procedure to take off PPEs. There are potential risks of infection with several HCWS undressing PPE simultaneously within a limited space. Actually, there had been reports of infection events due to inappropriate PPE undressing every now and then.11,12 Therefore, HCWs had to undress PPEs sequentially following a strict protocol, which became a factor contributing to extended work time in contaminated areas. The problem became serious when numerous HCWs were required to enter the contaminated area at the same time as a large number of patients were admitted. Additional ameliorating measures to reduce risk of ORAEs for non-PPE related factors include setting up reasonable shift arrangement and increasing the number of HCWs per shift to alleviate fatigue and insomnia. In our experience, screening of AEs  before entering contaminated areas, and appropriate intervention, when necessary, helped effectively reduce the negative impact of non-PPE-related factors. Needless to say, sufficient instructions and training on PPE on/off protocols are critical to ensure that HCWs are cultivating a good routine habit. One of the main reasons for occupational exposure at the early stage of the COVID-19 outbreak was insufficient protection for HCWs due to lack of PPE stocks and poorly implemented infection control measures. A study has confirmed that sufficient PPE could effectively decrease the occupational exposure of HCWs.13 Even if given sufficient supplies and assuming all being used adequately and reasonably, it’s still extremely important to ensure a thorough implementation of infection control measures, especially when many HCWs without much experience in dealing with infectious disease join the special workforce to combat the pandemic. For instance, by conveying the knowledge, improving the perception and behavior, strengthening the notion that “behavioral isolation” is superior to “physical isolation,” it is effective to maximize the contribution of PPEs in our experience.This study found that a long duration use of PPEs was the most important cause of ORAEs, which might be related to generally high-level protection while the effectiveness and necessity were not clearly defined. Although it is clearly not advisable to lower the protection level when the transmission mode of a novel severe respiratory infectious disease is unclear, optimizing the procedures of PPEs should be one of the key research areas to improve occupational safety for HCWs and enhance the quality of medical care, so that we can be more prepared for the emerging infectious diseases in the future. There are several key components of PPEs, and each may be improved to alleviate the risk of ORAEs. The protective clothing usually becomes sultry easily. Improving the air permeability of protective clothing material could be a practical way to reduce the burden of long-duration work while wearing these gowns. In practice, Tyvek medical protective clothing has excellent air permeability, with effective protectiveness, and has been highly approved for frontline HCWs.14 but also increase HCWs’ confidence to work against the viral infection. At the early stage of the pandemic, concerns and fears related to COVID-19 were prevalent among HCWs.15 So far, a majority of interventional research studies have assessed occupational exposure based on the SHEL model17 and the Reason model18; these methods analyzed occupational exposure caused by mismatchs between individual factors and the corresponding microenvironment from the perspective of system theory. The bundled interventions of this study were based on the findings of early investigations and then focused on taking actions against the most relevant issues. The bundled interventions had been effective, as indicated by the results of this study. Through these interventions, many HCWs became more compliant with the protection procedures; some incorrect perceptions, such as the notion that more and thicker PPEs offer better protection, were scientifically addressed. The results of our investigation and implementation in clinical practice indicate that this intervention model has high effectiveness and feasibility.One advantage of our bundled intervention model is the ability to make all aspects of the infection and AE risk controllable. Professional measures of infection control can not only decrease the infection rate,The limitations of this study are mainly reflected in 2 aspects. First, the self-control at different time points of clinical practice in this study is imperfect, as the HCWs are likely to get more experienced to deal with the daily routine at the later stage of this study. However, it is difficult to set a control to eliminate the influence of experience on our study results. Second, the statistical analyses of various types of ORAEs are limited by sample size. Thus, more intensive and in-depth studies are warranted in the future to support our results and conclusions.In summary, our study indicates that HCWs have suffered a high risk of occupational exposure and a high prevalence of ORAEs working in contaminated areas, related to various factors during the early stage of the COVID-19 epidemic. Timely, comprehensive, and multi-level interventions can significantly decrease the incidence of ORAEs and occupational exposures for HCWs working in contaminated areas.


In recent years, integrative physiology is gaining increased attention; novel findings in the area of molecular and systemic cardiopulmonary interaction overgrow the classical opinion that the adoption and transport of oxygen and elimination of carbon dioxide are their only functions. Mechanical, molecular, endocrine, and neural subsystems of the autonomic nervous system are integrative scales of these two mutually dependent organs, providing a wider range of adaptation of the organism to the growing requirements of the environment, fitness, and pathological changes.In the present Frontiers Research Topic, an international selection of investigators contributed original data to increase our current understanding about the complex cardiorespiratory interactions, providing novel findings about physiologic and pathogenic mechanisms and possible therapeutic advancement concerning the area of cardiorespiratory medicine.Several contributions focused on new methods in order to properly investigate cardiorespiratory interactions, especially considering that cardiac and respiration signals have periodic oscillatory dynamics that can also be time-varying, so this increasing complexity have to take into account that frequency, coupling strength and coupling function are also varying in time.Lukarski et al. developed a procedure for determination of the time window based on data analyses, as opposed to the previous practice of arbitrary choice. This study shows that the cardiorespiratory coupling strength and the similarity of form of coupling functions continuously change according to the breathing frequency, with greater values for slower breathing.In this view, Cui et al. provided a further contribution in developing quantitative measures for respiratory sinus arrhythmia (RSA). RSA has profound significance in physiology and pathology and is usually evaluated by means of two techniques, the time and the frequency domain. By mathematically modeling this modulation, the authors proposed a quantitative measurement of RSA by means of the cardiopulmonary resonance function (CRF) and cardiopulmonary resonance indices (CRI) that are derived by disentanglement of the RR-intervals series into respiratory-modulation component (R-HRV), and non-respiratory component (NR-HRV), using Granger causality function. Their results suggest a superior representation ability of this technique in comparison with heart rate variability (HRV) and cardiopulmonary coupling index, with profound significance in physiology, pathology, and in possible future clinical applications.Wessel et al. tested whether the xBRS method similarity among shapelets (that are short chunks of HRV time series), whose “shapes” are related to the respiration cycle; their results show distinctive patterns stable across age and sex, that are not only indicative of sleep and awake, but that are able to identify one more, potentially more sensitive indicator of sleep initiation. Additional studies are necessary that would involve contemporary classic polysomnography and novel, proposed index. In case of positive results, one of the possible applications of this approach could be related to public and general safety, by developing alarm systems that are able to recognize drowsiness in the person under the observation.One of these conditions, the deep sleep, is typically associated with an increased cardio-respiratory coupling, that corresponds to a maximal RSA. Based on that assumption, Limanskaya et al. examined a specific sleeping alteration, the central sleep apnea, by evaluating electroencephalogram, ECG, eye movements, air flow, thoracic respiratory muscle movements and myoelectric activity of the stomach and the duodenum in cats with sudden arrest of breathing during sleep. Their results suggest that the stereotypic coupling of activities in various visceral systems during episodes of central sleep apnea most likely reflects a complex adaptive behavior rather than an isolated respiratory pathology.Another study by Matić et al. explored the physiological background of the non-linear operating mode of cardiorespiratory oscillators as the fundamental question of cardiorespiratory homeodynamics and as a prerequisite for the understanding of neurocardiovascular diseases. Their results show that cardiac and respiratory short-term and long-term complexity parameters have different state-dependent patterns supporting the hypothesis of a hierarchical organization of complexity regulatory mechanisms. In particular, a specific and comprehensive cardiorespiratory regulation in standing with 0.1 Hz breathing suggests that this state could represent the potentially most beneficial maneuver for cardiorespiratory conditioning, critically important for intensive care rehabilitation of artificially ventilated patients, as most actual in this moment- COVID 19 patients.Another study by Schüttler et al. investigated the link among hyperventilation, sympathetic activity, and periodic repolarization dynamics . Their results suggest increased PRD values after hyperventilation, providing further insights about the alteration of ventricular repolarization associated to the hyperventilation.The interaction between breathing alterations and autonomic nervous system activity is another important subject, especially considering their possible pathogenic role in the pathogenesis of ventricular arrhythmias , that is a technique capable of improving cardiorespiratory interactions. In particular, they observed the effect of different degrees of IMT in amateur cyclists, analyzing electrocardiograms, non-invasive arterial pressures, and thoracic respiratory movements and quantifying cardiorespiratory coupling by means of squared coherence function, and causal model-based transfer entropy. In this way the authors demonstrated that the post-training increase of cardiorespiratory coupling might be the genuine effect of some rearrangements at the level of central respiratory network and its interactions with sympathetic drive and vagal activity.Other two studies focused on the cardiopulmonary interactions during physical activity. Ruiz-Blais et al. specifically evaluated HRV  in pairs of non-experts in different vocalizing conditions; their results show that HRV becomes more coupled when people make long (>10 s) sounds synchronously and this synchronization persists when the effect of respiration is removed: these results suggest that since autonomic physiological entrainment is observed for non-expert singing, it may be exploited as part of interventions in music therapy or social prescription programs for the general population.The interaction between cardiorespiratory coupling and singing is the focus of another study of this Research Topic. Previous investigations about the effects of singing together focused on the synchronization of HRV, experienced by choir singers . These complex mechanisms suggest particularly important implications in some diseases and during rehabilitation treatment. An unbalanced autonomic nervous system activity associated with different diseases can represent an important factor contributing to the occurrence of many specific cardiovascular complications  to the time series of HRV, systolic blood pressure variability and respiration pattern, demonstrating that obesity is associated with blunted involvement of non-baroreflex RSA mechanisms and with a reduced response to postural stress .Obesity is another pathological condition that is associated with an increasing occurrence of cardiovascular complications even in childhood and adolescence: in this condition autonomic nervous system alterations can represent an important factor contributing to the initiation and progression of many cardiovascular disorders. However, the impaired parasympathetic control in obese patients seems to be associated with a different relative contribution of baroreflex and non-baroreflex  mechanisms underlying the origin of RSA. In particular, The relationship between neural autonomic and humoral factors seems to be particularly important during rehabilitation of patients with chronic obstructive pulmonary disease (COPD):  might be a beneficial strategy against post-operative complications.Furthermore, inflammatory markers can have a role in modulating autonomic nervous system in specific conditions, especially after surgery. It is well-known the association among cardiac and extracardiac surgery, inflammation and autonomic nervous system activity (Amar et al., In conclusion, the high-quality contributions of this Research Topic significantly enriched our knowledge about the field of Integrative Physiology, shedding light on complex physiologic and pathogenic mechanisms, with relevant clinical implications for patients' management. These studies also provide important suggestions for further investigation in this emerging area.MA and TB contributed to the conception, design, and drafting of the work. TB and AV revised the draft. TB, AV, and MA approved the final version, agreed to be accountable for all aspects of the work, ensuring that questions related to the accuracy, or integrity of any part of it are appropriately investigated and resolved. All authors contributed to the article and approved the submitted version.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.


They are involved in the pathogenesis of neurodegenerative disorders such as Alzheimer's disease, amyotrophic lateral sclerosis, and Parkinson's disease , 2. In ain vitro and in vivo model systems, and have identified miRNA biomarkers, miRNA regulatory networks, miRNA pathways, and looked at miRNA therapeutics. These valuable studies shed light on the effective diagnosis and treatment of neurological disorders and have revealed the importance of studying miRNAs and their role in neurological diseases.In recent years, there have been many noteworthy studies looking at the role of miRNAs in neurological disorders. These have examined miRNA functions This Research Topic aims to examine the role of miRNA in neurological diseases. The special issue brings together five interesting papers, including three Reviews, a Systematic Review, and a Perspective article, discussing the role of miRNAs in multiple sclerosis, Alzheimer's disease, diabetic neuropathy, and Clathrin-Mediated Endocytosis.Zhou et al. performed a meta-analysis, aiming to assess the overall diagnostic accuracy of circulating miRNAs for multiple sclerosis, an immune-mediated chronic inflammatory demyelinating disease of the central nervous system. They searched publications from PubMed, Web of Science, EMBASE, the Cochrane Library, Chinese National Knowledge Infrastructure databases, and related papers up to July 20, 2019, to collect 600 patients with multiple sclerosis and 389 controls. These results suggest that miRNAs had reference value for multiple sclerosis diagnosis.The Systematic Review by Kou et al. reviewed the dysfunctional regulation of a series of miRNAs that were associated with the critical roles in the pathogenesis of Alzheimer's disease including the dysfunctional regulation of miRNAs associated with the deposition of Aβ, intracellular aggregation of hyperphosphorylated Tau protein, the loss of synapses, neuroinflammation, autophagic dysfunction, and aging. The perspective article written by Lukiw reviewed the current understanding of miRNA-146a, attributing to neurological diseases including Alzheimer's disease and prion disease. This study discusses the critical role of signaling along the NF-kB–miRNA-146a axis in brain cell fate. Clathrin-Mediated Endocytosis is a vital process for cell life and development. Gerasymchuk et al. discussed the role of miRNA regulating endocytic genes in neurodegeneration and cancer/invasion. They concluded that some endocytic-associated miRNAs with strictly proven roles in cancer and neurodegeneration are worth paying more attention to as possible therapeutic targets. Diabetic neuropathy is the most prevalent chronic complication of diabetes mellitus. miRNA-based treatment of diabetic neuropathy has shown evidence of therapeutic potential. Fan et al. reviewed the latest research progress on the roles of miRNAs as biomarkers and as potential clinical therapeutic targets in diabetic neuropathy. Moreover, the promise of exosomal miRNAs as therapeutics was discussed and recommendations for future research on miRNA-based medicines were provided.Alzheimer's disease is the most common form of dementia among older people and accounts for around 60% of all dementia cases. miRNAs are easily detected in brain and immunological cell types. In summary, these five papers provide valuable research or review works in understanding the relationship between miRNAs and neurological disorders. We hope this special issue can contribute to a better understanding of the potential of miRNA therapeutics for neurological diseases.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Patients affected with gliomas develop a complex set of clinical manifestations that deeply impact on quality of life and overall survival. Brain tumor-related epilepsy is frequently the first manifestation of gliomas or may occur during the course of disease; the underlying mechanisms have not been fully explained and depend on both patient and tumor factors. Novel treatment options derive from the growing use of third-generation antiepileptic drugs. Vasogenic edema and elevated intracranial pressure cause a considerable burden of symptoms, especially in high-grade glioma, requiring an adequate use of corticosteroids. Patients with gliomas present with an elevated risk of tumor-associated venous thromboembolism whose prophylaxis and treatment are challenging, considering also the availability of new oral anticoagulant drugs. Moreover, intracerebral hemorrhages can complicate the course of the illness both due to tumor-specific characteristics, patient comorbidities, and side effects of antithrombotic and antitumoral therapies. This paper aims to review recent advances in these clinical issues, discussing the medical management of gliomas through an updated literature review. Management of gliomas avails of multimodal and integrated curative options consisting of neurosurgical resection, chemotherapy (CT) and radiotherapy (RT). Despite recent therapeutic advances, including the introduction of novel anti-angiogenetic drugs like bevacizumab  and regoSpecifically, the control of seizures and symptoms related to peritumoral edema, and the treatment and prevention of hemorrhagic and thromboembolic events are core to the medical management of gliomas. These clinical issues are usually managed, along with curative treatments, by neuro-oncological multidisciplinary teams  requirinThe relevance of supportive care in the management of gliomas in clinical practice is rapidly growing. This is due to the trend towards improvement in survival, the increasing incidence especially in the elderly  and the This review aims to summarize knowledge and suggest approaches to optimize medical management of gliomas drawn from recent literature.BTRE contributes to morbidity and impacts on the quality of life of patients through the very occurrence of seizures, the side effects of medications and cognitive deterioration. Control of epilepsy therefore becomes paramount in the medical management of gliomas .Mechanisms of BTRE have been partly explained and probably depend on intrinsic epileptogenicity  and modification of the peri-tumoral environment  and glial gap-junctional transmembrane communication proteins) especially in low grade tumors . High grYoung age (< 40 years old)  has beenFrequency of seizures at onset and cumulative incidence during the illness are higher in low-grade gliomas (LGG) than in HGG. Seizures at the onset have been reported in up to 88% of LGG . OligodeRecently, association between glioma molecular markers and BTRE has been explored. Patients with isocitrate dehydrogenase 1 (IDH1) mutated gliomas have been found more likely to develop pre-operative seizures than wild-type IDH1 , 19; thiTumor location plays a significant role in conferring a higher risk of BTRE. The association with seizures is higher in cortical and juxtacortical tumors than in deep neoplasms , 22. TheThe volume of the glioma could also influence the risk of seizures. It was observed that HGGs presenting with seizures are usually smaller than those presenting with other symptoms, e.g., related to mass effect. Conversely, in the case of LGG, a larger tumor is more likely to present with seizures .epilepsia partialis continua) can develop during the course of illness  which increase the metabolism of chemotherapeutic agents and glucocorticoids. Notably, patients affected with gliomas are considered at higher risk than the epileptic population to develop side effects , 52. SeiCurrently, valproate is largely used to control seizures in gliomas due to its efficacy and possible positive influence on survival . Some coDiscontinuation of therapy in patients who achieve freedom from seizures is a frequent and challenging clinical issue. Factors to consider before withdrawing AEDs are the severity of seizures, the anti-tumor treatments performed, the evaluation of side effects, and psychosocial impact  . Two yeaWhile a recurrence of seizures in GBM patients with postoperative control of seizures should be considered as a marker of possible tumor relapse , this coElectroencephalography (EEG) is useful for diagnosing a seizure related to a glioma when there is clinical uncertainty about the diagnosis, or for patients with nonconvulsive seizures . In glioGliomas are associated with vasogenic edema, which occurs when plasma-like fluid enters the extracellular space through an BBB driven by a hydrostatic pressure gradient. The BBB leak is probably due to a reduced numbers of normal astrocytes in tumor tissue and to an excessive secretion of angiogenetic factors such as vascular endothelial growth factor (VEGF) . Newly fSteroids are the mainstay of edema treatment, but their exact mechanism is not completely understood. Dexamethasone could decrease brain edema inducing restoration of normal BBB permeability mimicking the BBB-inducing properties of astrocytes . In addiNotably, corticosteroids can change the appearance of gliomas on MRI, with effects on the size of the contrast-enhancing tumor core and of peritumoral edema , 93, parThese data confirm that dexamethasone use should be limited to symptomatic patients and those with radiological findings of increased ICP. Moreover, it should be tapered to the lowest dose as soon as patient’s condition improve.Alternative therapy or adjunctive therapy with a potential steroid-sparing effect have been considered. In patients with elevated ICP and consequent risk of herniation, mannitol and hypertonic saline, diuretics and fluid restriction, together with elevation of the bedhead and hyperventilation, help to rapidly reduce ICP in an emergency setting. On the other side, for long term control of edema and in refractory cases, antiangiogenic agents as bevacizumab  and cediranib (a tyrosine kinase inhibitor of VEGF receptors) have been proposed –97. It hPatients with HGG present with the highest risk of tumor-associated VTE out of all cancer patients, with observed rates as high as 7.5-39% depending on the use of thromboprophylaxis and the detection method , 99–102.Outcome data for malignant glioma patients are similar to those for cancer patients; a large neurosurgical cohort showed that patients with VTE had a 30% higher risk of death within 2 years  compared to those without VTE .VTE risk factors in glioma patients can be grouped into patient-, tumor-, and treatment-related risk factors Table 1.CT and anti-VGEF agents increase VTE risk in glioma –113. RT Biomarkers suitable to assess the VTE risk in HGG patients were recently described: platelet count, D-dimers, sP-selectin levels, factor VIII activity, prothrombin fragment 1 + 2, and leucocyte count. The authors also identified high-risk and low-risk patients with two risk assessment models .A central role in the pathogenesis of VTE in gliomas has been suggested for tissue factor (TF) , the majVery recently, a role in cancer-related VTE has been suggested for prodoplanin  which isAn assessment of VTE risk based on a validated assessment tool is crucial in cancer patients , 121. InFor patients undergoing major surgery for cancer, guidelines recommend continuing pharmacologic thromboprophylaxis for at least 7 to 10 days . In braiAlthough the risk of VTE remains high throughout the course of the disease, to date no study has demonstrated an advantage from prolonging prophylaxis beyond the perioperative period. A placebo-controlled trial, the PRODIGE study , aimed t3, and other usual contraindications.There is no standardized approach to the management of glioma patients suffering from a VTE because most existing guidelines address the general cancer population. Patients with brain tumors have unique management issues, including fear of ICH, medication compliance, and common drug-drug interactions. Despite fears of ICH, it appears to be safe to offer full therapeutic anticoagulation to patients with brain tumors presenting with a VTE , 101. InMost guidelines recommend LMWH over vitamin-K antagonist for treatment of acute VTE in cancer patients –131. In Current data suggest similar efficacy and safety for edoxaban as compared with dalteparin for VTE treatment in patients with brain tumors. However, evidence is so far very limited, and further studies are warranted. According to the current evidence, the most updated ASCO practice guidelines  recommenThe duration of secondary prophylaxis in patients with gliomas after a venous thromboembolism event should be planned individually, weighing the risk of ICH against the risk of VTE recurrence in patients whose tumor cannot be considered stable. However, it is lifelong in most patients  .Since glioma treatment, as brain RT and CT, may alter the structure and integrity of the intracranial vessels, it has been associated with an increased risk of both ischemic and hemorrhagic cerebral events. Specifically, RT plays an important role in glioma management but its involvement in accelerating atherosclerosis is well recognized, as is its influence in the development of aneurysms, teleangectasias, and cavernomas in pediatric primary brain tumors treated with RT –149. TheConsidering the effect of CT on hemorrhagic risk in glioma patients, a possible negative influence has been attributed to bevacizumab, a recombinant humanized monoclonal antibody directed against VEGF and used for the treatment of recurrent and progressive glioblastoma multiforme , 154 DesConversely, regorafenib demonstrated to improve both progression-free and overall survival in recurrent glioblastoma patients ; regorafCurrently there is not specific treatment for glioma-related hemorrhages. If surgical management is not required, edema treatment and blood pression control are the main therapy goals . In patiThis paper reviewed some important symptoms and complications of gliomas, focusing on epilepsy, edema, and thromboembolic and hemorrhagic events. Further relevant clinical issues also commonly arise in supportive care, as the management of cognitive deficits, fatigue, mood disorders, and hematological complications of CT. These aspects need to be carefully prevented and treated since failure to control them can negatively influence patient survival and quality of life. Notably, adequate medical management can prevent avoidable hospital admissions, determining higher healthcare costs . TherefoThe quality of available evidence on these topics is low and several points are yet to be clarified. For instance, there is still an open discussion on the role of prophylactic AED use, which most guidelines do not recommend. The majority of studies supporting this approach were performed with older AEDs. Recently released AEDs could reduce potential harm deriving from adverse effects and drug-drug interaction and make the risk/benefit ratio more favorable. Conversely, there is no evidence that they are more effective than older AEDs in preventing seizures in glioma patients. At the same time, routine use of perioperative prophylaxis, although frequent, is based on limited evidence . In the Thromboembolic events in cancer patients, including gliomas, are a topic of growing interest and increasingly the focus of studies and guidelines. Since DOACs have shown a significant reduction in the risk of intracerebral bleeding compared with vitamin k antagonists in patients with both atrial fibrillation and VTE, the idea that the same advantage could be present in subjects with brain tumors is reasonable. However, the number of patients with brain tumors included in recent trials to test the use of DOACs in cancer patients with established VTE was very small, and the risk of intralesional bleeding in patients with gliomas undergoing anticoagulant therapy with said agents has not yet been established. More trials are needed to define the anticoagulant agent with the best efficacy and safety profile in this subgroup of cancer patients.The risk of ICH in glioma patients is not only related to anticoagulation and intralesional bleeding but is encountered throughout the whole illness trajectory. Future studies could establish if there are radiological and molecular markers that could better estimate ICH risk and stratify the glioma population in order to adjust therapies and render these very severe events preventable. Moreover, the influence of antiangiogenetic drugs on this risk should be better assessed.MZ, LN, and AB conceived and drafted the review. BG, VZ, and GL revised the manuscript for important intellectual content. All authors contributed to the article and approved the submitted version.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.


Fermented dairy products include a wide range of foods that are highly appreciated worldwide. The production processes, the type of milk, practices adopted during feeding, milking, and beyond can affect the quality and safety characteristics of these products. A vast array of microorganisms can be found in milk, and microbial succession during fermentation of multiple products, as well as during cheese ripening contributes to the desired properties of these foods. In addition to sensory and safety aspects, microorganisms present in fermented dairy foods can positively affect the health of people due to their potential probiotic nature and the production of beneficial metabolites such as vitamins, antioxidants, and antimicrobial compounds.Despite recent innovations on microbial cultivation techniques, and the widespread use of a myriad of newly developed “omic” techniques, including genomic approaches through the use of High Throughput Sequencing in combination with advanced metabolomics, there are many dairy fermented products with limited information about their microbial composition (diversity) and dynamics (succession). This is particularly true for traditional regional products, which represent a rich niche for discoveries involving microorganisms with better conditions for recovery from disturbances and more reliable and robust for industrial production. The unknown microbiota can reveal new mechanisms of interactions and functions and new bioactive molecules with beneficial effects on the sensory aspect of food and on human health.microbiological safety and quality aspects of fermented dairy products.The goal of this Research Topic was to deepen the current knowledge in the microbial safety and quality aspects of fermented dairy products, gathering studies on the different types of products, practices, and how the microbiota affected the quality and safety attributes of these much-appreciated foods. This Research Topic brings a series of 14 articles related to the Pineda et al. tackle product diversity according to Brazilian geographical regions, the microbiological safety, and the huge challenges faced by the Brazilian artisanal cheese sector. The authors highlight that one of the main challenges is related to risks associated with foodborne pathogens when the quality of the raw milk is unsatisfactory. Artisanal cheese regulations have constantly been revised and adapted, considering the small-scale production of Brazilian artisanal cheeses, thus research collaborative efforts may help the sector to move toward better quality and safety goals. It is noteworthy that the economic income of thousands of rural families depends on artisanal cheese production in the country and there is an increased appreciation for artisanal cheese consumption in recent years. Geronikou et al. summarize the current knowledge on the identification of contaminant yeasts in white-brined cheeses, their occurrence and spoilage potential, interactions with other microorganisms, as well as guidelines to prevent cheese spoilage. The proliferation of spoilage yeast depends on ripening and storage conditions at each specific dairy, product characteristics, nutrients availability, and interactions with the microbial consortium, ultimately leading to decreased sensorial properties, shorter shelf life, and impaired quality. White-brined cheeses are worldwide produced with many different process flow charts. However, even small variations might have an impact on the parameters and, thereby, on the yeast species being able to proliferate. Detailed knowledge on variations on spoilage potential at strain level is still missing for this type of cheese. Furthermore, the acquisition of scientific knowledge about yeast interactions with other microorganisms related to milk and the cheese matrix will add to an optimized production of white-brined cheese of enhanced quality.Two review articles provide important information for the cheese sector. The first presents an updated view on the diversity and safety of artisanal cheeses produced in Brazil, and the second addresses safety and technological issues regarding yeast contamination in white-brined cheeses. Listeria monocytogenes. This important microorganism can adapt and survive in food and food processing facilities where it can persist for years. The paper presented by Ricci et al. evaluated the heat resistance of L. monocytogenes in matrices involved in the production of Mozzarella di Bufala Campana Protected Designation of Origin (PDO) cheese. The 12 tested L. monocytogenes strains showed heterogeneous heat resistance profiles that ranged from 7 to <1 Log10 CFU/mL reductions after 8 min at 60°C. D-values and z-values, calculated for the most heat resistant strain, between 60 and 70°C were affected by the food matrix, being especially increased in drained cheese curd. As cheese curd stretching is not an isothermal process, a built secondary model was used to simulate microbial inactivation, and the authors were able to estimate the lethal effect of the process to be around 4 Log10 reductions. The data supplied may prove to be useful for Mozzarella cheese producers in determining appropriate time and temperature (kinetic parameters of heat inactivation) for producing fresh pasta filata cheese avoiding the presence of L. monocytogenes and improving microbial safety, efficacy, and sustainability of the process.Milk is susceptible to contamination with pathogenic microorganisms. Microbial food safety along the dairy chain is an important topic, from public health and industry perspectives. The three papers submitted that dealt with food safety addressed issues related to the foodborne pathogen Bechtel and Gibbons analyzed the population genetic structure of 504 L. monocytogenes strains isolated from food with publicly available genome assemblies. The purpose of the study was to understand if genetically distinct populations are associated with particular foods. Using comparative and population genomic analysis, they identified genes that were present at a greater frequency in the population associated with cheese. The results suggest that particular L. monocytogenes genotypes may be associated with the colonization and persistence in certain food environments, such as dairy and cheese, and indicate potential candidate genes involved in the specialization to particular food substrates. This type of study can be very useful for tracking certain genotypes and to better understand food-borne outbreaks. Similarly, Mafuna et al. characterized 143 L. monocytogenes isolated in South Africa for their strain's genetic relatedness, virulence profiles, stress tolerance, and resistance genes. Examination of genes involved in adaptation and survival showed that some sequence types are well-adapted in food processing environments due to the significant over-representation of benzalkonium chloride resistance genes, stress tolerance genes, prophage (φ) profiles, plasmids profiles, and biofilm formation associated genes. The information provided in this study is important for a better understanding of the adaptation and survival of L. monocytogenes in the food-processing environments and the efficacy of using biocide disinfectants in facilities. Later in this editorial, a paper conducted in Italy by Cremonesi et al. will approach the effect of chlorine usage for sanitation procedures on the raw milk microbiota.The paper carried by The next eight papers deal specifically with the analyses of the cheese microbiome. The composition of the microbiota has an important impact on the quality and safety of cheese due to the growth and interaction between microorganisms during processing and ripening. Therefore, much effort has been made by the authors to create molecular tools and omic systems to investigate the microbial community composition of cheese.Dreier et al. developed a high-throughput quantitative real-time polymerase chain reaction (HT-qPCR) approach for rapid and cost-efficient quantification of microbial species in cheese. Preliminary results from model and downgraded commercial cheeses showed that the application of microfluidic HT-qPCR to complex fermented products could be of interest for identifying the microbial origin of quality defects. This new system is a promising approach that will allow, particularly in the production of raw milk cheese, simultaneous monitoring of the quality-relevant ripening microbiota, thereby opening up new perspectives for the control and assurance of high product quality. Afshari et al., Bottari et al., and Unno et al. used integrated molecular, analytical chemistry methods, and omics approaches to valuating the complexity of the microbiota and their metabolites involved in the cheese ripening.Afshari et al. used bacterial 16S rRNA-gene sequencing, untargeted metabolomics, and data integration analyses to characterize and differentiate commercial Cheddar cheeses. Microbiota and metabolite compositions could be used to distinguish diverse time-ripened cheeses. Individual amino acids and carboxylic acids were positively correlated with the ripening age for some brands. The results suggest that multi-omics analyses have the potential to be used for discovering biomarkers for validating cheese age and brand authenticity. The paper by Bottari et al. used culture-dependent and independent microbial counts, high throughput 16S rRNA sequencing, length heterogeneity (LH-PCR), and ultra-performance liquid chromatography coupled to electrospray ionization tandem mass spectrometry (UPLC/ESI-MS) analysis to evaluate whether the composition of the bacterial community of Parmigiano Reggiano PDO cheese along with the specific peptide composition are more affected by the ripening times or by the cheese making process. The ripening time had the greatest impact on microbial dynamics and, consequently, on peptide composition. The potential use of peptides as markers of a specific microbial composition affords the possibility of taking advantage of it to protect and valorize the specificity and connection of traditional cheese to its production territory. The paper by Unno et al. integrated metagenomics using metagenomic amplicon sequencing and metabolomics with high-performance liquid chromatography (HPLC), and headspace gas chromatography mass spectrometry (HS-GC/MS) to reveal the microorganisms and components relationships in surface mold- and bacterial smear-ripened cheeses. Correlation analysis revealed that the abundance of specific bacteria was related to the formation of specific organic acids, free amino acids, and volatile compounds in these kinds of cheeses. The study will contribute to elucidate the role of non-starter cultures and possibly to select candidates for adjunct culture.The paper by Johnson et al., one aspect of cheese quality that remains poorly understood is the variability of microbial subpopulations due to temporal or facility changes within production environments. In their work, the aim was to quantify the microbiome variability by measuring day-day and facility-facility changes. Microbial communities were characterized using 16S rRNA metabarcoding and by plating on selective growth media. Interestingly, facility differences were greater on food contact surfaces, whereas daily differences within each facility were mostly explained by variation in the milk and cheese. The results highlighted the complexity of the Cheddar cheese facility microbiome and demonstrated daily and facility-facility microbial variations, which might influence cheese quality.According to Mancini et al. focused on the microbial and bacteriophages characterization from facilities that use natural whey starter (NWS) cultures for Trentingrana (Grana-like) PDO cheese production. Using culture-dependent methods and metataxonomic analysis, Lactobacillus helveticus was found occurring as the dominant and Levilactobacillus brevis as codominant NWS cultures. One hundred and twenty distinct phages were identified from 303 bacterial isolates from the NWS cultures. The authors found a possible correlation between bacterial starter biodiversity and the number of recovered lytic phages. They speculated that the presence of high biodiversity of NWS dairy bacteria biotypes is relevant to avoid phages dominance in NWS cultures, observing the recovery of a lower number of phages from the dairy plants with the higher biodiversity in L. helveticus biotypes. Phage predation can cause loss of NWS activity and generates a defective cheese. Also using the case of Trentingrana cheese, Cremonesi et al. evaluated the influence of chlorine products (sodium hypochlorite detergent) usage for sanitizing equipment on raw milk, NWS, and cheese microbiota and volatilome. Samples were subjected to culture-dependent and metagenomic analyses. Cheese volatilome was determined by solid-phase micro extraction-gas chromatography-mass spectrometry (SPME-GC-MS). As expected, a difference in microbial population related to chlorine usage in bulk milk, vat, and NWS samples was evidenced. The paper results support the idea that chlorine influences the milk and cheese microbiome and, consequently, cheese quality, safety, and sensory attributes. Furthermore, chlorine replacement is not associated with an increase of spoilage bacteria, staphylococci, and coliforms, but it leads to an increase in the milk microbial biodiversity. Further studies on sanitation strategies alternative to chlorine-based protocols are needed.The paper produced by Pisano et al. produced probiotic Caciotta cheeses from pasteurized ewes' milk by using combinations of autochthonous microbial cultures, containing probiotic strains. It was demonstrated, using multivariate statistical analysis of 1H nuclear magnetic resonance spectroscopy-based metabolomics data, significant variations in the cheese' profiles both in terms of ripening time and strains combination when compared to a control cheese produced using commercial starter cultures. The data obtained have indicated the applicative potential of autochthonous lactic acid bacteria cultures, containing probiotic Lactobacillus and Kluyveromyces strains, for the production of potential functional cheese.Cheese has been demonstrated to be an optimal carrier product to deliver viable probiotic bacteria. Perkins et al. combined culture-dependent techniques with whole-genome shotgun sequencing to light up the phylogenetic relationships among Geotrichum candidum and Galactomyces spp. strains of environmental and dairy origin. G. candidum is a yeast culture used on mold- and smear-ripened cheeses during ripening to promote the development of sensorial properties in the cheese surface. It was proposed a new multilocus sequence typing (MLST) scheme to optimally genotype isolates, substantially improving the knowledge on this culture to allow a better selection and control of G. candidum strains throughout the ripening.In the final paper, All authors have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


Parasitic infections of the central and peripheral nervous systems represent a significant source of morbidity and mortality, especially in humans living in low-to-middle income endemic countries. Examples of these are cerebral malaria, neurocysticercosis, African and American trypanosomiasis and toxoplasmic encephalitis, which may have a predilection for the CNS.via the blood-brain barrier (BBB) and via the blood-CSF barrier and (ii) induce neurological damage have not been fully elucidated yet.In spite of the known association between parasitic infections and specific neurological, cognitive and mental disorders, the exact mechanisms by which “neurotropic” parasites (i) enter the central nervous system (CNS) Toxoplasma and the extracellular African trypanosomes causing chronic CNS infections. Some of these neuroinvasion mechanisms were also described for fungi such as Cryptococcus neoformans, Aspergillus fumigatus and Candida albicans , Schlüter and Barragan discuss how immune cells can help the spread of Toxoplasma and are programmed by infection of Toxoplasma to spread into the CNS, and how parasite specific Tcell-mediated immune responses control but do not eradicate the infection. Additionally, the function of brain resident cell populations is delineated, i.e., how neurons, astrocytes and microglia serve both as target cells for the parasite but also actively contribute to the immune response is discussed. Mounting evidences that chronic CNS toxoplasmosis may impact in neuropsychiatric diseases or modulate cognitive functions are also presented. Focusing on ocular toxoplasmosis, S. Lie et al. analysed transcriptomes from primary human retinal pigment epithelial cells and cell lines infected with T. gondii strains in vitro. T. gondii infection triggered the immunological activation of T. gondii-infected retinal pigment epithelial cells, cells that form the blood - ocular barrier.Trypanosoma brucei, is a major cause of mortality and morbidity in animals and man. Infection with this parasite results in an early hemolymphatic-stage followed by a late encephalitic-stage when the parasites migrate into the CNS. Herein, Kennedy and Rodgers present an overview of the clinical features of HAT, with special emphasis on specific features of the late stage of the disease. The epidemiological implications of previously unrecognized asymptomatic individuals is discussed as well as biological features of T. brucei, new drug candidates and diagnostic tools.Human African trypanosomiasis (HAT) or sleeping sickness has been recognized as a scourge in sub-Saharan Africa for centuries. The disease, caused by the protozoan parasite M. Bentivoglio et al. highlight that T. brucei circulating in the bloodstream can attack the CVOs and choroid plexus, providing a route for brain penetration. From the choroid plexus trypanosomes can seed into the ventricles and initiate accelerated infiltration of T cells and parasites in periventricular areas. Trypanosomes can also invade CVOs such as the median eminence located in the base of the third ventricle, and by crossing the border into the BBB-protected hypothalamic arcuate nuclei. Activity in arcuate nucleus neurons affects sleep/wake behavior. Data showing that trypanosome invasion of the CVOs can contribute to triggering initial and distinct CNS imbalances of HAT and the mechanisms involved are discussed.Circumventricular organs (CVOs), neural structures located around the third and fourth ventricles, harbor, similarly to the choroid plexus, vessels devoid of a continuous nonfenestrated barrier, which enable them to sense immune-stimulatory molecules in the blood circulation, but may also increase chances of exposure to microbes. However, attacks to CVOs by microbes are rarely described. Plasmodium, cause severe alterations and inflammation in the brain vasculature, without entering the brain parenchyma. Sequestration of Plasmodium-infected red blood cells in brain microvessels is a hallmark of cerebral malaria pathology. The role of innate immune responses in cerebral malaria is addressed here by Pais and Penha-Goncalves. They describe how recognition of various parasite-derived molecules by brain endothelial cells innate immune receptors mediates their activation, and trigger inflammatory responses that lead to microcirculatory and coagulation disturbances and to altered vascular permeability impairing BBB integrity.Other pathogens, such as via hematogenous spread of larval stages to small vessels, by in situ deposition or embolism of eggs following anomalous migration of adult worms to the CNS, attaching to the nasal neuroepithelium and penetration via the olfactory nerve pathway, or directly invading the neural skull and intervertebral foramina. Neurocysticercosis, caused by blood dissemination of Tenia solium larval stages (cysticerci), is the most common helminth infection of the CNS in humans. Clinical presentation and the immunology of neurocysticercosis vary according to the type and location of cysts inside the brain parenchyma or in the cerebral ventricles and subarachnoid spaces   . In thisM. D’Alessandre Sanches et al., who show the ability of 3 non-albicans Candida species to spread to the CNS in the mouse model, as these species are becoming more frequently involved in CNS candidiasis infections. They show that Candida glabrata, Candida krusei and Candida parapsilosis are able to disseminate to the CNS and promote local inflammation in both immunocompetent and immunosuppressed mice early after infection.Although fungal infections of the CNS are uncommon, prolonged systemic circulation of fungi can affect the CNS, thus contributing to morbidity and mortality of the infected patients . This RTvia the production of parasitic molecules (such as cysteine proteases from Entamoeba) and/or via the immune responses stimulated by the infection. The altered activity of peripheral neurons in these infections, through gut-brain communication may modulate immune activity. Distress in the enteric nervous system plays a key role in the pathophysiology of diarrhea upon exposure to several enteric protozoan and metazoan parasitic infections . This distress has also been indicated to play a role in echagasic megasyndromes and post-infectious complications.Parasitic infections also affect the peripheral nervous system (PNS), probably The roles of systemic innate and adaptive immune responses in the perpetuation or eradication of parasitic infections in the brain is interconnected with the pathogenesis of parasitosis. Understanding these roles will help advance the development of preventive measures against parasite-induced neurological diseases. This RT has covered recent advances in the pathogenesis of parasites affecting the CNS and the PNS as well as the role of the immune responses in these infections, highlighting prospects for potential interventions.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.Supported by the Swedish Foundation for International Cooperation in Research and Higher Education.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.


Developmental psychologists have been facing a series of paradigm shifts within the field. Not to mention the replication crisis—which sheds light to the importance of cross-cultural research encompassing non-Western, Educated, Industrialized, Rich and Democratic (WEIRD) samples–, scholars are also giving emphasis on studies about individuals' strengths. With these aspects in mind, the book “Roma Minority Youth across Cultural Contexts: Taking a Positive Approach to Research, Policy and Practice” argues that, by adopting a positive youth development (PYD) framework, our current understanding of factors associated with minority health and well-being might benefit in unique ways. Specifically, the robust collection of 13 chapters provides insight into one of the most tyrannized minority groups worldwide: the Roma minority  might assist PYD-based studies. Moreover, the section highlights in what manner Roma minority groups diverge from the majority youth, which seems to be particularly timely for policy makers compromised in providing positive development of Roma and other ethnic minority groups across the globe.In addition, the book contains a section of mixed-method studies conducted in European countries with large proportion of Roma people, including Bulgaria, Kosovo, Albania, and Serbia. Taken together, readers will notice that the samples of these studies provide a rare chance to critically reflect on the myriad of PYD implications, notwithstanding the seminal, North American roots of the PYD. However, contributors of each chapter performed comprehensive analyses of cultural-specific and further generalizable scope of their findings for those studying and working with minority groups, with examples of policy implications and suggestions of ways to guarantee the well-being for future generations of Roma minority.Clearly, there are several interesting lessons that the book offers. By applying the PYD methodological approach with Roma youth, the work presented has implications on the knowledge about a growing, yet stigmatized and vulnerable population. Additionally, the focus on a positive approach enhances our understanding of individual , cultural, and contextual  factors in Roma youth. The authors' experience with cross-cultural research provides both individual vs. comparative insights of issues regarding this minority in a variety of contexts, thus enabling inferences on experiences shared and non-shared across nations. Finally, the volume has a great potential to underpin future efforts in studying developmental processes in the face of the PYD perspective.The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.