The insertion of long-term central venous catheters is a standard of care for children affected by malignancies, although it can be associated with life-threatening complications. The present paper reports an unusual mechanical complication related to the use of a long term tunneled central venous catheter in a pediatric oncologic patient. An 18 months old child, diagnosed with stage M high-risk retroperitoneal neuroblastoma, underwent ultrasound-guided placement of a 6 Fr bilumen long-term tunneled central venous catheter in the right internal jugular vein prior to the beginning of induction chemotherapy. The correct position of the distal tip of the catheter was confirmed by fluoroscopy. After 4 months of regular use of the device, the patient experienced neck swelling during high-dose chemotherapy infusion. A chest x-ray showed a dislocated catheter and bilateral pleural effusion. CT scan demonstrated the tip of the catheter rupturing the medial wall of the right jugular vein and entering the mediastinum; furthermore, pneumomediastinum, subcutaneous neck emphysema and bilateral pleural effusion were noticed and a thrombus was evident in the right jugular vein at the insertion in the brachiocephalic vein. The patient was then transferred to the Intensive Care Unit and bilateral thoracostomy tubes were placed urgently . The dislocated catheter was removed electively on the following day under fluoroscopy. Despite ultrasound-guided placement and long-term uneventful use of the catheter, life-threatening central venous catheter-related mechanical complications can occur; the current case report emphasizes the importance of careful monitoring of patients with central venous catheters in order to quickly diagnose and treat potentially lethal complications. For children with cancer, the insertion of long-term central venous catheters is standard of care , 2. ReceIn the present case report, the authors describe a case of central venous catheter dislodgment with associated intrapleural extravasation, occurred 4 months of regular use of the device.An 18 months old child was diagnosed with stage M high-risk retroperitoneal neuroblastoma. As per institutional protocol and according to current national and international guidelines , 5, 6, aThe device worked properly for the whole period (4 months) of induction therapy; during this time, the patient had no local trauma, and repeated radiological examinations, performed to assess chemotherapy response, verified the correct position of the catheter tip.After surgical excision of the primary mass, the patient received high-dose chemotherapy in preparation for autologous stem cell reinfusion. During in-hospital infusion of busulfan, the patient presented neck swelling. A chest x-ray showed dislocated catheter and bilateral pleural effusion ; the CT Given the potential sudden deterioration of the clinical conditions, the patient was transferred to the intensive care unit and bilateral thoracostomy tubes were placed urgently. During the procedure, 500 mL of clear fluid were evacuated from pleural spaces  with a Busulfan concentration of 786.88 ng/mL; after evacuation of busulfan solution, normal saline was flushed and aspirated repeatedly through thoracostomy tubes in order to remove any residue of cytotoxic drug. Once the patient had been stabilized, the dislocated catheter was removed electively on the following day under fluoroscopy .Post-operative course was uneventful; the patient was transferred from Intensive Care Unit to the Oncology Department after 72 h. A new central venous catheter was placed, under ultra-sound guidance, in the left internal jugular vein 7 days after the removal of the previous catheter, without complications .The use of long-term tunneled central venous catheters greatly facilitates the administration of cytotoxic and supportive therapy to children affected by malignancies , 8; on tMalposition and unintentional pleural puncture are the two most common mechanical insertion-related problems; they mainly occur in the early post-procedural period and are most commonly associated with the use of the “landmark approach” , which cLate mechanical complications include occlusion, which is more likely with catheters placed in the subclavian vein and is usually related to thrombosis or pinch-off syndrome, and migration of the tip of the catheter, which may occur with trauma to catheter site or accidental pulling of the device .Catheter placement techniques have improved in the recent decades, thanks to the use of ultra-sound to reduce the risk of malposition and pleural puncture –14.In the present case, the patient had a central catheter inserted in the right internal jugular under ultra-sound guidance and fluoroscopic control, which is the most internationally recommended technique , 12; desThe occurrence of bilateral pleural effusion in this patient is difficult to explain. Hydrothorax secondary to infusion extravasation has been reported as an early complication after the placement of the catheter; the underlying mechanism consists in the perforation of the lateral wall of superior vena cava and subsequent catheter tip misplacement in the thorax, both because of initial catheter malposition  or vascuThe cause of pneumomediastinum is uncertain. The tip of the catheter was far from trachea, as shown in the radiologic images , 3, whicWe suppose that the thrombus in the distal part of the internal jugular vein may have progressively dislodged the tip of the vascular catheter, which eroded the medial wall of the vein in a proximal site; the solution infused through the dislodged catheter have then diffused into the mediastinal soft tissues and into the pleural cavities, even in the absence of a previous trauma of the pleura itself.In conclusion, life-threatening central venous catheter-related mechanical complications may occur despite the use of all the state-of-the-art measure to reduce the risk of complications  and after several months of uneventful use of the catheter itself; the present case highlights the importance of careful monitoring of patients with central venous catheters, especially when they develop unexpected symptoms or when catheters seem to be malfunctioning, in order to rapidly diagnose and promptly treat potentially lethal complications.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.TD'A: study design, data collection, and draft writing and editing. GPe: study design, literature search, and draft writing and editing. AC and AI: study supervision and draft revision. GPa and GN: technique description and draft revision. 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.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.


Functional neurological symptom disorder (FND) is characterized by the ideogenic neurologic presentation deriving from unconscious stressors or conflicts. The symptoms of FND usually begin with a psychiatric illness—most commonly depression, but with the release of the latest version of International Classification of Diseases-11 (ICD-11), a new favoring factor comes to our mind: prolonged grief disorder (PGD), the newcomer to psychopathology.The purpose of this case-report is to highlight the several key differences between PGD and depression, and the role of PGD in the onset of FND.The authors report the case of a 22 years old woman with a history of frequent seizures with loss of consciousness and the absence of stimulus-response, which started soon after the death of her 31 years old brother. Psychologically, the patient presented sustained interest in the deceased, self-blame, confusion, emptiness and low mood. On a physical exam, the patient showed periocular hyperpigmentation.The emergent symptoms and signs were resistant, failed to resolve with medication alone and continued to persist across all settings. The neurological dysfunction remained present and interfered with the patient’s functioning, until applying grief-oriented psychotherapy, which was the most efficient approach.In conclusion, PGD represents a favoring condition for the onset of FND and it is most often mistaken with depression. Therefore, it is crucial to distinguish between these two disorders, as there is solid evidence that treatment for depression is far less helpful than targeted grief treatment.No significant relationships.


Streptococcus (Strep A). The primary objectives of APSGN surveillance are to monitor trends in age- and sex-specific incidence, describe the demographic and clinical characteristics of patients with APSGN, document accompanying risk factors, then monitor trends in frequency of complications, illness duration, hospitalization rates, and mortality.Acute poststreptococcal glomerulonephritis (APSGN) is an immune complex-induced glomerulonephritis that develops as a sequela of streptococcal infections. This article provides guidelines for the surveillance of APSGN due to group A This document provides surveillance case definitions for APSGN, including clinical and subclinical APSGN based on clinical and laboratory evidence. It also details case classifications that can be used to differentiate between confirmed and probable cases, and it discusses the current investigations used to provide evidence of antecedent Strep A infection.The type of surveillance recommended depends on the burden of APSGN in the community and the objectives of surveillance. Strategies for minimal surveillance and enhanced surveillance of APSGN are provided. Furthermore, a discussion covers the surveillance population and additional APSGN-specific surveillance considerations such as contact testing, active follow up of cases and contacts, frequency of reporting, surveillance visits, period of surveillance, and community engagement. Finally, the document presents core data elements to be collected on case report forms, along with guidance for documenting the course and severity of APSGN. Streptococcus pyogenes (group A Streptococcus [Strep A]), or less frequently Lancefield group C or G Streptococcus [Acute poststreptococcal glomerulonephritis (APSGN) is a delayed immune-mediated sequela of infections, usually pharyngitis or skin infections, caused by nephritogenic strains of tococcus . The reptococcus . Althougtococcus .Acute poststreptococcal glomerulonephritis occurs most commonly in children aged between 5 and 12 years; in HICs, it increasingly affects adults older than 60 years, especially those with chronic medical conditions . The incAcute poststreptococcal glomerulonephritis may be asymptomatic , characterized by microscopic hematuria and reduction in serum complement, or symptomatic  with acute nephritic syndrome and occasionally with nephrotic syndrome . In prosAn effective routine surveillance system for APSGN serves to monitor trends in the following (1) age- and sex-specific distribution of clinical and subclinical APSGN; (2) demographic and clinical characteristics of people with confirmed clinical and subclinical APSGN; (3) disease burden estimates; and (4) cases of APSGN over time and space, to detect clusters or outbreaks.Enhanced surveillance structures are ideal adjuncts to routine surveillance but are not required in every surveillance system. Enhanced surveillance may also aim to determine and monitor the following: (1) age- and sex-specific incidence of clinical and subclinical APSGN; (2) the clinical outcomes and the frequency of complications of APSGN, such as acute kidney injury, hypertension, recurrent or chronic proteinuria, and chronic kidney disease; (3) the proportion of confirmed APSGN cases secondary to different antecedents, e.g., Strep A pharyngitis, impetigo, and/or scabies; and (4) the environmental, behavioral, and/or clinical risk factors associated with clinical and subclinical APSGN.emm types, presence of vaccine antigens, and antimicrobial susceptibility. Specialized surveillance could potentially: (1) record strain-specific disease burden; (2) identify strain-specific outbreaks; (3) predict or evaluate the effectiveness of prospective or existing vaccines; (4) monitor temporal trends in Strep A strains causing APSGN; and (5) track over time antimicrobial resistance among Strep A isolates preceding APSGN.Additional surveillance objectives may be addressed by specialized surveillance programs, vaccine trials, or research projects. These additional activities, conducted outside routine surveillance programs, can help describe selected genotypic or phenotypic features of Strep A isolates (strains) causing APSGN, such as Standardized case definitions are important for obtaining accurate surveillance data, enabling comparisons of surveillance data across jurisdictions, and monitoring the impact of interventions. The definitions and methods presented here may also be used as clinical endpoints for vaccine efficacy trials and for postlicensure effectiveness studies.The laboratory tests required to confirm a case of APSGN may not be available at all surveillance sites or may be unavailable at the time for a variety of reasons. Therefore, APSGN cases will be considered definite, if laboratory confirmation is available; or probable, if laboratory confirmation is not available or is limited. Close contacts are individuals who had stayed overnight in the house of a confirmed case in the 2 weeks preceding the onset of their illness.An outbreak of APSGN is defined as 2 or more probable or confirmed cases in persons from the same community with onset within 1 week of each other and with at least 1 case in a person with a reduced complement C3 or C4. Alternatively, an outbreak of APSGN can also be defined as at least 1 confirmed case and 2 probable cases in persons from the same community, with illness onset within 1 month of each other and the affected persons are not known contacts of each other .Clinical specimens and laboratory diagnostics required for the diagnosis and classification of APSGN cases are summarized in Nephritis may be associated with multiple clinical syndromes, including both infectious and noninfectious etiologies . Case ascertainment may be active or passive see .For each data source, surveillance staff should adhere to the following: (1) know the purpose of the data source, e.g., whether data have been routinely collected as part of patient care, mandatory collection of data under legal mandates, collected for research purposes, or other; (2) identify any legal mandates governing the operations of the data source that may affect the accessibility or quality of data from that source; and (3) describe the representative population for the data.The selection of surveillance strategies depends on specific epidemiologic and clinical characteristics of the disease outcome of interest, the overall surveillance objectives, surveillance location, services’ accessibility, and the resources available  if the population is covered by numerous hospitals or (2) if there is a substantial likelihood that cases occurring within the surveillance region may attend a tertiary or specialist hospital outside the surveillance region. Cases occurring in people residing outside the defined catchment area should be excluded. One alternative is to conduct surveillance in a smaller, high-risk population over a longer period of time, thus increasing the number of person-years at risk.Healthcare utilization surveys can be used to determine those accessing healthcare to estimate the population served, or the denominator, that corresponds to the cases of interest , 30. ThiConsiderations in choosing a population include likely incidence of APSGN, representativeness of the wider population when considering generalizability, accuracy of total and age-subgroup population data, and ease of case ascertainment. This includes the (1) number and accessibility of surveillance sites/hospitals and (2) likelihood that cases will attend these hospitals. Additional factors include availability of trained staff to conduct surveillance, quality of record keeping in hospitals, or potential to improve this, and availability and quality of relevant laboratory investigations. Availability of kidney biopsy is also a factor.International Classification of Diseases (ICD) codes, then all codes that include the term glomerulonephritis, hematuria, proteinuria, or nephritic/nephrotic syndrome and acute kidney injury should be cross-checked to validate actual cases  require more frequent and longer term follow-up to determine the risk of chronic kidney disease. The typical case may be followed annually; however, the total duration and extent of follow-up of the illness outcome of patients with APSGN will be determined by the specific protocol and available resources.If a case of APSGN is detected, household contacts may be prospectively evaluated because of the high familial incidence . FamiliaThe schedule of passive surveillance will be dictated by the pattern of case presentation at the surveillance site(s). Case ascertainment can be improved if the active surveillance includes regular visits to surveillance sites to review clinical and laboratory records for missed cases and to share with healthcare workers the goals and methods of Strep A surveillance. This may be informed by the average duration of hospitalization for inpatients or timing of follow-up visits for outpatients at the surveillance facilities.Given the low incidence of APSGN relative to Strep A pharyngitis and impetigo, longer periods of surveillance are generally required to obtain accurate estimates of incidence and of strain distribution. Several years of surveillance are generally required to evaluate temporal trends, or identify epidemics, which tend to be cyclical (occurring approximately every 5 years) .Acute poststreptococcal glomerulonephritis incidence is seasonal in many places, with peaks generally correlated with antecedent oropharyngeal and skin infections . If possCommunity engagement helps provide a considered approach to surveillance and ensures that the project has community value. It also provides the community with an opportunity to clearly express their values and concerns and develop a degree of ownership. The time required to forge relationships between surveillance staff and communities should not be underestimated and must be built into the surveillance protocol at the outset. The level of community engagement in the design, implementation, monitoring, and evaluation of surveillance will depend on available resources and community capacity. Key stakeholders include community leaders, teachers, health staff, and volunteers.One-off and ongoing feedback of aggregated surveillance data, and its interpretation, should be provided to the communities and regional/remote health services. Funding for activities to support the feedback process should be built into all surveillance budgets and protocols from the outset. It will often require translation to local language and then into an accessible format. Feedback is best given by local health providers; adequate support and training to local health providers should be provided as necessary.Case report forms should be based on collecting only the information required to achieve the surveillance objectives. General surveillance variables include unique identifier, date and time of first enrollment or specimen collection, and site where participant is seen, such as clinic, school, and household. The documentation of each encounter should also contain a surveillance visit number/episode number if repeated episodes from the same person are included. Key demographic variables include date of birth, if available, or age , sex, ethnicity/race, and residential postcode, state, and country. Clinical and epidemiologic variables include APSGN diagnostic category, epidemiologic risk factors, clinical risk factors, evidence of preceding Strep A infection, indicators of severity of illness, laboratory findings, treatment, and follow-up. Although not expected as part of routine surveillance, it may be appropriate for some enhanced surveillance programs to document the course of the episode after the onset of illness. For consistency in reporting, the course of an episode should be measured in a reproducible way. The duration of an episode of APSGN can be measured by the length of hospital stay in days or duration of clinical signs/symptoms in nonhospitalized patients. Because there are no defined grades of severity of APSGN, severity of disease can be monitored by capturing the duration of hypertension, hematuria, edema, proteinuria, and any complications.Open Forum Infectious Diseases online. Consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author.ofac346_Supplementary_DataClick here for additional data file.


Poxviridae remains elusive. However, emerging sequence data on currently circulating and archived poxviruses, such as the genera orthopoxviruses and capripoxviruses, display a wide degree of divergence. This genetic variability cannot be explained by clonality or genetic drift alone, but are probably a result of significant genomic alterations, such as homologous recombination, gene loss and gain, or gene duplications as the major selection forces acting on viral progeny. The objective of this review is to cross-sectionally overview the currently available findings on natural and laboratory observations of recombination in orthopoxviruses, capripoxviruses, and leporipoxviruses, as well as the possible mechanisms involved. Overall, the reviewed available evidence allows us to conclude that the current state of knowledge is limited in terms of the relevance of genetic variations across even a genus of poxviruses as well as fundamental features governing and precipitating intrinsic gene flow and recombination events.Poxviruses are double-stranded DNA viruses with several members displaying restricted host ranges. They are genetically stable with low nucleotide mutation rates compared to other viruses, due to the poxviral high-fidelity DNA polymerase. Despite the low accumulation of mutations per replication cycle, poxvirus genomes can recombine with each other to generate genetically rearranged viruses through recombination, a process directly associated with replication and the aforementioned DNA polymerase. Orthopoxvirus replication is intimately tethered to high frequencies of homologous recombination between co-infecting viruses, duplicated sequences of the same virus, and plasmid DNA transfected into poxvirus-infected cells. Unfortunately, the effect of these genomic alterations on the cellular context for all poxviruses across the family  In contrast to DNA viruses, RNA viruses have evolved a survival strategy involving high mutation rates, large effective population sizes and short generation times to evade and counter the host immunity . In theiOrthopoxvirus, Parapoxvirus, Leporipoxvirus, and Capripoxvirus genera. Numerous outbreaks in both humans and animal populations have been attributed to these viruses in the past, with the human pathogen variola virus (VARV) being successfully eradicated in the previous century , sheeppox virus (SPPV) and goatpox virus (GTPV) as well as the myxoma virus (MYXV) from the genus Leporipoxvirus. The Capripoxviruses pose a serious threat to the global livestock industry  must be able to replicate in the absence of wild-type virus in the absence of complementation. This requires that the disrupted gene be non-essential. In a laboratory setting, this is observed when an essential gene is disrupted using homologous recombination with selection markers. In this case, an essential gene disrupted virus is generated by visualization of a fluorescent protein, however, this virus cannot be plaque purified without the function of the essential gene provided by wild-type virus or through gene complementation in vitro .It is also worth noting that if two nearly identical viruses recombine, it can be difficult, if not impossible, to identify recombinant viruses as the genome sequences will share significant sequence similarities. In this case bioinformatic tools capable of detecting recombination events need to be used, however their description is beyond the scope of this review.The previously described high recombination rates of poxviruses, allow insights into the recombination process, however these observations have predominantly focused on orthopoxviruses and this can be extrapolated to other poxviruses. Recombination in vaccinia was described through analysis of the marker gene, viral thymidine kinase, during serial passages under different growth conditions . Under sA study by Reversible gene copy number variations as a means of adaptation was also observed at another VACV locus . These sThe processes of replication and recombination in poxviruses are fundamentally linked, either through direct involvement or by utilizing the same enzymes. It has been speculated that recombination could be involved during the initiation of replication, even in the presence of a primase . RecombiAvailable evidence on orthopoxviruses suggests poxvirus replication occurs in membrane-bound virosomes in the cytoplasm of the host cell, called virus factories. Individual infecting particles generate separate factories shortly after virus infection . These sThe genes required to produce all the components involved in viral DNA replication, repair and recombination have been identified. The genomes are large double-stranded linear DNA molecules with terminal repeat regions, that are covalently closed on the ends. DNA replication requires the viral DNA-dependent-DNA-polymerase protein E9, while A20, I3, H6, D4, D5, B1, and A22 are also collectively required to support replication, repair and recombination . The simFor interviral recombination to occur, different viruses must infect the same cell. In cell culture, the likelihood of recombination occurring could increase due to an increase in the likelihood of co-infection with different viruses. Furthermore, during the selection of viruses in cell culture the most important factor is the replication fitness of recombinant viruses. This is due to the lack of an adaptive immune system for host defense in cell culture. It was demonstrated in the 1950’s that recombination can occur between two different vaccinia viruses which differed in five phenotypic characteristics; pock morphology, hemagglutinin production, heat resistance, mouse neuropathogenicity, and skin lesions in rabbits. The characterization of recombinant viruses exhibiting different phenotypes demonstrated that 17 of the 149 new viruses displayed a combination of characteristics . More reIt is likely that many different recombinant viruses could be obtained from co-infection of different lumpy skin disease viruses in cell culture. Unfortunately, the phenotypic properties of the recombinant viruses that were derived from a commercial LSDV vaccine (KEVIVAPI), and known to contain sequence elements derived from the LSDV LW-1959/vaccine and Kenyan sheep and goat pox ovine 240 (KSGPO-240) strains, and from GTPV, have not been evaluated . ExperimOngoing surveillance of circulating viruses enables not only the early detection of infection in the field, but also tracking of the genetic variants evolving under environmental pressures . Orthopo, these viruses are exposed to unusual environmental factors that could impose additional pressure on the evolutionary machinery of the viruses, providing researchers with the unique opportunities to track virus evolution on the genomic level under natural circulation  strains, using the currently available genome sequences of the capripoxvirus members , might be the best reported example of host-virus coevolution in the field, following a new cross-species introduction. There are two examples of this coevolution on two different continents, Australia and Europe.A Oryctolagus cuniculus). This accidentally initiated one of the largest natural experiments in host-pathogen coevolution. The virus strain originally released in Australia, MYXV-SLS , is believed to be derived from an isolate first obtained in Brazil in circa 1910  hosts, it has been highly pathogenic to the naive European rabbit (Oryctolagus) host, making it a classical example of a pathogen that is highly virulent in a new host species with no history of adaptation.The second example is in Europe, where the virus was introduced in 1952 as a means to control wild rabbit population, again using the Brazilian Standard laboratory strain  is the result of recombination between MYXV and Shope fibroma virus SFV; . The autLepus europaeus) and the Iberian hare (Lepus granatensis) with clinical signs suggestive of myxomatosis. Since the rabbit (Oryctolagus cuniculus) was the only target host of the myxoma virus, the observed findings strongly argued for host range expansion within the family Leporidae due to genome alterations. The virus was isolated from a dead female wild hare and designated MYXV-Tol. Analyses of the MYXV-Tol complete genome sequence revealed an insertion of ~2,800 bp in the left terminal region of the genome in comparison to the sequence of MYXV-Lau. This new recombinant region disrupted the M009L gene of MYXV-Lau, without completely deleting the gene, instead regions of the M009L gene were present and flanking the new 2,8 kbp region. Moreover, this recombinant insertion contains at least four ORFs that are predicted to encode four viral proteins homologous, but not identical, to the poxvirus gene families exemplified by the M060R, M061R, M064R, and M065R genes from MYXV. The complete genome of MYXV-Lau contains a locus at ~57,500 bp that includes a set of six ORFs (M060R to M065R) conserved in all MYXVs, including MYXV-Tol . The SNPs assigned as either identical to LSDV/KSGPO-240/Kenya/1958 (gray) or LSDV/LW-1959/Vaccine (black) are presented in The percentage of transition mutations in LSDV parental sequences was 65%, which is comparable with the 72% of SNPs identified in the VACV TP05 and DPP17 clones . Based oRecombination and the generation of novel recombinants have been associated with accumulation of various phenotypic advantages . The comThe majority of the ORFs under selection were involved in either transcription, replication or virion formation . The posRecombination plays an important role in the evolution of viruses including poxviruses. High-throughput sequencing of additional poxvirus genomes is contributing to the elucidation of poxvirus molecular evolution from the fundamental perspective. The apparent low mutation rates are offset by high recombination potential under selective conditions manifested by horizontal gene transfer, gene gain and loss and homologous recombination. The orthopoxviruses have enjoyed the majority of the research attention, since some of its members are deadly human pathogens. In contrast, other members of the Poxviridae family have only recently been gaining research focus, due to their expanded global distribution and a high impact on the economy. Owing to the advent of molecular tools, numerous studies have described novel poxviruses subjected to significant genetic changes and all of these novel viruses were associated with potentially new virulent phenotypes. The unprecedented spread of LSDV from Africa into Europe, Russia and Asia, with particular emphasis on the novel recombinant LSDVs, emphasizes our current lack of knowledge with respect to capripoxviruses. The current state of knowledge is limited in terms of the relevance of genetic variations across even a genus of poxviruses as well as fundamental features governing and precipitating intrinsic gene flow and recombination events. Understanding these mechanisms provides tools for harnessing evolution to the benefits of humankind. The increased amount of genome information available together with improvement of tools for analysis will allow for detailed understanding of the evolutionary history of poxviruses and monitoring of adaptation-driven genetic alterations in poxviral genomes in the field.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.This work was supported by the grant no. 075-15-2021-1054 from the Ministry of Education and Science of Russia to implement objectives of the Federal Scientific and Technical Program for the Development of genetic technologies during 2019–2027.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.


Communication of clinicians at the emergency department is a barrier to patient satisfaction due to lack of human connection, lack of control over the situation, low health literacy, deficient information, poor support at a time of uncertainty all affecting perceived quality of care. This explorative study tests drivers of patient satisfaction with communication of clinicians at the emergency department. The sample comprises 112 Americans from the New York greater area, who visited an emergency department in the past year. A conjoint-based experimental design was performed testing six messages in six categories. The categories encompass acknowledged aspects of communication with health providers enabling to compare among them when exploring communication at the ED by patient preferences. Respondents rated messages by the extent to which it drives their satisfaction with communication of clinicians at the emergency department. Based on the similarity of patients’ response patterns to each message, three significantly distinct mindsets of patient preferences regarding communication exchanges with clinicians at the emergency department emerged. Different conduct and communication messages drive the satisfaction of members of each mindset with the communication of clinicians at the emergency department. The strong performing messages for one mindset are irrelevant for members of other mindsets. Clinicians may identify the patient-belonging to a mindset and communicate using mindset-tailored messages. This novel strategy may enable clinicians to implement patient-centered communication, by mindset, promoting patient satisfaction and enabling clinicians to better cope with patients in the chaotic emergency department environment. Patients arriving to the ED experience a sudden change in their routine perhaps evoking anxiety and fear . Pay-forCommunication with patients is an overarching category of patient satisfaction in the ED. Positive interpersonal exchanges in communication encourages questions, enhance internal locus of control and health literacy, create a human connection, demonstrate respect in non-verbal language, confidential, honest, compassionate, reliable allowing patient involvement ,7,8,9,10Poor interpersonal exchanges between patients and clinicians at the ED result in a gap in quality of care increasing length of hospitalization and costs, decreasing the efficient utilization of resources . AdditioOvercoming the communication barrier at the ED will lead to better patient understanding, trust, satisfaction, and improved outcomes . EffectiKnown drivers of patient satisfaction with communication of clinicians at the ED are: Interpersonal skills  ; comfortDespite the knowledge on these drivers of patient satisfaction with communication, to date, their implementation in communication at the ED is challenging and unsuccessful ,34,35. TUpon participation in this online study participants signed an informed-consent form for both participation and publication. Participants were informed that they could stop their participation in this online study at any time.The sample comprised 112 American respondents, ages 18–80 with 58 females and 54 males from the New York greater area. This sample size is consistent with the suggested sample size in conjoint analysis studies, particularly when aiming at stability of coefficients rather than stability of means and standard deviations ,39,40. IWe utilized an experimental design requiring the allocating participants to different groups using repeated measures, where the same participants took part in each condition of each of the independent variables  . Thus, pAs typical in conjoint-analysis messages fall into categories each with messages. The dependent variable was ‘satisfaction with clinician-patient communication at the ED’. The independent variables were six categories of acknowledged communication elements of patient-centered care that drive patient satisfaction with communication of clinicians ,47. CateThe categories of messages contained one message from each category. Participants were instructed to rate the combination as a unity ,45. The The experimental design enabled the deconstruction of responses to the messages by ordinary least-squares regression (OLS) ,45,50. WWe performed OLS to generate individual level equations for each respondent relating to the presence/absence of the thirty-six messages. The OLS coefficient is the conditional probability that the specific message adds to the satisfaction. A coefficient of six or higher is statistically significant, given the standard error of about 4 for the coefficient. A higher coefficient means higher satisfaction. OLS was run for the total panel and for each key subgroups , incorporating all relevant data into one regression model for the sample. The response to these vignettes, uncovered by OLS, reveals the part-worth contribution of each message to satisfaction with judgment bias reduced . Since tNext, we analyzed response patterns to each message, using k-means clustering algorithm with 1-Pearsons’s R distance measure . FundameThe response rate for the on-line sample was a high response rate of 82%. To test the reliability, we created three sets of coefficients: from the total panel, and from each half-set. The two half sets of data were highly correlated with data for the total panel .We created models for satisfaction with communication of clinicians using OLS, one model for each respondent, each with an additive constant and 48 coefficients . The additive constant is an estimated parameter representing the intercept in a linear equation that may be interpreted as the predisposition of the respondent group to agree to a set of messages in the absence of any specific message. The response to each combination of messages, the coefficient of the OLS, reveals the power that each respondent attributes to each message as a driver of satisfaction .To highlight the best-performing messages and eliminate a high variability due to lack of calibration among respondents, we transformed the ratings to a binary scale. Ratings 7,8, and 9  were transformed to 100, classified as powerful drivers and ratings below 6  were transformed to 0, classified as weak or negative drivers. OLS analysis was performed to create an individual-level regression model for each respondent. This type of individual regression approach has been widely used in conjoint analysis studies ,45. The p < 0.05)). p values of the OLS regression in To simplify the analysis, we present only messages with positive regression coefficients, driving satisfaction with communication of clinicians in the ED. Negative regression coefficients mean either that the message is neutral (irrelevant for satisfaction) or counterproductive, driving dissatisfaction. Regression coefficients for the models relate to the presence/absence of the messages to the rating of drives/does not drive, after binary transformation.  that emerged from k-means clustering.K-means clustering was applied on the 48 coefficients to create clusters . Three mSince the three mindsets are distributed across the population, a PVI is required to identify the belonging of individuals in the population to a mindset in the sample.This study tested the power of numerous communication messages as drivers of patient satisfaction with communication of clinicians in the ED. This study makes several contributions. Theoretically, clustering by the similarity in patients’ patterns of response to messages is a novel strategy which revealed three distinct mindsets, similar in size, representing what drives patient satisfaction with communication of clinicians in the ED for members of each mindset. Methodologically, this study used a patented methodology of conjoint-based experimental design, overcoming the typical biases of surveys, and simultaneously testing various messages crafted to reflect the complexity in our reality which affects patient’s satisfaction with communication of clinicians at the ED. Practically, the web-based prediction tool enables clinicians to quickly identify the mindset-belonging of each patient and communicate with each patient using mindset-tailored messaging.The novelty of this explorative study is a breakthrough in removing barriers to patient satisfaction with communication of clinicians by identifying the mindset-belonging and using mindset-tailored specific messages. Findings indicate that patients have different response patterns to different communication messages of clinicians. In contrast to prior studies that viewed patient satisfaction as inflfluenced by patient sociocultural, psychosocial, and disease-related characteristics , our finTo promote patient satisfaction, communication should be accorded to mindset-belonging. Patients who belong to mindset 1, need clinicians to carefully listen to them, acknowledge them as individuals and enable them to feel comfortable. This finding supports previous findings on the importance of acknowledging the patient visiting the ED as experiencing a time of uncertainty, perhaps a crisis, and communication should aim at enhancing patient wellbeing ,5,8. PatThese findings echo a recent study on the four voices of clinicians: a content task-oriented voice, a process-oriented voice, a comprehension-oriented voice and a learning orientation amongst which clinicians need to shift . While iUsing communication by mindsets, clinicians may improve patient satisfaction regardless of the setting, the diagnosis, or the demographics. The strategy of using a few targeted mindset-tailored messages, may facilitate patient-centered communication even among ED clinicians working at a chaotic work environment, who find such communication as challenging ,53. FurtSince respondent are people who accepted the invitation to participate in this study, they may carry a self-selected bias. Additionally, the geographic area from which respondents were recruited, may limit the generalization of this study to other countries. Last, it is also possible that the association between satisfaction and communication messaging is affected by other aspects of respondents’ visits to the ED.This study starts to fill a knowledge gap in the state of the art examining targeted communication messaging as means to raise patient satisfaction with communication of clinicians in the ED. Understanding the drivers of satisfaction regarding communication of clinicians in the ED is essential to patient satisfaction. Patients, however, have different preferences of communication. Establishing communication by mindsets in a practical and functional manner may carry implications for delivery of care on the local, national, and international level. Thus, the knowledge derived from this explorative study highlights a potential novel approach and a new communication tool of mindset-tailored messaging. The use of the PVI, employs technology as a useful tool for improving communication.2 ED clinicians may identify patients by their belonging to one of three mindsets and use communication messages by patient mindset-belonging, highlighting a few messages with each patient throughout the visit to the ED. Although encounters between vulnerable patients and clinicians in the ED are short and fragmented, we present a potential path to overcome the communication barrier and promote satisfaction. Tailoring communication by mindsets may bridge the gap between bio-clinical care and psycho-social care . CliniciTo promote patient satisfaction with communication of clinicians in the ED, clinicians may identify patient-belonging to a mindset and communicate using mindset-tailored messages. These results highlight a novel strategy enabling clinicians to implement patient-centered communication, by mindset-belonging, in the delivery of care. Since the work environments in emergency departments is chaotic, clinicians may use only a few messages that are effective drivers of patient satisfaction for members of each mindset, to better cope with the complexity of patient encounters in the emergency department.


Stroke is a disease with high incidence, mortality and disability rates. It is also the main cause of adult disability in developed countries. Stroke is often caused by small emboli on the inner wall of the blood vessels supplying the brain, which can lead to arterial embolism, and can also be caused by cerebrovascular or thrombotic bleeding. With the exception of recombinant tissue plasminogen activator (rt-PA), which is a thrombolytic drug used to recanalize the occluded artery, most treatments have been demonstrated to be ineffective. Stroke can also induce peripheral organ damage. Most stroke patients have different degrees of injury to one or more organs, including the lung, heart, kidney, spleen, gastrointestinal tract and so on. In the acute phase of stroke, severe inflammation occurs in the brain, but there is strong immunosuppression in the peripheral organs, which greatly increases the risk of peripheral organ infection and aggravates organ damage. Nonneurological complications of stroke can affect treatment and prognosis, may cause serious short-term and long-term consequences and are associated with prolonged hospitalization and increased mortality. Many of these complications are preventable, and their adverse effects can be effectively mitigated by early detection and appropriate treatment with various medical measures. This article reviews the pathophysiological mechanism, clinical manifestations and treatment of peripheral organ injury after stroke. Stroke refers to cerebrovascular damage and focal or widespread brain tissue damage due to a variety of causes, including ischemic stroke and hemorrhagic stroke. Stroke involves brain cell and tissue necrosis and has obvious seasonality, especially during the cold season. Although there are an increasing number of in-depth studies on stroke, few methods can be used to treat stroke .Stroke has the second highest death rate worldwide. Although the mortality rate of stroke has decreased significantly in various countries due to the continuous development of medical technology, the incidence of stroke is on the rise . AccordiThe pathophysiological mechanism of stroke is complex, and brain damage usually affects the normal function of peripheral organs and can even cause serious damage . At the Stroke breaks out a strong inflammatory cascade in the brain, but the peripheral immune system is inhibited by immune regulation of compensatory release of neurotransmitters, this phenomenon is defined as stroke-induced immunosuppression (SIIS) . The dirThere are two main theories about the pathophysiological mechanism of SAP: Aspiration Theory and stroke-induced immunosuppression (SIIS) . A smallThe main causes of SIIS are the transformation from Th1 phenotype to Th2 phenotype of lymphocytes, the decrease of lymphocytes and NK cells in blood and spleen, and the impairment of defense mechanism of monocytes and neutrophils . One of Neurogenic pulmonary edema (NPE) after acute stroke is an acute respiratory distress syndrome (ARDS), which is characterized by acute onset, obvious infiltration of pulmonary interstitial fluid and rapid regression . The patPost-stroke pneumonia is usually directly associated with bacterial infections, including aerobic Gram-negative bacilli and Gram-positive cocci ,the mostThe treatment of NPE mainly includes two aspects. on the one hand, it is based on the treatment of primary central nervous system injury, with emphasis on reducing intracranial pressure to prevent sympathetic nerve discharge, which is considered to be the main culprit of lung injury . AnotherAdiovascular disease is regarded as the predis-posing risk factor for stroke ,cardiovaIn vitro and in vivo studies have shown that the intermediates formed during the oxidation of catecholamines are related to cardiotoxicity  maintain endothelial cell activation. During this period of ischemia, a large number of reactive oxygen species (ROS) are produced in the brain and immune cells. Then, reactive oxygen species can activate endothelial cells, cause oxidative stress and destroy the blood-brain barrier . ResidenMore and more experimental studies have shown that there are interactions between intestinal microbiota and central nervous system as well as heart, which are called brain-gut axis and intestine-heart axis. The main function of the gut-blood barrier is to regulate the absorption of nutrients, electrolytes and water, and to prevent pathogenic microorganisms and toxic substances from entering the bloodstream . Stroke The incidence of stroke-cardiac syndrome after stroke is very high, and the damage of cardiac function affects the prognosis and mortality of patients to a great extent. Almost 80% of AIS patients develop hypertension for various reasons. The side effects of severe hypertension increase the risk of cardiopulmonary complications, cerebral hemorrhage and cytotoxic edema, and are associated with adverse outcomes after AIS . β-blockAcute renal injury (AKI) is one of the common complications after stroke, which can lead to renal failure . StudiesThere is a strong two-way relationship between stroke and kidney disease, which may be related to their similarities in anatomy, hemodynamics and vascular regulation . The gloAfter stroke, the hypothalamus-pituitary-adrenal axis can be activated to regulate the release of glucocorticoids from the adrenal gland. High levels of glucocorticoids can directly affect the function of glomeruli and renal tubules, resulting in the decrease of GFR . At the Activation of the renin-angiotensin-aldosterone system can promote systemic and glomerular capillary hypertension, and the direct fibrogenic and pro-inflammatory effects of angiotensin II and aldosterone may also lead to renal damage . Renin-aImmune and inflammatory responses play an important role in the progression of stroke and are also important causes of AKI and CKD . Macrophin vitro study reported that astragaloside IV (AS-IV) improved renal function and renal fibrosis by inhibiting podocyte dedifferentiation and Mesangial activation induced by overexpression of miR-21  causes the damaged brain to secrete various antigens such as ATP, high mobility group protein 1 (HMGB1), heat shock protein (HSP) and nicotinamide adenine dinucleotide (NAD) . These aAfter MCAO, the levels of TNF-α, IFN-γ, IL-6, MCP-1 and IL-2 secreted by mouse splenocytes increased significantly . In addiSome experiments have proved that compared with the rats without splenectomy two weeks before permanent middle cerebral artery occlusion, the area of cerebral infarction was significantly reduced and the number of macrophages, activated microglia and neutrophils was also greatly reduced . HoweverStroke cuts off the connection between the central nervous system and the gastrointestinal system, resulting in dysphagia, gastrointestinal bleeding, delayed gastrointestinal emptying, etc . DysphagGIB is a common complication in patients with acute stroke and may affect stroke treatment, such as antiplatelet or anticoagulation therapy . The incAt present, the pathogenesis of GIB after stroke is not fully understood. Stress ulcer caused by acute brain injury, increased gastric acid secretion or mucosal ischemia caused by overactivity of vagus nerve may be one of the causes of GIB.Aspirin is a commonly used antiplatelet drug in patients with stroke, and its low-dose side effects may also cause gastrointestinal mucosal damage, leading to gastroduodenal ulcer . A meta-The treatment and prevention of stroke patients with gastrointestinal bleeding should follow routine guidelines. ASA (antiplatelet-statin-antihypertensive) is a drug used for secondary stroke prevention to prevent cerebrovascular thrombosis in patients with cerebrovascular disease or patients at risk of cerebrovascular disease . HoweverPeripheral organ injury and dysfunction are very common after stroke, which usually occur within one week after stroke, so measures need to be taken to prevent and treat them in time. The most common complications after stroke include pulmonary infection, heart failure, acute renal injury and gastrointestinal bleeding. Understanding the pathogenesis, high risk factors and onset time of these complications is helpful for early diagnosis and treatment. The interaction between brain and peripheral organs after stroke is almost always carried out through humoral regulation and neuroregulation. The activation of the immune system and inflammatory response are very important for stroke. They affect many peripheral organs and thus affect the outcome of stroke. Here, we also emphasize and discuss the role of immune and inflammatory responses in all the organs under discussion, hoping to clarify the relationship between them and stroke. However, there are still many problems that have not yet been overcome. The injury of peripheral organs after stroke is usually not caused by the interaction of two or several systems, but by the participation of multiple systems throughout the body. There is no experimental model that can summarize all aspects at present. Elucidating the interaction between central and peripheral organs and peripheral organs will help us to develop more effective treatments.JW and JZ wrote the initial draft. YY contributed to reviewing the literature. QX and YL prepared the figures and table. SF and XX collected the literature. LG and ZJ designed the manuscript and prepared the final version. The authors read and approved the final manuscript.This study was supported by the National Natural Science Foundation of China (Nos. 82071339 and 81771283) and the Natural Science Foundation of Hubei Province (Nos.2020CFB613).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.


The relationship between transcription and aging is one that has been studied intensively and experimentally with diverse attempts. However, the impact of the nuclear mRNA export on the aging process following its transcription is still poorly understood, although the nuclear events after transcription are coupled closely with the transcription pathway because the essential factors required for mRNA transport, namely TREX, TREX-2, and nuclear pore complex (NPC), physically and functionally interact with various transcription factors, including the activator/repressor and pre-mRNA processing factors. Dysregulation of the mediating factors for mRNA export from the nucleus generally leads to the aberrant accumulation of nuclear mRNA and further impairment in the vegetative growth and normal lifespan and the pathogenesis of neurodegenerative diseases. The optimal stoichiometry and density of NPC are destroyed during the process of cellular aging, and their damage triggers a defect of function in the nuclear permeability barrier. This review describes recent findings regarding the role of the nuclear mRNA export in cellular aging and age-related neurodegenerative disorders. Eukaryotic transcription is a complex stepwise process comprised of the transcription initiation, elongation, and termination and requires multiple factors, including transcription machinery , transcription cofactors (coactivator or corepressor), and chromatin regulators . During Aging is a process that is accompanied by the progressive impairment at the molecular, cellular, and organ levels, eventually leading to the decay of biological and physiological functions and the increased risk of diverse aging-related diseases such as cancer, cardiovascular, and neurodegenerative diseases ,4. The rRAS gene can induce the oncogenic pathway in mammalian cells [The transcription of genes triggers an increased opportunity for damage or mutation to affect DNA because the transcription machinery-mediated unwinding of the DNA double helix leads to exposure of single strand DNA to mutagenic agents . The traan cells . Furtheran cells . In varian cells . AlthougSimilarly, the correlation between transcription and aging has been studied intensively through various experiments. However, extraordinarily little is known about the effects exhibited on the aging process as a result of nuclear events after transcription takes place, and such research has not been focused up to date. Thus, this review provides an initial overview of the current studies and recent progress in elucidating the role of the nuclear RNA export in cellular aging and the pathogenesis of neurodegenerative disorders.In eukaryotic cells, the nuclear export of mRNA transcripts requires multiple cellular events including transcription, maturation of pre-mRNA, and the assembly of mature mRNA with specific RNA binding proteins, an establishing messenger ribonucleoprotein (mRNP) complex, and the mRNA transport through the nuclear pore complexes (NPCs) into the cytoplasm .The process of mRNA processing is cotranscriptionally coupled to the mRNA transport pathway. In particular, 3′-end mRNA processing is clearly linked with the mRNA export, and the involved factors are evolutionary conserved from yeast to humans ,14 Figu. In yeasThe transcription and export complex-2 (TREX-2), composed of Sac3, Thp1, Cdc31, Sem1, and Sus1, physically and functionally interacts with both the Spt-Ada-Gcn5 acetyltransferase (SAGA) transcription coactivator complex and NPC to link the transcription, mRNA export, and targeting of active genes to NPC  Figure A. The N-The eukaryotic NPC is composed of about 30 nucleoporin proteins and has a radial symmetry of eightfold. Its structure is composed of three main parts, a central core spanning the nuclear envelope (NE) membrane, a nuclear basket, and long cytoplasmic filaments, and selectively allows most of the mRNPs to disperse in and out of the nucleus in order to maintain a barrier of nuclear permeability . The traThe mRNP anchors to the NPC by interacting directly between the mRNA export factors and basket nucleoporins located in the nucleoplasmic region . In yeasgcn5 or ngg1, a gene encoding a linking protein between Gcn5 and SAGA [The connection between gene expression and aging is reflected in the diverse transcription factors that can operate as the key factors in regulating the various cellular processes ,58,59,60and SAGA ,63, wherand SAGA ,65. A loand SAGA . In addiand SAGA . AlthougThe THO complex is required for the environmental stress response and maintaining a normal fly lifespan. Mutations in the THO complex resulted in a shortened lifespan and strong sensitivity to certain environmental stressors. This is suppressed by the upregulation of c-Jun N-terminal kinase signaling which regulates stress tolerance and longevity . Genome-+ RNA in cells lacking Sus1 were rescued by an increased dosage of the mRNA export factors Mex67 and Dbp5, whose association with the nuclear rim was affected by Sus1, suggesting that boosting the mRNA export process restores the defect of mRNA transport and further damage in the growth and lifespan by lack of Sus1  affects cellular lifespan. In addition, the induction of the smooth mRNA transport by an increased dosage of Mex67 or Dbp5 rescues the decreased lifespan in sus1Δ cells, implying that the prevention of nuclear RNA accumulation plays an important role in cellular aging [The link between gene transcription and aging has been well characterized in diverse studies. The gene expression profile is extremely changed in senescent cells, indicating the various biological events that occur during the process of aging , and thear aging . Therefomog1Δ is aggravated by the additional loss of factors for H2B ubiquitylation [The histones are subject to multiple PTMs, including acetylation, methylation, phosphorylation, ubiquitination, and sumoylation, and such patterns of PTM constitute codes that regulate elaborate chromatin-based processes ,114,115.tylation . Direct tylation . Additiotylation , histone


Excessive consumption of alcohol is not only a social problem, but it also significantly increases the morbidity and mortality rates of many societies. A correlation has been demonstrated between alcohol consumption and increased mortality from cancer, accidents and injuries, liver cirrhosis and other causes. Alcohol abuse increases the incidence of hemorrhagic stroke and the risk of ischemic stroke, induces serious arrhythmias, adversely affects blood pressure and damages the heart muscle. The dose and way of drinking alcohol play a crucial role in assessing whether this drink allows people to maintain health or whether it is a great health and social threat. The beneficial effects of low and moderate doses of alcohol on the occurrence of cardiovascular diseases have been shown in many population studies and meta-analyses in which the effect of U-shaped or J-shaped curves relating alcohol intake to cardiovascular mortality was observed, especially in ischemic heart disease. However, due to the fact that alcohol consumption is associated with many health hazards, it is not recommended to consume it as a preventive action of cardiovascular diseases. Moreover, recent studies suggest that association of low-to-moderate alcohol consumption with the reduction in cardiovascular risk is a result of lifestyle changes and that any reduction in alcohol consumption is in fact beneficial in terms of general health. Alcohol is one of the most important risk factors for mortality . Recent This sentence expressed in the biblical Book of Sirach is still valid in spite of the passage of several thousand years . In 1926The published results of a 13-year prospective observational study involving a group of 12,000 British physicians clearly indicated the beneficial effects of moderate alcohol consumption on the cardiovascular system . These oPart of the observational Seven Countries study of the Italian population living in rural regions also showed a link between moderate, regular alcohol consumption and life expectancy . In the In the majority of observational prospective studies and meta-analyses, it was shown that the relationship between alcohol consumption and the incidence of coronary artery disease and stroke took the shape of the letters U or J on the graph. The lowest risk of cardiovascular disease and coronary artery disease was observed in people consuming moderate amounts of alcohol. This risk increased especially in people abusing alcohol, but also in non-drinkers. There was a higher risk of falling ill and dying, mainly due to injuries, poisoning, suicide, liver cirrhosis, cancer and stroke observed in heavy drinkers ,13,14,15Through the analyses of data from nine representative surveys from the districts keeping the National Health Interview Survey (NHIS) in the United States in 1987–2000 and including data of 245,207 people, it was found that low and moderate alcohol consumption (slightly more than one drink daily) may be a factor that reduces the risk of cardiovascular death. Among those who were lifelong abstainers or had been rare-drinkers in the past and those who stopped drinking, the risk of dying from cardiovascular disease was higher than in moderate drinkers .2+-handling proteins and gap junctions, the actual impact of ethanol on cardiac electrophysiology and reentrant arrhythmias is still unclear. Sutanto et al. postulate ethanol concentration-dependent electrophysiologic phenomenon eliciting both the inducibility and stability of reentrant arrhythmias, particularly in the presence of disease-associated remodeling. Another interesting observation was an anti-fibrillatory effect of low levels of ethanol within atrial muscle  Alcohol intake comprised 38% beer, 29% red wine, 24% champagne or white wine, 6% spirits, 3% fortified wine and 0.2% other alcoholic beverages. Investigators found that light-to-moderate drinkers had the lowest heart disease risk, followed by people who abstained from drinking. People who drank heavily had the highest risk. They also found that light-to-moderate drinkers tended to have healthier lifestyles than abstainers; moreover, taking just a few lifestyle factors into account significantly lowered any benefit associated with alcohol consumption. The genetic analyses also revealed differences in cardiovascular risk across the spectrum of alcohol consumption, with minimal increases in risk when going from zero to seven drinks/week, much higher risk increases when progressing from seven to fourteen drinks/week (in both men and women) and very high risk—twenty-one or more drinks/week. Authors suggest a rise in cardiovascular risk even at levels deemed low-risk—below two drinks per day for men and one drink per day for women .Hu et al., in the group of 40,386 males, proved the harmful effect of alcohol consumption on both cardiovascular and all-cause mortality, underlining potential health benefits associated with the reduction in alcohol intake even in the group of low-to-moderate consumption .Evidences from different experimental studies have suggested that these beneficial effects are due to polyphenols found in red wine, especially resveratrol. Therefore, there is a need for further clinical studies, especially randomized, double-blind, placebo-controlled trials, to objectively confirm the possible health-promoting effects of this substance and to determine both the efficacy and safety and possible therapeutic potential ,63. MoreOn the contrary, obesity, poor diet, low physical activity, smoking and excessive alcohol consumption are correlated with a higher incidence of CVD, dementia and diabetes ,66. The possibility of the protective effect of small and moderate doses of alcohol on cardiovascular diseases is significant from the point of view of public health. All over the world, cardiovascular diseases are the main cause of death, so even a minimal reduction in their relative risk can translate in absolute terms into a significantly lower number of incidence and death from cardiovascular diseases. However, due to the fact that alcohol consumption is associated with many health hazards, it is not recommended to consume it as a preventive action of cardiovascular diseases .


Frail chronic patients consume the largest share of resources in advanced healthcare systems, with more hospitals waiting to receive them in the acute phase (awaiting paradigm) than there are effective public health interventions to keep them out of hospitals as much as possible. Effective chronic care management (CCM) requires organizational research as much as biomedical research . Otherwise, excellent clinical care is wasted by poor coordination among professionals and institutions, with frail patients and their families paying the most expensive price. Comprehensive health technology assessment (HTA) procedures include organizational, social, and ethical dimensions to precisely capture the environmental factors that make medical interventions effective, accessible, and sustainable. Clinical outcomes and financial data are used extensively to evaluate care pathways from the providers’ perspective, but much remains to be done to capture equally important indicators from the perspective of patients and society. The authors hypothesize that the ordinary use of patient-reported experience measurement (PREMs) in HTA can help reduce gaps and inequalities by identifying frail patients on time, curbing the risks of isolation and the burden on care givers, preventing complications and inappropriate emergency care use, improving adherence, health communication and behavior, supporting risk assessment, and relieving the frequency of the healthcare environment. Patient experience can be understood in two main ways ,2 Figur. In a brIn a narrow sense, the experience of patients represents the way they perceive the healthcare environment, the care pathways they undergo, and the professionals they encounter. Examples are the access to treatment , the continuity of care  and the communication with care providers .Patient adherence ;Caregiver burden ;Quality, safety, and cost-effectiveness of care .Both types of experiences significantly affect.Therefore, capturing the experience of patients can help design different type of interventions to improve individual wellbeing, community health, and financial sustainability .This is even more true in elderly patients affected by psychosocial frailty and chronic morbidities. Non-communicable chronic diseases are known to represent one of the main epidemiological, social, and financial challenges worldwide ,4,5, witFrail chronic patients are the population minority consuming the largest share of resources in advanced healthcare systems ,12,13, w® include organizational, social and ethical dimensions to capture the environmental factors that make medicine more effective, accessible, and sustainable [Supporting the ordinary work of chronic care managers, case managers and clinical managers;Focusing on the connections between units  in addition to their single performances;Enhancing the benefits of clinical care with organizational and educational interventions;Providing specific outcomes for such interventions;Identifying the need for complementary interventions ;Assessing their impact on the care pathway;Evaluating the impact and perception of innovative care technologies aimed specifically at the chronic patient.Comprehensive Health Technology Assessment (HTA) procedures such as the European Network for Health Technology Assessment (EuNetHTA) Core Modeltainable ,16. Clintainable . Despitetainable ,19, the tainable . In thisWaiting time to receive care;Discharge information received;Support received during access to care, treatments and follow-up;Perceived degree of communication and cooperation from the team taking care of the patient;Safety concerns;Relations with the staff;Awareness on part of the medical practitioner about a patient admitted to hospital and/or undergoing surgery;Involvement in care pathway decisions;Being treated in an age-proper way ;Being encouraged to ask;Being listened carefully;Clarity of information received;Kindness and courtesy;Adequacy of the healthcare environment ;Possibility to ask questions before subscribing informed consent.Increasing questionnaires are developed by researchers to evaluate the healthcare benefits actually perceived by patients. Patient-reported outcome measures (PROMs) are administered directly at patients or proxies at different stages before intervention (when possible) and after (when appropriate), investigating the variations they perceived in relevant domains to their health and health-related quality of life . As such, they mainly describe the patient experience in the broad sense. PROMs can be employed in HTA to integrate conventional clinical outcomes (physician-reported) and financial data: indeed, plenty of questionnaires are available to grasp different conditions  and support care decisions on different levels  ,22. On tSimilar to PROMs, these questionnaires can be administered at different stages of care, directly to the patient or proxy . Unlike PROMs, PREM questionnaires are more spread as bottom-up, spot initiatives for the internal use of facilities or occasional comparisons between facilities ,26,27. across the cycle of care. While the former use can help enhance the individual performance of professionals and units  [Most importantly, PREMs are more often employed within the single facilities than -skills) ,26,27,28-skills) .On these grounds, PREMs seem the most suitable indicators to identify chronic care gaps directly from the patients, and tackle clinical, organizational, and financial waste across the continuity of care .The direction of a clinical manager, be it the general practitioner for monopathological, non-complex patients or a specialist physician with expertise on the prevailing condition in more critical, frequently hospitalized patients, ensuring the coordination of multiple treatments from a medical perspective;The coordination of a case manager, be a nurse or another non-medical care professional  who works as the reference point for the patient and eventual care giver, booking visits, prescribing drugs, renovating routine referrals, monitoring ordinary parameters, ensuring the connection of units from an organizational perspective ;The provision of all necessary treatments from a care manager, either directly or indirectly . The more gravity and complexity of the patient, the greater the possibility that the care manager is part of a hospital network; the lower the severity and complexity, the greater the possibility that the care manager is a primary care provider . If clinical managers and case managers are flesh-and-bone professionals, the care manager represents the formal institution they work for.Although there is no universal protocol for CCM, the care of patients with chronic (co)morbidities generally requires the design of a patient-oriented pathway around integrated, multidisciplinary providers , takes an indefinite duration, is subject to updates and may be binding for patients. To meet these requirements, three fundamental pillars are commonly introduced:Pay-per-coordination solutions are often introduced to encourage appropriate CCM. For instance, the Chronic Related Groups experience (CreG) in the Region of Lombardy, Northern Italy, introduced a bundle payment covering all of the treatments needed by patients affected by some pilot chronic diseases , reducing the use of emergency care and hospital admissions given equal health conditions perceived by patients . That piPREMs can help policy makers fill this gap, both when social care is functional to health care adherence  and when social care is aimed at improving general wellbeing and safety. Personal Health Budgets for chronic patients and their care givers were also introduced in the United Kingdom under the general framework of universal personalized care, coordinated by clinical managers working for NHS care managers and subsidiary providers . in support of conventional treatments , investing to make bureaucracy more effective and integrating different databases on shared digital platforms . In the NHS, social prescribing is even being recommended in alternative of conventional medical treatment where it is cost-effective and appropriate [In both programs the collection of PREMs can help policy makers, clinical managers and care managers identify gaps through the cycle of care and adopt cost-effective solutions ropriate . PREMs nThe ordinary issues faced by frail, chronic patients in advanced healthcare systems make the systematic use of PREMs in CCM worth-trying, no matter how excellent is the quality of care provided in acute facilities. In Sweden, a study on elderly patients hospitalized for myocardial infarction reports the consequences of health care fragmentation before and after the admission to hospital: 50% were not visited by any operator up to one month before emergency hospitalization; 79% has resorted to the emergency room for inappropriate needs; 14% had not received any written information to understand who to contact from the moment of discharge; 30% did not know who to consult in case of adverse events and complications) . The RegCollecting PREMs under the provision of managed (chronic) care can help reduce gaps and inequalities by identifying frail patients on time, reducing the risks of isolation and the burden on care givers, preventing complications and inappropriate emergency care use, improving adherence, health communication and behavior, supporting risk assessment, and relieving the frequency of the healthcare environment whenever possible . Clinical managers should explain the pathway in a plain language and be open to questions. Case managers should spare avoidable visits and contacts to clinical managers by providing routine information, ordinary prescriptions and low-complexity parameters monitoring, possibly taking advantage of remote care technology. Telemedicine supported by artificial intelligence for instance may help address the shortage of specialized care professionals outside hospitals and major urban centers. Care managers should identify room for improvement across the organization taking advantage of the direct perspective of patient and care giver, enhancing the soft-skills of health care professionals through financial incentives and/or professional training and/or making the whole service more accessible .CCM does not require the administration of additional treatments; it works on the way these treatments are integrated in a patient-centered perspective . From this perspective, PREMs are optimal indicators for organizational, legal, social, and ethical impact in HTA procedures. For example, the following items were employed to express the equity, legal, and organizational dimensions of an enhanced-recovery after surgery perioperative pathway :Accessibility of the technology in the area ;Accessibility of the treatment to protected citizens, such as frail elderly and disabled patients;Accessibility of the technology to all patient categories, including those affected by severe comorbidities;Accessibility to post-discharge facilities;Post-discharge facility decision is shared with the patient;Potential impact in reducing waiting lists;General inclusivity;The technology respects the cultural, moral and religious identity of the patient.Equity domain:Ability to safeguard the patient’s autonomy;Economic accessibility to the patient;Removal of the disease-related social costs in charge of the patient;(Impact of) Social determinants of compliance and technology comprehension;Patient satisfaction;Ability to improve the patient’s quality of life (of the patient);Ability to improve function (perceived);Ability to improve the family caregiver’s quality of life;Reduced time spent in the healthcare environment.Burden removed by the technology:Need to regulate the technology ;Regulatory protection of specific patients;Is patient-information about the technology exhaustive?Degree of sensitive data protection;Safety criteria.Legal domain:Most of these items would be appropriate to assess a CCM program and many PREMs among those exemplified in the previous section would be suitable outcomes. In this study, the items were assessed by qualitative interviews to the healthcare professionals involved in the pathway. The use of standard PREMs would bring the assessment to a further level, taking into consideration the direct experience of patients and caregivers and allowing for comparisons between different patients, professionals, and facilities.Patient-reported experience should not be confused with patient-satisfaction, although the latter may be included as a single indicator among others . MoreoveWe believe that the ordinary use of PREMs in HTA can increase the direct (patient-related) and indirect (care giver- and society-related) benefits of CCM by enhancing all of the dimensions of value: personal value, by improving or maintaining the wellbeing of patients; technical value, by improving the (cost-)effectiveness of medical treatment through better adherence and patient-centered organization; allocative value, by reducing waste and freeing up financial, human and time resources; and societal value, by translating health benefits into socio-economic benefits, such as more productivity, reduced welfare dependency, and more time to dedicate to those people and activities which make everyday life worthy-living.


In this study, the relevance of Lorentz and Coriolis forces on the kinetics of gyratory Maxwell nanofluids flowing against a continually stretched surface is discussed. Gyrotactic microbes are incorporated to prevent the bioconvection of small particles and to improve consistency. The nanoparticles are considered due to their valuable properties and ability to enhance thermal dissipation, which is important in heating systems, advanced technology, microelectronics, and other areas. The main objective of the analysis is to enhance the rate of heat transfer. An adequate similarity transformation is used to convert the primary partial differential equations into non-linear dimensionless ordinary differential equations. The resulting system of equations is solved using the finite element method (FEM). The increasing effects of the Lorentz and Coriolis forces induce the velocities to moderate, whereas the concentration and temperature profiles exhibit the contrary tendency. It is observed that the size and thickness of the fluid layers in the axial position increase as the time factor increases, while the viscidity of the momentum fluid layers in the transverse path decreases as the time factor decreases. The intensity, temperature, and velocity variances for the suction scenario are more prominent than those for the injection scenario, but there is an opposite pattern for the physical quantities. The research findings are of value in areas such as elastomers, mineral productivity, paper-making, biosensors, and biofuels. The heat and mass transfer analysis of the non-Newtonian hydrodynamic boundary layer flow phenomenon has attracted the interest of many researchers due to the enormous number of potential applications in engineering and industry. The well-known Newtonian liquids  basic theory is incapable of elucidating the fluids’ internal microstructure. Non-Newtonian liquids  include quince paste, animal blood, cement sludges, esoteric lubricating oils, effluent slurry, and liquids containing synthetic polymer additives. One such rate-type non-Newtonian fluid model is called the Maxwell nanofluid model which predicts the stress relaxation time. The extensive choice of methodological and engineering applications associated with Maxwell nanofluids, such as biochemical, gasoline, polymer, and nutrition release, has motivated many investigators to scrutinize the features of Maxwell nanofluids with respect to numerous geometrical and substantial limitations. The convective Maxwell hybrid nanofluid stream in a sturdy channel was studied using the Laplace transform strategy , wherebyNanofluids are fluids that incorporate an appropriate distribution of metal and metallic nanoparticles at the nano size and are engineered to perform specific functions ,16,17,18The bioconvection phenomenon occurs as a result of the existence of a density gradient in the flow field. Consequently, the movement of particles at the macroscopic level enhances the density stratification of the base liquid in one direction. The presence of gyrotactic microorganisms in nanofluid flow has attracted the interest of many researchers due to their potential application in relation to enzyme function, bio-sensors, biotechnology, drug delivery, and biofuels. These applications have motivated researchers to undertake numerical studies on bioconvective nanofluid flow with microorganisms in different flow field geometries. Chu et al.  investigThe careful review of the literature detailed above shows that little attention has been paid to the self-motile denitrifying microbes contained in Maxwell nanofluid spinning flows through an elongating sheet under an externally applied magnetic field. To the best of our knowledge, none of the studies cited has considered the interpreted problem. Consequently, the main objective of this study was to explore the mass and heat transfer impacts on transitory hydromagnetic Maxwell spinning nanofluid 3D radiative flow comprising microbes and suction/injection processes. Many authors ,36,37 haWhat effects do relaxation of the Deborah number, the Coriolis effect, and an applied magnetic field force have on the hydrodynamics of heat flux, fluid viscosity, and concentration level variances using injection/suction?What impact do Brownian motion and thermophoresis have on heat and mass transfer rates and the skin friction factor for suction/injection?How do Brownian motion, the relaxation Deborah number, and time-dependent factors impact on the temperature profile?What is the bioconvection impact on the motile dispersal function with suction/injection?The following research questions are addressed in this study:The transitory magneto-hydrodynamic ficiency . To avoisertions ,42,43:t<The following similarity transforms are used to alleviate the complexity of the articulated problem as ,44:(11)ΓM, In the context of Equation , EquatioThe physical quantities  numbers, and the coefficient of skin friction are expressed here as:Equation , we get:The finite element analysis (FEA) is a computational approach for discovering numerical approximations to ODEs and PDEs with complicated boundary conditions. This is an efficient approach for resolving technological problems, especially those involving fluid diversities. This methodology represents an excellent numerical strategy for solving a variety of real-world problems, particularly for heat transfer via fluids and biomaterials . Reddy ,48 preseThe system of Equations (12)–(17) reduced as:For numerical calculation, the plate length has been specified as Here m, n = 1, 2, 3, 4, 5, 6) are expressed as: Therefore, the stiffness element matrix, matrix of unknowns and the force vector/matrix for the finite element model are followed as: Here, This section describes through FE analysis how suction/injection impacts the mechanisms of a Maxwell spinning fluid when it is impacted by the Coriolis effect, magneto-hydrodynamic effects, and micro-organisms. Three different patterns of arcs are mapped on fluctuating values of the intravenous injection/suction esh size . For disorted by ,53. Furth et al.  and Musth et al. , who preM is increased. M continues to increase. A large discrepancy in values adjacent to the surface of the sheet, M and M, the rotating factor M and M, the rotating parameter M and rotation factor M and (Pe) see a,b. Furthas a significant influence on the temperature dispersion and concentration.intensifies the impact of the Coriolis force causes the transverse momentum to decrease for increasing values of the rotation factor.with the infusion capability, the velocity, temperature, and concentration components are reduced.Increase in the Coriolis and Lorentz’s forces has a decreasing impact on the velocity magnitude, anda declining impact on injection is associated with a larger amount in the injection case has a larger the wall thickness of the heat transfer performance increases with increasing rotating parameter.It is becoming increasingly evident that the simultaneous enhancement of Brownian and thermophoresis factors has a negative effect on the distribution of temperature, andhas substantial consequences for temperature dispersion.for tiny particles, the volume fraction shows rising effects with higher relaxation Deborah number.Higher input to the relaxation Deborah number and the unsteady parameter has a negative impact on the magnitude of the primary and secondary velocity, butMotile microorganism viscosity reduces in the context of augmented bioconvection Peclet and Lewis numbersIn this article, a finite element simulation was exploited to investigate Maxwell nanofluid flows over a bidirectional elongating surface with bio-convection, suction/injection, Coriolis, and Lorentz forces for three-dimensional spinning flow. Based on the results, the following inferences can be made:This study has involved an analysis of the parameters that their impact on dynamic of fluid flow problems and can be extended in future to include Blasius and Sakiadis flow, and Darcy–Forchheimer and thermoelastic Jeffrey nanofluids.


Immunotherapy has become the breakthrough strategies for treatment of cancer in recent years. The application of messenger RNA in cancer immunotherapy is gaining tremendous popularity as mRNA can function as an effective vector for the delivery of therapeutic antibodies on immune targets. The high efficacy, decreased toxicity, rapid manufacturing and safe administration of mRNA vaccines have great advantages over conventional vaccines. The unprecedent success of mRNA vaccines against infection has proved its effectiveness. However, the instability and inefficient delivery of mRNA has cast a shadow on the wide application of this approach. In the past decades, modifications on mRNA structure and delivery methods have been made to solve these questions. This review summarizes recent advancements of mRNA vaccines in cancer immunotherapy and the existing challenges for its clinical application, providing insights on the future optimization of mRNA vaccines for the successful treatment of cancer. In the recent decades, achievements in the understanding of the immune system have shed light on the treatment of cancer by immunotherapies . Variousin vivo delivery methods of RNA vaccines to achieve higher efficiency. For instance, in addition to electroporation, novel vectors such as polyplexes, lipid nanoparticles, peptides and cationic nanoemulsions have been used for the delivery of RNA vaccines  and the chemical capping methods  tails Figure 1 methods . These c methods , 18. To  methods .Secondly, post-translational modifications of mRNA can inhibit the immune recognition of mRNA. Studies have revealed that minimization of mRNA reorganization by the innate immune system could prevent sensing and destruction of mRNA translation, resulting in increased expression , 20. ForThirdly, increased purity of RNA and removal of impurities can prevent the degradation of mRNA. During the process of transcription, double stranded RNA impurities are easily formed, which leads to the immunogenicity of mRNA cancer vaccines. Thess and co-workers have shown that the RNA impurities could be removed by optimization of the sequence and purification of RNA by high-pressure liquid chromatography (HPLC), which could result in reduced immunogenicity and improved stability of mRNA vaccines . HoweverFourthly, optimization of the ORF of mRNA can improve mRNA translation. Increased GC content in the ORF can be applied to improve stability . MethodsFinally, optimization of the untranslated 5’ UTR and 3’ UTR of mRNA can also significantly improve stability and protein expression . For exain vivo delivery of mRNA vaccine have greatly inhibited its clinical application. Therefore, it is of urgency to increase the delivery efficiency of mRNA vaccines. There are mainly three types of vectors used for in vivo delivery: viral, non-viral and cell-based vectors. Dendritic cells (DCs) are usually used as cell-based vectors for adoptive transfer of mRNA cancer vaccines. Designated ‘nature’s adjuvants’, dendritic cells (DCs) are a group of bone marrow-derived antigen-presenting cells that play essential roles in activating and mediating immune response  is one of the most commonly used polymer-based vectors for mRNA vaccine delivery , 57. Thein vivo delivery of mRNA cancer vaccine have impaired its clinical application. Although progress has been made over the past decades to overcome these limitations, challenges still exist on the development of mRNA cancer vaccines. To promote the wide application of mRNA cancer vaccines, more strategies should be taken to improve the stability and translation rate of mRNA vaccines.The successful application of mRNA vaccines for Covid19 has demonstrated the great potential of mRNA vaccines as novel therapies for the treatment of lethal diseases. It’s reported that mRNA-based vaccines can induce immune response in cancer cells, leading to the destruction of cancer cells and the control of tumour growth. Conventional therapies of cancer treatment such as chemotherapy and radiotherapy often suffer from multi-drug resistance and strong toxicity, whereas mRNA-based cancer vaccines have shown enhanced efficacy and reduced toxicity. Therefore, mRNA-based vaccines have gained more and more popularity for the development of novel immunotherapies. However, the instability and In conclusion, mRNA vaccines have the potential to significantly affect the battle against cancer. Future studies should cast more investigations on the combination of mRNA cancer vaccines and conventional cancer therapies.X-YZ, D-XY and CZ conceived the topic, revised and proofread the manuscript. L-JD and QW drafted the paper and prepared the figure and table. All authors approved the submitted version.This study was supported by the Major Projects in Provincial and National Union Construction of Henan Medical Science Research Plan (SBGJ202001002).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.


Nature Medicine (Recently, four studies on the potential value of small-molecule metabolites by high-throughput functional metabolomics were published in Medicine . These sMetabolic abnormalities lead to the accumulation or deficiency of small-molecule metabolites, which are related to phenotypic variation, can reveal the pathological mechanisms of various diseases and decipher therapeutic potential . FunctioN-acetyltransferase 2 gene, which is linked to the risk of bladder cancer.High-throughput metabolomics technology has been used to identify phenotypic variation arising in the human plasma metabolome that is influenced by dietary, genetic, and microbial factors. in vivo that affect systemic health. The authors further observed the potential causal relationship to assess the contribution of the microbiome to the plasma metabolome and found that the increased level of adenosylcobalamin biosynthesis was related to the reduced level of 5-hydroxytryptophan that is associated with Parkinson’s disease; the plasma level of hydrogen sulfite was related to Eubacterium rectale, which interfered with cardiovascular function, nervous system, and inflammatory process (Since small-molecule metabolites are closely linked to the phenotype, they govern the modulation of its function, thus reflecting the interactions with the environment. The gut microbiota generates active metabolites which enter into the circulation system and regulate host metabolism responses and metabolic disorders  process . In shorIn order to verify the attributions of global metabolites, Taken together, these groundbreaking studies provide substantial support for the use of high-throughput metabolomics for identifying small-molecule metabolites and improving disease diagnosis, prognosis, and treatment response for ameliorating the quality of life in patients. Small-molecule metabolites showed a correlation with the functional status of a biological system. They pave the way for the understanding of metabolic alterations under different conditions to design the intervention strategy for manipulating small-molecule metabolites. These clinical applications also provide excellent examples to illustrate how the metabolites could facilitate the prediction of diseases or treatment, better explore potential molecular mechanisms within disease progression, and enable precision-targeted therapies.Advancements in high-throughput metabolomics technologies have demonstrated the potential value of the investigation of metabolite signatures and allowed the researcher to establish comprehensive metabolic profiling to provide insights into metabolic functions. However, several challenges need to be addressed in future research. Endogenous metabolites may participate in all kinds of metabolic processes, thus affecting human health, but it is still difficult to detect them quickly while maintaining their metabolic status. Future research should define and continue to focus on the functional correlation with disease pathogenesis. Nevertheless, method standardization and processes should be reflected in each stage, and the predictive ability and diagnostic value of the established metabolic profiles need to be further validated in a large number of cohort studies. In the future, advanced artificial intelligence, computational algorithms, and big data mining analytics will be urgently needed to improve coverage of low-abundance metabolites for clinical validity. From clinical to experimental and from experimental to clinical, multiple cycles of validation can achieve the optimal model to thoroughly understand the functional significance of small-molecule metabolites.