Background and Objectives: Bones and the skeletal muscle play a key role in human physiology as regulators of metabolism in the whole organism. Bone tissue is identified as a complex and dynamic living unit that could react to physical activity. Hormones, growth factors, signaling factors, and environmental factors control osteogenesis, and it could be regulated at a post-transcriptional level. MicroRNAs (miRNAs) can interfere with mRNAs translation. Increasing data suggest that miRNAs, through different pathways, are involved in the regulation of bone marrow mesenchymal stem cells (BMSCs) differentiation and physical activity-induced bone remodeling. The purpose of this narrative review is to investigate the potential protective role played by physical activity in affecting miRNAs expression in close tissues and elaborate on the complex network of interplay that could drive various metabolic responses of the bone to physical activity. Materials and Methods: A bibliographic search of the scientific literature was carried out in scientific databases to investigate the possible effect of physical activity on age-related features detected in the musculoskeletal system. Results: Several studies suggested that the musculoskeletal system interacting at a biomolecular level could establish crosstalk between bone and muscle in an endocrine or paracrine way through myokines released by muscle at the periosteal interface or in the bloodstream, such as irisin. Mechanical stimuli have a key role in bone formation and resorption, increasing osteogenesis and downregulating adipogenesis of BMSC via regulation of expression of runt-related transcription factor 2 (Runx2) and peroxisome proliferator-activated receptor gamma (PPARγ), respectively. Conclusions: Increasing data suggest that miRNAs, through different pathways, are involved in the regulation of BMSCs differentiation and physical activity-induced bone remodeling. Modulation of miRNAs following physical exercise represents an interesting field of investigation since these non-coding RNAs may be considered defenders against degenerative diseases and as well as useful prognostic markers in skeletal and muscle-skeletal diseases, such as osteoporosis. The bone and the skeletal muscle play a key role in human physiology since they not only fulfill a mechanical role in locomotion and movement but are also prominent regulators of metabolism in the whole organism. Bone tissue is identified as a complex and dynamic living unit that could react to physical activity or any type of mechanical loading such as exercise training . A recenBone mass constitutes approximately 14% and 11% of total body mass in females and males. Moreover, mechanisms of age-related acceleration in bone loss in older males are different from those associated with menopause. Age-related reduction in the osteogenic differentiation has been connected to adipo-osteogenic differentiation of bone marrow mesenchymal stem cells (BMSCs)  and exprThe literature data show that regular physical activity is one of the most widely used nonpharmacological strategies that help to improve human performance status and can help to obstruct several diseases such as age-related muscle wasting, obesity, and osteoporosis (OP) . ModulatOP is a set of alterations that include reduction in bone quality and density, impairment of skeleton, and consequently increment of risk of fracture . The excIn the literature, there are not enough accurate studies that compare different types of intensity training (resistance and endurance training) plans and estimate miRNAs variable expression in adipo-osteogenic trans differentiation of BMSCs ; but, thThe purpose of this narrative review is to investigate the potential protective role played by physical activity in affecting miRNAs expression in close tissues and elaborate on the complex network of interplay that could drive various metabolic responses of the bone to physical activity. Thus, it could lead to the establishment of peculiar positive crosstalk in the skeleton-muscle system. A bibliographic search of the scientific literature was carried out in scientific databases to investigate the possible effect of physical activity on age-related features detected in the musculoskeletal system. Consequently has been evaluated if regulation of osteogenic differentiation, through changes in the production of transcription factors or modulation of miRNAs typical of postmenopausal osteoporosis, could lead to a possible improvement in disease. The MeSH terms “microRNAs” and “Osteoporosis” were used in association with “Physical activity”. The search strategy related to the population, intervention, and outcomes was constructed around search terms for “Bone Mineral Density”, “osteogenesis”, “Exercise,” “high-intensity interval training”, “resistance exercise”, “endurance”, “continuous moderate-intensity exercise”, “modulation miRNAs” and “Postmenopausal”. The present study was based on comprehensive reviews and research studies on both mice models and human samples. The research was conducted by findings that led to an improvement in osteoporotic status. The criteria of inclusion in the study were considered the factors that after different physical activity helped to improve musculoskeletal system aging at different biomolecular levels on various linked signaling pathways.Both patients with postmenopausal osteoporosis ,16 and oIt has also been shown that PPARγ influences bone loss in humans and animals partly through the limitation of osteoblast differentiation from BMSCs . AccordiEndurance activity and muscle-specific overexpression of peroxisome proliferator-activated receptor gamma coactivator (PGC)—1 alfa stimulates FNDC5 expression in skeletal muscle and consequently leads to increased irisin level . Irisin,Age-related changes in irisin levels are less marked in men compared to women; in fact, Park et al. in 2019 reported in postmenopausal women that sarcopenia status was characterized by low levels of circulating irisin . PreviouData showed that irisin and its precursor were overexpressed in skeletal muscle of myostatin KO mice line, underlining a signaling pathway activated by mutation of myostatin that, indirectly, drives browning of WAT through the regulation of its pathway (AMPK-PGC1-Fndc5) ,28. A moThe levels of biomarkers , known as osteogenic markers, change following the various stages of osteoblast differentiation; however, in order to modulate monocyte to osteoclast differentiation, osteoblasts may produce receptor activator of NF-kB ligand (RANKL) and osteoprogeterin (OPG) such as macrophage colony-stimulating factor (M-SCF). RANKL/RANK, jagged1/Notch1, and Wnt/b-catenin are three significant regulatory feedbacks driven by osteoblasts, which could affect the BMD through the adjustment of osteoclast and osteoblast functions. Various studies investigated the modulation of these pathways and also showed a gain of progenitor cell number in peripheral blood after different physical exercises . In 2019Osteogenesis could be induced through the irisin naturally produced after exercise training as well as by the recombinant irisin (r-irisin) injected . ColaianPreviously data have been already shown an upregulation of irisin blood levels after swimming exercise, but Kang et al. also reported a direct impact on BMD operating in a positive manner: indirectly on IL-1 and body fat reduction and directly on bone metabolism marker pathways such as beta-catenin, osteocalcin, and CTX-1, increasing PGC-1alfa/FNDC5 expression in bone tissue . Other fTurner et al. showed that the osteogenic reaction to mechanical stimuli was greater in young rats compared to aged ones, even if, once activated, the cells of older rats had the similar power to reply to mechanical loading as the young ones . A recenMany studies have shown that long-term aerobic exercise enhances PGC-1α expression levels in the skeletal muscles of high-fat diet-fed mice, resulting in the aerobic oxidation of fatty acids. However, this physical activity is inconvenient for older people while considering static strength training (ST) mode more suitable for older people . A positWeight training and weight-bearing training, such as running and walking, have been practiced to improve bone metabolism in aging ; moreoveBone homeostasis needs a fine regulation of transcription factor gene that is either highly expressed or osteoblastic specific in cells of the osteoblast commitment lineage. Other level of regulation could include both nuclear protein such as STAT1, that could weaken the function of osterix, runx2, and or ATF4, and proteins of matrix nuclear, such as SATB2 favoring osteoblast differentiation, raising the activity of runx2.Moreover, a superior and issued regulator key of gene expression has been represented by microRNA . Along wThe bone expression of MiR-214 was identified as a negative regulator of the bone formation marker gene  in aged people  Figure . ConsequMechanical strain targeting sclerostin, an inhibitor of wnt/beta-catenin pathways, might both increase osteoblastic bone formation and drop osteoclastic bone resorption , and it Moreover, data showed that also miR-133 was particularly deregulated in the bone tissue of OVX mice  as in thIt was yet reported that WAT produced FNDC5/irisin after physical activity , and theMoreover, some miRNAs, miR-1-3p, miR-133a-3p, miR-133b-3p, and miR-486-5p, in whole blood from men decreased more after a 6-week short-term sprint interval training (SIT) intervention than after a single session of SIT. High-intensity exercise may reduce age-related decline factors  through Alipour et al. investigated the decrease in miR-34 in response to physical exercise; they showed for the first time the negative effect of swimming exercise on the expression of miR-34 on pancreatic tissue of mice with type 2 diabetes; in general, these findings displayed the modulation through physical activity on molecular axis miR-34/SIRT1/P53 . PreviouPostmenopausal women and men aged 50 years and older with hip or vertebral fractures, regardless of T-score, should be considered for pharmacological treatment. Fracture incidence goes down after therapy, mostly in patients with previous fractures whether the T-score classification is normal, osteopenia, or osteoporosis. Moreover, in general, no unified advice administers to all patients; management of treatment must be individualized. In accordance with the treat-to-target approach, osteoporotic patients should be risk stratified before starting treatment .Firstly, the goal of medication would be a therapy that succeeds in decreasing the risk in an adequate manner, combining the patient needs . FracturLifestyle recommendations should include a diet with adequate total calcium intake incorporating calcium supplements if intake is insufficient. Magnesium is essential for calcium absorption, but magnesium extra-supplementation does not increase BMD . De CastHormone replacement therapy is suggested only for women who have moderate to severe menopause disorders. In current years, research has highlighted the role of phytoestrogens (selective estrogen receptor modulators) as an alternative treatment that can improve the same symptoms but with fewer side effects; among them, soy isoflavonoids have raloxifene-like beneficial effects on the bone metabolism. Many menopausal women use phytoestrogens to preserve their bone mass. Both therapies, the phytoestrogens and hormones, produce a significant decrease in the bone resorption process. The comparative valuation showed no significant differences between the efficacy of the phytoestrogens and the hormone therapy on BMD and bone resorption when administered to groups of women with the same clinical and sociodemographic features ,79.The results of this study underline that the effects of physical activity spread to multiple levels. It might perform a role in maintaining bone quality by realizing mediators of bones (osteokynes) that influence their expression, acting as intermediaries released by other tissues; or releasing mediators from bone  that affect themselves both directly and indirectly and via the specific effect of physical activity on neighboring tissues  . Among tPhysical exercise is considered the main negative factor regulator of age-related mutations and could perform a positive anabolic effect on bone either indirectly through endocrine regulation or directly via mechanical signals caused by muscle contraction, supporting the close interaction between bone and muscle . One of Age-related alterations could involve not only tissue loss but also metabolic and endocrine deviation linked to an elevation of proinflammatory cytokines . The basLittle evidence is available regarding which type of exercise session elicits a more strong effect on the release of myokines or proteins/hormones. Further, it is important to know the existence of wide inter-individual variability in the biological responses to a given exercise session to ensure a better-personalized exercise prescription. In fact, there are some subjects achieving meaningful benefits (known as “responders”) and others showing no changes (“non-responders”) . ExercisA significant increase in irisin levels during an acute bout of exercise to exhaustion has been observed immediately after high-intensity interval exercise (HIIE), continuous moderate-intensity exercise (CME), and resistance exercise (RE) and declined 1 h later, indifferently in individuals with metabolic syndrome as well as healthy individuals . HIIT, wIrisin levels, according to the diurnal change concentration over 12 h, are related to the type of physical activity usually performed and to muscular strength, contractility and volume. During physical activity, a better increase in irisin concentration has been shown after anaerobic activity compared to aerobic activity; the levels of irisin proved better in resistance exercise compared with endurance exercise alone and resistance and endurance exercises combined. Moreover, a study in adults reported an increase in irisin following acute exercise but a decrease in irisin after a 12-week period of endurance and strength training. Irisin levels are a determinant of measures of areal and volumetric bone mineral density and bone strength estimates in athletes . Even hiEmerging evidence reported that muscle-bone communication may be obtained by the release of myotube-derived exosomal miRNAs, called myomiRs, and some osteocyte-derived exosomal micro(mi)RNAs, called osteomiRs, to their microenvironment cells. So, myokines and myomirs can also be mediators of intracellular pathways between neighbor and far tissue . The traDifferent types of exercise could stimulate bone formation, and the literature has already shown that these effects could have a beneficial rebound on BMD in postmenopausal women . PhysicaRecently the regulatory functions of epigenetic factors, such as miRNAs, in the physiological and pathological processes have been widely investigated. In particular, modulation of miRNAs following exercises represents an interesting field of investigation since these non-coding RNAs may be regarded as useful prognostic markers, as well as a protector against disease. Moreover, their rapid yet transient regulation with exercise prompts that they may concur to the positive adaptation, modulating various intracellular stress signals by targeting, or triggering, the expression of master genes coding for specific transcription factors that may control the mutually exclusive fate of progenitors cells.Based on this integrated perspective, this narrative review may represent a relevant help to future investigation aimed at characterizing the possible role of specific types of physical activity to condition miRNAs expression and, consequently, their involvement in the pathways related to chronic bone disease, such as OP. Therefore, it would be useful to find the potential ability of those treatments, both pharmacological and alternative, such as physical exercise, to modify transcription factors by acting on an epigenetic level.It would be helpful to investigate how exercise could facilitate osteoinduction; indeed, physical activity has been proposed as a supplementary method of recovering bone health in regenerative medicine.Mechanical load, while stimulating irisin, downregulates myostatin levels, linking the functional bone-muscle unit. Therefore, the emerging role of irisin and its low levels in postmenopausal women with sarcopenia status suggested that irisin could be a potential marker for staging and early diagnosis for sarcopenia. Moreover, the treatment with a low dose of recombinant irisin was able to gain in quality of bone mass; therefore, it would be useful to highlight its role as a therapeutic target in osteoporotic aging in the future implications. Further studies need to verify if the different impacts on various transcription factors could be conditioned by different types of exercise. With a view to the future, supportive care, such as regular physical activity, acting on the miRNAs balance adjusting their transcription factors involved in different chronic disorders, could decrease the pharmacological load and would be able to help modify the clinical history of the disease.


According to the WHO’s Global Health Estimates 2019, the deleterious complications of cardiovascular disease, in particular ischemic heart disease and stroke, account for 27% of deaths worldwide, rendering it the single most detrimental disease globally.Extensive effort has been put into preventive interventions, such as anti-smoking campaigns, educational programs for dietary changes and exercise to improve overall cardiovascular health and prevent development of cardiovascular risk factors already in preschool students .Pharmacological interventions so far mainly focused on modulation of blood pressure, hyperlipidemia and glucose metabolism, as well as antithrombotic therapy, but further optimization has stalled .Atherosclerosis is the leading underlying pathology of cardiovascular disease, and shares many features with other chronic inflammatory conditions. The concept of bone marrow derived macrophages destabilizing atherosclerotic lesions has been widely accepted, and recent scientific findings have broadened our understanding on how every part of the immune system plays a role in vascular inflammation  and how The CANTOS trial, published in 2017, was the first to prove that an anti-inflammatory therapy by targeting interleukin-1β with a monoclonal antibody is sufficient to reduce recurrence of cardiovascular events . This brThis Research Topic addresses the current state-of-the art in innate and adaptive immunity with its implications for cardiovascular complications. Comprehensive review articles and extensive original research studies broaden our view on organ crosstalk in vascular disease, and explore therapeutic options.Sauter et al. report on the role of macrophages, dendritic cells and platelets in advanced atherosclerosis. Kaiser and colleagues build-up on this work, giving unique and in-depth insights on platelet-neutrophil crosstalk. They address mechanisms of immune and immunothrombotic responses, describe the involvement in different cardiovascular conditions such as atherosclerosis, thrombosis, ischemia-reperfusion injury and COVID-19-related pathology and depict recent therapeutic approaches. Funk-Hilsdorf and colleagues genuinely summarize the present knowledge on the role of innate and adaptive immune responses in pathogenesis and disease progression of pulmonary hypertension. By dissecting the contribution of various immune cell subsets to progression of pulmonary vascular wall remodeling or protection from its aggravation, they delineate challenges and chances of understanding inflammation as a crucial disease mediator of pulmonary hypertension.In a narrative review, Hasselbach et al. summarize how limited inflammatory clearance after an insult, such as ischemia, viral infection or even surgical stress, can exacerbate heart failure. The COVID-19 pandemic has shown us how there is no “one size fits all” for therapy of inflammatory insults, especially not in patients with underlying cardiovascular disease.Additional review articles focus on specific diseases. Wortmann et al. highlight the importance of modulating inflammation as one of the few conservative treatment options of aortic disease. They analyze how targeting the NOD-, LRR- and pyrin domain-containing protein 3 (NLRP3) inflammasome can reduce aortic disease burden and associated complications, and may thus translate into clinical treatment options to prevent aortic wall destruction in humans.In their systematic review of the preclinical evidence, Vornholz et al. demonstrated that right-sided stroke results in acute heart failure with reduced ejection fraction, bradycardia, hypotension, and elevation of cardiac troponin. In parallel, they observed a cardiac and systemic inflammatory response to stroke, with IL-6 and IL-1ß-dominated inflammation in the heart and increased cardiac and systemic numbers of granulocytes. Severity of cardiac alteration was associated with increased mortality. This study adds to the growing body of evidence that the heart is an end organ during cerebral injury.By using an innovative stroke model in mice, Bello and colleagues highlight the role of Indoleamine-2,3-dioxygenase (IDO) in different immune-related cardiovascular diseases. They focus on its potential for decision-making and tailoring treatment strategies in autoimmunity and neurodegenerative disorders and address its role as a perioperative predictive biomarker in bacterial infection, influenza, sepsis, surgical trauma and in diseases related to oxidative stress.In their review, Kumawat. They report anti-inflammatory effects of an anti-IL17A affibody on vascular smooth muscle cells and fibroblasts in vitro. In a mouse model of atherosclerosis, inflammation was reduced but burden of atherosclerotic plaque development remained unchanged.A potential therapeutic approach is introduced by the group around The article collection spans the entire range from reviews summarizing the current knowledge in targeting innate and adaptive immunity, addressing specific diseases and describing predictive biomarkers to exploring therapeutic options to improve cardiovascular disease.Research in innate and adaptive immunity in cardiovascular disease has proven that extensive studies on animal models can be translated into clinical trials, under careful consideration of who is in need of additional therapeutic options. Substantial progress has been made and several inflammatory targets have proven their central role for preventing cardiovascular disease and for treating its complications. However, this article collection also demonstrates that much more research effort is needed and that it is a long way to go in order to remove cardiovascular diseases from the top ranks on the WHOs list of leading causes of death.


Neutrophil extracellular traps (NETs) are extracellular fibrous networks consisting of depolymerized chromatin DNA skeletons with a variety of antimicrobial proteins. They are secreted by activated neutrophils and play key roles in host defense and immune responses. Gastrointestinal (GI) malignancies are globally known for their high mortality and morbidity. Increasing research suggests that NETs contribute to the progression and metastasis of digestive tract tumors, among them gastric, colon, liver, and pancreatic cancers. This article explores the formation of NETs and reviews the role that NETs play in the gastrointestinal oncologic microenvironment, tumor proliferation and metastasis, tumor-related thrombosis, and surgical stress. At the same time, we analyze the qualitative and quantitative detection methods of NETs in recent years and found that NETs are specific markers of coronavirus disease 2019 (COVID-19). Then, we explore the possibility of NET inhibitors for the treatment of digestive tract tumor diseases to provide a new, efficient, and safe solution for the future therapy of gastrointestinal tumors. Gastrointestinal tumors are a general term for benign and malignant tumors that originate in the digestive tract. Gastrointestinal neoplasms are mainly composed of tumors occurring in the colon, rectum, stomach, pancreas, and liver, causing a heavy burden on public health care. The above-mentioned tumors in the gastrointestinal tract are extremely lethal and deserve full attention. Colorectal cancer (CRC) of the colon and rectum represents the second most prevalent cause of cancer-related deaths, while gastric cancer (GC) ranks as the fourth leading contributor to death worldwide according to cancer statistics . RecentlThere is now a growing body of research demonstrating that the immune system has a part to play in tumor suppression as well as treatment. Among them, the role of neutrophils is also becoming a research hotspot in the comprehensive treatment of GI cancers . NETs, cThis review first elaborates on the formation mechanism of NETs in detail. Then, the relationship between NETs and the tumor microenvironment was investigated. According to the latest research, NETs’ effects on digestive tract tumors are introduced in detail, including tumor growth, metastasis, angiogenesis, etc. In addition, we also list the current targeted drugs that can inhibit NET production to prevent digestive tract tumor progression and discuss the development process of these drugs in clinical trials. In addition, the influence of NETs after surgical stress on GI cancers is comprehensively analyzed. Then, the different detection and quantification methods of NETs in GI tumors are briefly summarized. Finally, we highlight the correlation between COVID-19-induced NETs and cancer progression. We will also analyze the use of NET-associated inhibitor drugs in GI cancers.Some research has found that some neutrophils can promote tumor invasion and metastasis . SubsequIn 1996, maximal activation of neutrophils using PMA was observed, with neutrophil lobulated nuclei decondensing and aggregating, cell and nuclear membrane rupturing, and nuclear material filling the cytoplasmic space . This prStaphylococcus aureus s (S. aureus), Escherichia coli (E. coli), damage-associated molecular patterns (DAMPs), platelets, and Toll-like receptor 2/4 (TLR2/4), lymphocyte function-associated antigen 1 (LFA1) of neutrophils bind to these allergens, promoting the non-lytic NETs formation. This formation is also accompanied by chromatin de-concentration, followed by protein-modified chromatin expulsion through vesicles without disrupting the plasma membrane. The integrity of the nuclear and cellular membranes of neutrophils is not compromised under this NET formation pathway. After releasing the NETs, neutrophils are still alive and possess phagocytic and chemotactic capabilities [Recent studies suggest that NETs are generated by neutrophils in two ways ,34 Figu. The firbilities . Howeverbilities . This fiThe inflammatory response associated with immune cells infiltrating the tumor microenvironment (TME) is thought as an indispensable mediator leading to tumor progression and metastasis along with immunotherapy response ,44,45,46NETs can promote tumor growth by triggering the exhaustion of T cells. De Andrea et al. found a negative association between CD8+ T-cell density and the NET area in tissue microarrays of bladder and NSCLC cancer after adding CD8 dye to the multiplex panel . FurtherNETs and cancer-associated fibroblasts (CAFs) promote each other and work together to support the occurrence of cancer. CAFs are not only the major component of the tumor microenvironment but also an important factor in GI tumor metastasis. They may maintain tumorigenesis by modulating the immune response to some extent ,68. Colin Hutton used single-cell high-throughput flow cytometry to classify pancreatic fibroblasts as two separate but formerly unrecognized subpopulations according to CD105 expression: CD105-negative and CD105-positive. CD105-negative fibroblasts are correlated with enhanced immune cell infiltration and immune responses against tumors, whereas CD105-positive pancreatic fibroblasts allowed tumor growth in vivo. There may be a more complex transcriptional program behind the expression of CD105 to select the direction that mediates the transformation of fibroblasts into tumor-promoting or tumor-suppressing . In addiIn summary, NETs promote tumorigenesis by inhibiting tumor suppressor factors like the suppressive effect of immunity and promoting tumor-promoting factors like CAFs in the tumor microenvironment.There is a certain relationship between NETs and gastric cancer. The formation of NETs was first identified in the microenvironment of GC tissues by Yiyin Zhang et al. NETs levels and neutrophil buildup was reduced in peripheral blood (PB) from neoplastic to paraneoplastic tissues. Higher levels of peripheral blood NETs at baseline are related to poorer progression-free survival (PFS). Their study also showed that NETs have better tumor serodiagnostic capabilities than routine biomarkers, like carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA) in GC. These suggest that NETs have a significant role in oncogenesis and tumor growth in GC .NETs may promote tumor development by inducing epithelial–mesenchymal transition (EMT) and promoting vascular remodeling. It has been observed that NETs can impair endothelial cells so that trapped neoplastic cells may disseminate and form neo-metastases following adhesion to activated endothelial cells . SpecifiFurthermore, NETs may affect tumor development by regulating RNA expression. Numerous studies have revealed that RNA has emerged as a direct mechanism for the transformation of healthy cells into tumor cells, which has a critical function in cancer diagnosis and prognosis ,81, espeThere are currently a series of corresponding treatments for the etiology of abnormal blood coagulation in gastric cancer patients caused by NETs. Of note, the combined use of sivelestat, deoxyribonuclease I, and activated protein C significantly abolished the procoagulant activity (PCA) of NETs . AbnormaAll in all, NETs can directly contact tumor cells, regulate gene expression to promote tumor development, and may also be involved in abnormal blood coagulation in patients with gastric cancer, leading to aggravation of symptoms. The multiple action pathways of NETs also provide directions and means for corresponding drug development and treatment.A positive feedback effect between CRC  progression and NET formation has been identified and several mechanisms have been proposed to trigger the formation of NETs in the CRC microenvironment. For example, in KRAS-mutated CRC cells, potential prognostic and predictive markers for CRC ,97 have Advanced CRC is prone to distant metastasis, the most common site of which is the liver . NETs coAfter realizing the possible role of NETs in colorectal cancer metastasis, some studies further verified this relationship and explored new directions for future treatment by inhibiting the formation of NETs. Using preclinical murine models of lung and colon cancer combined with in vivo video microscopy, Rayes et al. found that NETs functionally contributed to metastatic progression and that blocking NETosis through multiple measures markedly inhibited spontaneous metastasis to the lung and liver . DNase IIt is well known that cancer-related thrombosis is strongly associated with poor prognosis, and patients with CRC are generally at higher risk for venous thrombosis. NETs, as intermediate substances, also mediate the mutual promotion of cancer and blood coagulation. A study revealed a novel link between coagulation, neutrophilia, and complement activation, in which NETs are also important factors. It found that elevated circulating lipopolysaccharide (LPS) induced the upregulation of complement C3a receptor on neutrophils and activation of the complement cascade, which led to NETosis, induction of N2 polarization, and coagulation, thus accelerating tumorigenesis. This provides a favorable explanation for the promotion of tumor development through coagulation . On the The two key immune cells of the liver that contribute to the capture of pathogens are neutrophils and Kupffer cells . AlthougNASH is a progressive, inflammatory fatty liver disorder and one of the risk factors for HCC. The chronic inflammation caused by steatosis through production of NETs plays an important role in its pathogenesis. Studies have found that elevated free fatty acids such as linoleic acid and palmitic acid in NASH can stimulate liver-infiltrating neutrophils to form NETs, which then cause monocyte-macrophage infiltration and increases in inflammatory cytokines such as IL-6 and TNF-α. Increased inflammatory cytokines affect the tumorigenic, inflammatory microenvironment of the liver and participate in the occurrence and development of HCC. Furthermore, a study has shown that the production of inflammatory cytokines is caused by an increase in NET-activated TLR4 signaling. The active TLR4 signaling induced naive T cells to differentiate into Tregs. The differentiation of naive T cells into Tregs led to the malignant transformation of epithelial cells and the occurrence of liver cancer . That isNETs can not only affect the local inflammatory microenvironment in NASH patients, but may also lead to the hypercoagulable state of blood in patients. A recent study found that plasma levels of NET markers were considerably higher in NASH patients than in healthy controls. NETs exert cytotoxic effects on endothelial cells, rendering them with a pro-coagulant and pro-inflammatory phenotype . SubsequCancer Letters, HBV used NETs to exacerbate the progression of hepatocellular carcinoma. Specifically, HBV induced S100A9 to activate the RAGE/TLR4–ROS signaling pathway to allow massive NET formation [Many studies have illustrated that neutrophils and the NETs they produce play complex roles in the pathophysiology of alcoholic liver disease ,122. Excormation . In addiormation . Due to NETs are closely related to the development of HCC. Van der Windt et al. used neonatal streptozotocin and a high-fat diet to induce a NASH–HCC mouse model . At 20 wThe fundamental impact of mitochondrial metabolism on all steps of tumorigenesis  is widely recognized . The rolNotably, the NP-neutrophil targeting approach can be used to prevent NET formation in GI cancers . Some reAlthough the use of nanoparticles and other strategies combined with NETs provides a useful direction for clinical anticancer treatment, it has not yet been put into clinical practice, and cancer surgery or liver transplantation is still relatively common. In these surgical operations for liver cancer, hepatic ischemia-reperfusion injury (IRI) often occurs . Recent Pancreatic cancer is often associated with poor prognosis, in which neutrophils are abnormally recruited into the tumor microenvironment, leading to tumorigenesis . SignifiRecent research showed that NETs play an emerging role in PDAC progression and inflammation-associated metastasis. Just as NETs promote the proliferation of cells such as gastric and colorectal cancers, NETs also boost the proliferation of pancreatic cancer cells. Recently, it was found that NET-associated IL-1β was involved in the EMT process of pancreatic cancer through the EGFR–ERK pathway . NETs caIn addition to the above-mentioned key substances affecting the growth of pancreatic tumors, NETs can also be used as factors affecting blood coagulation in patients with pancreatic cancer. In a clinical trial, in patients undergoing pancreatectomy for pancreatic cancer, the formation of circulating NETs in pancreatic tumor tissue was significantly reduced, although intraoperative lidocaine infusion which can decrease bleeding combined with epinephrine did not improve overall or disease-free survival . In a clDespite the advances in therapeutic strategies in GI cancers, surgical resection of malignant tumors remains the mainstay treatment. Subsequent surgical stress constitutes one of the key factors that suppresses immunity and affects the prognosis of GI patients ,167. AltAs for the mechanism of NETs affecting surgical stress, NETs may interact with the coagulation system, leading to poor surgical outcomes. Hongji Zhang is dedicated to researching NETs after surgical stress. His group found tumor capture and growth can be promoted by the influx of neutrophils after surgery . SurgicaSince surgery remains the most suitable and only promising treatment for patients with metastatic disease, what we can do is to better understand the underlying mechanisms associated with post-surgical tumor recurrence and prevent recurrence and worsening of the situation. According to the above, NETs are the key factors triggering surgical stress and postoperative recurrence. Therefore, utilizing NETs as a therapeutic target to treat surgical stress may be an effective treatment option. Using DNase to inhibit NETs is a potential approach for further clinical applications. In a mouse model of surgical stress and liver metastasis, DNase I inhibition of NET formation has been shown to reduce the development of postoperative metastases . RecombiFrom the above studies, we know that NETs play a non-negligible role in gastrointestinal tumors, thereby, the methods of NET detection and quantification are particularly important. At present, the most commonly used detection methods for NETs are use fluorescence microscopy to identify specific markers: citrullinated histone H3 (citH3) or MPO, NE, and DNA complexes  . HoweverNoteworthily, imaging flow cytometry (IFC) as an emerging technology goes beyond the qualitative limitations of traditional flow cytometry ,187 to eThe recent development of computational methods for quantifying NETs has greatly improved the ability to study NETs. These methods range from using ImageJ to user-friendly applications and even more sophisticated machine learning methods. One of the computational methods for quantifying NETs, DNA Area and NETosis Analysis (DANA), is a novel ImageJ/Java-based program . This coCoronavirus disease 2019 (COVID-19), has induced a pandemic with more than 620 million confirmed cases and 6.5 million deaths worldwide by October 2022. Due to the global pandemic of COVID-19, there has been considerable scientific interest in determining the interdependence of COVID-19 in cancer progression, as well as investigating the increasing risk of potential and life-threatening consequences of COVID-19 infection with the underlying medical conditions of cancer. A recent systematic review of 52 studies on COVID-19 and cancer showed that cancer patients have a high probability of dying from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) . COVID-1It is a well-established concept that neutrophilia is as an indicator of severe respiratory symptoms and adverse outcomes in COVID-19 patients ,206,207.NETs have also been described as potential biomarkers of COVID-19 prognosis ,211,212.https://clinicaltrials.gov/ accessed on 6 November 2022. There are a large number of registered clinical trials including a drug related to the inhibition of NETs, though few of them are currently completed. We will need to wait for the final results of these clinical trials to confirm whether these drugs that inhibit NETs can be effectively used for the treatment of gastrointestinal tract tumors, although preclinical data suggest that these drugs are promising targets for the treatment of GI tumors.Considering the crucial role of NET in disease progression caused by SARS-CoV-2, it is extremely urgent to focus research on the detailed mechanism of action of NETs affecting the disease and the development of drugs targeting specific steps in the mechanism of action. A review summarized a series of targeted agents for NETs in COVID-19 patients, including metformin, vitamin D, aspirin, N-acetylcysteine, etc. . ClinicaDiscoveries about the impact of NETs on gastrointestinal tumors inspire and support the idea of potential therapeutic approaches that block NETs to effectively control tumor progression and metastasis. Among these emerging therapies, NET inhibitors in combination with immune checkpoint inhibitors for targeted treatment of gastrointestinal tumors may be a new therapeutic approach. It has been shown that DNase I can inhibit neutrophil extracellular traps, leading to a reversal of anti-PD-1 blockade resistance by increasing CD8+ T cell infiltration and cytotoxicity . In addiHowever, the current studies have some limitations. First, before putting into clinical trials, research on anti-NETs therapy mainly uses xenograft mouse models for experiments, which cannot realistically simulate the complex tumor microenvironment in tumor patients, so the factors considered may be limited . Second,NETs released by neutrophils were initially thought to act as an innate immune response to various infectious and inflammatory stimuli to combat microbial invasion, but an increasing number of studies have identified a pathological role for NETs in tumorigenesis and metastasis. Quantitative analysis of NETs by multiple methods can help us diagnose and prognose gastrointestinal cancers. Based on the understanding of the mechanisms by which NETs act on tumors, various drugs have been used in combination with immunotherapy to reduce the production of NETs and thus increase the survival rate of cancer patients.However, we still need further studies to elucidate the detailed potential mechanisms of the interaction between NETs and gastrointestinal cancer. With a clearer and more specific understanding of the mechanism of action, more precise and efficient drugs can be developed to target specific NETs at different stages and types of tumors in the future. The use of safe and effective methods to transport drugs related to NETs inhibitors for the treatment of gastrointestinal cancers may also be an emerging research hotspot in the future.


Biomarkers for holistic animal welfare monitoring represent a considerable unmet need in veterinary medicine. Epigenetic modifications, like DNA methylation, provide important information about cellular states and environments, which makes them highly attractive for biomarker development. Up until now, much of the corresponding research has been focused on human cancers. However, the increasing availability of animal genomes and epigenomes has greatly improved our capacity for epigenetic biomarker development. In this review, we provide an overview about animal DNA methylation patterns and the technologies that enable the analysis of these patterns. We also describe the key frameworks for compound DNA methylation biomarkers, DNA methylation clocks and environment-specific DNA methylation signatures, that allow complex, context-dependent readouts about animal health and disease. Finally, we provide practical examples for how these biomarkers could be applied for health and environmental exposure monitoring, two key aspects of animal welfare assessments. Taken together, our article provides an overview about the molecular and biological foundations for the development of epigenetic biomarkers in veterinary science and their application potential in animal welfare monitoring. Due to growing consumer concerns for animal welfare, the definitions and assessment tools for measuring animal welfare are continually being investigated and improved . To dateEpigenetic mechanisms allow the context-dependent expression of genetic information. This is exemplified by the mechanisms that underpin cellular differentiation: while the many cell types of an individual organism largely contain the same DNA sequence, they can have very different phenotypes with very different functions. Epigenetic mechanisms canalize specific cell fates and mediate their plasticity by establishing, maintaining and modulating cell type-specific gene expression patterns. These features establish epigenetics as an appealing concept for many scientific fields, particularly at the interface between the genome and the environment , 3.On the mechanistic level, epigenetic regulation is usually linked to DNA methylation, histone modifications and small RNAs. Among these, DNA methylation represents the longest known and best analyzed epigenetic modification. About 4–5% of the cytosines in the human genome are present as 5-methylcytosine . These dFor a long time, DNA methylation research has been focused on human, mouse and a few other models. However, the availability of next-generation sequencing technologies has enabled epigenome mapping for any species with a complete genome sequence . This haCytosine-5 DNA methylation has been highly conserved in eukaryotic evolution , 15. TheThe key forces that shape DNA methylation landscapes are the antagonistic activities of DNA methyltransferases and demethylases. DNA methyltransferases are encoded by the DNMT family of genes that use S-adenosylmethionine as a methyl-group donor . DemethyOn the molecular level, DNA methylation is generally considered to restrict transcription factor binding, thereby affecting gene expression . In agreThe evolutionary diversity of animal DNA methylation patterns  contradiIt should be noted that some insect lineages, such as dipteran flies, completely lack DNA methylation, while retaining the full capacity to execute cellular differentiation programs . These fChemically, DNA methylation is defined by the strong covalent carbon-to-carbon bond that connects the methyl-group to the cytosine residue. As such, DNA methylation has several features that distinguish it from other epigenetic modifications, such as histone modifications and small RNAs. For example, DNA methylation is a direct chemical modification of DNA, which can be analyzed without any requirements for the preservation of associated molecules and structures. Also, it can be detected at single-base resolution, and thus achieves the highest possible level of resolution for an epigenetic mark. Furthermore, the stability of the modification greatly facilitates sample preservation and limits artifacts that are due to sample storage. In principle, DNA methylation is as stable as DNA itself and thus represents an excellent substrate for analytical detection.The methodological challenges for the detection of DNA methylation patterns lie in the relatively limited biochemical impact of the methyl-group. For example, methyl-groups have a negligible effect on the hybridization of nucleic acids, thus precluding the use of many traditional molecular detection methods. Methylation-sensitive restriction enzymes were valuable tools during the early years of molecular epigenetics research , but theThe arguably most robust methods for DNA methylation analysis are based on the ability of sodium bisulfite to induce a methylation-dependent polymorphism into the DNA sequence : sodium Because WGBS datasets contain millions of independent and variable data points, their analysis is challenging and time-consuming. In addition, WGBS requires considerable (>20X) sequencing coverage to achieve reasonable robustness, which can cause high costs. Finally, it has been shown that 70–80% of WGBS sequencing reads from human samples never change their methylation, suggesting that a more focused approach that is based on dynamically methylated subgenomes is more effective . One widBisulfite-induced, methylation-dependent polymorphisms can also be detected on array-based platforms. Arrays have played a major role in the analysis of nucleic acids, as they are often more streamlined and cost-effective than sequencing-based technologies. Arrayed primer extension  has provWhile the robustness of bisulfite-dependent technologies has greatly advanced our understanding of animal methylomes, studies need to be designed carefully, in order to avoid artifacts and confounding factors . For exaOver the past years, molecular biomarkers have developed into a key tool for modern agriculture, as they allow the monitoring of large groups of animals and provide objective quality assurance . In thisXenostrobus secures) was interpreted to facilitate phenotypic adaptation (Oncorhynchus kisutch) associated the lower fitness of hatchery-reared salmon with DNA methylation patterning. The results showed a significant number of methylation differences between hatchery-reared animals and wild animals from the same river , which is a widely distributed, invasive freshwater crayfish. Due to their very young species age of about 30 years, the animals have maintained a largely monoclonal genome with negligible genetic variation , consistent with the known function of DNA methylation in mammals . It has via audits on farm with visual assessments of housing conditions and animal physiology on a macroscopic level. However, the are no internationally agreed standards or assessments of animal welfare to include in audits, with some aspects designed based on human perception rather than data-driven assessments of welfare. This can create confusion for import-export markets and a lack of trust in welfare labels. DNA-methylation clocks for agriculturally relevant species, like broiler chickens (The needs for biomarker-based analytics in veterinary medicine are diverse. As mentioned above, methylation clocks may be used to identify reduced health status in real time during the design of breeding programs or the rearing of livestock on farm. However, the uses for the clock extend beyond the age estimation of the animal. As incomes and education levels rise, consumers have been shown to take a greater interest in the quality of food they are eating and are increasingly willing to pay premiums for meat products that align with their values, including animal welfare . Currentchickens , could pEnvironment-specific DNA methylation signatures in livestock, could likewise provide analytics to monitor the breeding and rearing in health-promoting environments. In this regard, consumers have been shown to universally value transparency regarding the source from which their food is derived . ThroughEnvironment-specific DNA methylation signatures could also be used to assess specific meat quality certifications relating to how an animal was reared. For example, animal products can be certified and labeled with many distinct attributes including antibiotic-free, GMO-free, raised without hormones, halal, kosher, organic, free range, pasture raised, grass fed, grain fed, etc. Establishing DNA methylation profiles to distinguish these specific characteristics through analysis of meat products would provide transparency and assurance to consumers. To date, many of these attributes cannot be assessed with analytics and are again reliant on audits. Where analytics do exist, they may be lacking in accuracy. For example, antibiotic testing currently involves chemical analysis to find residues of antibiotics present in the meat, milk or eggs of animals . HoweverDNA methylation signatures may thus provide a solution for the unforgeable assessment of multiple aspects of quality and certification from a single small sample of meat. The exceptional stability of DNA methylation patterns in post-mortem tissues provides an important foundation for this approach . MethylaResearch over the past few years has shown that DNA methylation patterns can be highly diverse across the animal kingdom. The increasing availability of robust technologies for methylation mapping at single-base resolution has unlocked the potential of epigenetic biomarkers for animal welfare assessment. Notably, it has already been demonstrated that it is possible to develop compound biomarkers for animal livestock that integrate multi-dimensional, context-dependent information. Potential application fields include the quantitative assessment of animal welfare through DNA methylation clocks and tamper-resistant origin tracing of meat products by environment-dependent DNA methylation signatures. To fully realize their potential, these biomarkers will require robust technology platforms. Customized methylation arrays  represenAll authors contributed to the writing of the manuscript, read, and approved the final manuscript.


Over the last two decades or so, a substantial body of evidence has developed showing that the immune and cardiovascular systems are intertwined. There are two aspects to this revolution. First, it is by now firmly established that the immune system contributes to the progression of cardiovascular disease (CVD), atherosclerosis in particular, although the intricacies are not fully understood. Nor do we understand how the immune system affects the initiation and progression of various cardiac conditions or myopathies. The second aspect is that the immune system can be engaged to target CVD. For instance, proof of concept evidence was recently presented that cardiac fibrosis can be attenuated by immunotherapy, involving adoptive transfer of CAR T cells expressing a cognate T cell receptor against fibroblast activation protein (FAP) . A subseImmunomodulatory Approaches in Cardiovascular Diseases. Immunomodulatory approaches can be defined as “all interventions that modulate and curb the immune response of the host rather than targeting the disease itself” . This collection of 11 articles covers a broad swath, including reviews and original research articles, preclinical studies, a clinical trial, and case reports. They cover such topics as cardiovascular and metabolic diseases, cardiorenal syndromes, atrial fibrillation, Graves' disease, cardiac sarcoidosis, COVID-19, stress-induced myocardial remodeling, and dilated cardiomyopathy . After a brief introduction to immunomodulatory approaches in diabetic cardiomyopathy and nephropathy, this comprehensive article reviews the epidemiology and classifications of cardiorenal syndrome, which denotes the confluence of heart-kidney relationships such that dysfunction of one may initiate disease in the other via common neurohormonal, hemodynamic, biochemical, and/or immunological feedback pathways. The authors focus in on therapeutic approaches that target the immunomodulatory pathways implicated in diabetes-induced cardiorenal syndrome, namely the renin-angiotensin system, JAK/STAT signaling, and oxidative stress.A comprehensive review by Wu et al.). A second article presents a case series reporting the successful treatment of cardiac sarcoidosis with tumor necrosis factor alpha (TNFα) antagonists . This life-threatening disease, which lacks clear recommendations for treatment, is a rare inflammatory condition in which clusters of white blood cells form granulomas in different areas of the heart, which may disrupt heart rhythm, blood flow, and normal heart function. Apropos of the present COVID-19 pandemic, an article by Zareef et al. addresses the course of SARS-CoV-2–induced illness in pediatric patients, both otherwise healthy children and those with congenital heart disease. Consequences include myocarditis, cardiogenic shock, arrhythmias, and multisystem inflammatory syndrome. Another original research study by Itani et al. presents data supporting the hypothesis that the inflammatory immune response is exacerbated in patients with both atrial fibrillation and cardiometabolic syndrome compared to either condition alone. They examined inflammatory cytokines and fibrotic markers as well as cytokine genetic profiles. Their approach has importance for the development of novel immunomodulatory therapeutic strategies for treating atrial fibrillation.Two case-based reviews highlight the impact of the immune system on the heart and/or vascular system and the therapeutic importance of targeting it in the real world. One article deals with treatment of autoimmune myocarditis in Graves' disease, which is an immune system disorder that results in overproduction of thyroid hormones (hyperthyroidism) . The findings support the idea that patients with coronary artery disease have an inflammatory immune microenvironment, which may be responsive to anti-inflammatory therapies under investigation. A preclinical study in Apoe−/− mice examined the therapeutic possibility of targeting complement activation in atherosclerosis . Complement activation has been implicated in the development of atherosclerosis, but how that occurs is not known. The present study was based upon the observation that in ischemia-reperfusion injury, ischemia induces exposure of neoepitopes recognized by natural self-reactive IgM antibodies, which in turn activate complement. The authors used a novel construct (C2scFv-Crry), consisting of a single chain antibody (scFv) linked to a complement inhibitor (Crry) that functions at C3 activation. The scFv moiety was derived from C2 IgM mAb, which recognizes phospholipid neoepitopes known to be expressed after ischemia. In Apoe−/− mice fed a high-fat diet, C2scFv-Crry administration decreased atherosclerotic plaque in the aorta and aortic root, reduced deposition of endogenous total IgM in the plaque, decreased lipid content in the lesion, and reduced serum oxLDL levels. Thus, neoepitope targeted complement inhibitors may be a novel therapeutic strategy to combat atherosclerosis. Somewhat related, leukocytoclastic vasculitis is a systemic autoimmune disease that is characterized by inflammation of the vascular endothelium and includes cutaneous small vessel vasculitis (CSVV) and anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV). Risk haplotypes, genetic variants, susceptibility loci and pathways associated with vasculitis immunopathogenesis have been identified and have laid the foundation for personalized medicine with targeted therapies. A review article by Yap et al. discusses pathways involved in disease pathogenesis and the underlying genetic associations in different populations worldwide. As noted, specific genetic variants predisposing individuals to CSVV and their pathogenic mechanisms are incompletely defined. Determining the immunopathogenic pathways in vasculitis and associated genetic variations will enable development of targeted personalized therapies.Two articles in the series deal with atherosclerosis. One gene expression-based bioinformatics study provides a comprehensive analysis of the immune cell infiltrates and aberrant pathway activation in atherosclerotic plaque . The authors found that amlexanox, an anti-inflammatory and immunomodulatory drug, attenuated the myocardial hypertrophy, fibrosis, and inflammation seen with isoproterenol. These actions were enhanced by the adenylyl cyclase activator, forskolin. In isolated macrophages, amlexanox acted by inhibiting a GRK5-mediated proinflammatory effect and, along with forskolin, facilitating cAMP-mediated immunoregulation. Finally, dilated cardiomyopathy, characterized by dilation and systolic dysfunction of one or both ventricles, may have a genetic basis or occur due to various etiologies that cause myocardium inflammation. New insights provide a better understanding of the pathogenesis of dilated cardiomyopathy by linking the genetic and inflammatory causes together. A review by Kadhi et al. summarizes the genetic and inflammatory causes underlying dilated cardiomyopathy and the pathways amenable to immunomodulatory strategies to salvage and prevent heart failure linked to the disease.Stress, including the psychological pressures of daily life, can adversely affect the structure and function of the heart, for example takotsubo cardiomyopathy. A study in the series examined maladaptive cardiac remodeling in an isoproterenol-induced cardiomyopathy mouse model  [Grant Number 103507/103487/103941/103944], Collaborative Research Stimulus (CRS) [Grant Number 103556], and Agence Nationale de la Recherche (ANR) [Grant – ANICOV-HF].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.


Many current clinical therapies for chronic diseases involve administration of drugs using dosage and bioavailability parameters estimated for a generalized population. This standard approach carries the risk of under dosing, which may result in ineffective treatment, or overdosing, which may cause undesirable side effects. Consequently, maintaining a drug concentration in the therapeutic window often requires frequent monitoring, adversely affecting the patient’s quality of life. In contrast, endogenous biosystems have evolved finely tuned feedback control loops that govern the physiological functions of the body based on multiple input parameters. To provide personalized treatment for chronic diseases, therefore, we require synthetic systems that can similarly generate a calibrated therapeutic response. Such engineered autonomous closed-loop devices should incorporate a sensor that actively tracks and evaluates the disease severity based on one or more biomarkers, as well as components that utilize these molecular inputs to bio compute and deliver the appropriate level of therapeutic output. Here, we review recent advances in applications of the closed-loop design principle in biomedical implants for treating severe and chronic diseases, highlighting translational studies of cellular therapies. We describe the engineering principles and components of closed-loop therapeutic devices, and discuss their potential to become a key pillar of personalized medicine. The development of polypeptide-based therapeutics such as antibodies and hormones has opened up exciting avenues for treating diseases previously considered incurable . HoweverThus, closed-loop designs, as schematically illustrated in in-situ monitoring of biologically relevant markers, but also are self-sustainable once implanted  to trigger gene expression from various endogenous promoters and permit therapeutic cell reprogramming  in the blood is an important biomarker of nutritional status, and has various potential applications . For exa sensors .2 concentration in the blood, because these parameters reflect energy utilization. For example, diabetes can cause ketoacidosis, which can be used as a biomarker detectable by a pH sensor and rerouted to a chimeric promoter to produce and deliver a therapeutic polypeptide such as GLP-1 or insulin. A practical method to achieve this within the physiological range was developed by rerouting the human proton-activated cell surface receptor TDAG8 to a CREB1-operated chimeric promoter  . By reroClosed-loop systems are also applicable for endocrine signaling, for example to promote bovine insemination. For this purpose, sperm cells were co-encapsulated in cellulose-based implants with designer cells that expressed cellulase upon detection of luteinizing hormone, which is a trigger of ovulation. The expressed cellulase degraded the cellulose capsules, enabling the release of sperm at the desired time-point during ovulation of the animals, and led to successful fertilization  Figure .Vibrio harveyi, which interfered with biofilm formation by the pathogenic yeast Candida albicans  was detected by engineered mammalian cells expressing a Pseudomonas autoinducer sensor (PAiS). This enabled the release of autoinducer-inactivating enzyme MomL from a LasR-operated promoter, as well as the biofilm-degrading hydrolases PslG and PelA  to achieve spearmint-inducible gene expression  or adeno-associated viral (AAVs) particles for the delivery of larger DNA fragments, might also make it possible to deliver longer gene fragments including those encoding complete closed-loop therapeutic circuits. It should be noted that modern viral vector-based strategies focus on establishing episomes, which are extrachromosomal DNA particles, in order to reduce the risk of integration into tumor suppressor genes.Another current focus of research in gene therapy is direct Furthermore, there is still room for improvement of the closed-loop circuitry itself, as not all disease biomarkers have natural receptors that could be used to trigger the expression of therapeutic proteins from engineered cells. Prominent examples would be biomarkers of a physical nature, such as neuronal electrical discharges and increase in body temperature (fever), or intracellular proteins that are systemically released due to necroptosis of a specific cell type. As we have described, synthetic biology enables new-to-nature receptors to be constructed through rational design and the combination of different functional modules, thus enabling the detection of such biomarkers. Expanding the range of detectable cues would further extend the scope of closed-loop systems, as multiplexing of several disease biomarkers would be possible and should increase the therapeutic specificity. Finally, to enable the treatment of conditions that require an immediate response, such as anaphylactic shock, closed-loop circuits could be integrated into specialized endocrine cells that contain intracellular protein storage vesicles . Upon ac


Perspectives of patients as clients on healthcare offer unique insights into the process and outcomes of care and can facilitate improvements in the quality of services. Differences in the tools used to measure these perspectives often reflect differences in the conceptualization of quality of care and personal experiences. This systematic review assesses the validity and reliability of instruments measuring client experiences and satisfaction with healthcare in low- and middle-income countries (LMICs).We performed a systematic search of studies published in PubMed, SCOPUS, and CINAHL. This review was reported according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Studies describing the development and psychometric properties of client experience and satisfaction with general health care were included in the review. Critical appraisal of study design was undertaken using the Appraisal tool for Cross-Sectional Studies (AXIS). The Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist and Terwee’s criteria were used to appraise the psychometric properties of the included studies. A narrative synthesis approach was used in the interpretation of the findings.Of the 7470 records identified, 12 studies with 14 corresponding instruments met the inclusion criteria and were included in the final review. No study assessed all the psychometric properties highlighted by the COSMIN criteria. In most instruments, we found evidence that initial development work incorporated client participation. The most evaluated measurement properties were content validity, internal consistency, and structural validity. Measurement error and responsiveness were not reported in any study.Reliability and validity should be considered important elements when choosing or developing an instrument for professionals seeking an effective instrument for use within the population. Our review identified limitations in the psychometric properties of patient experience and satisfaction instruments, and none met all methodological quality standards. Future studies should focus on further developing and testing available measures for their effectiveness in clinical practice. Furthermore, the development of new instruments should incorporate clients' views and be rigorously tested or validated in studies with high methodological quality.CRD42020150438.The online version contains supplementary material available at 10.1186/s12913-023-09129-9. Improvements in the quality of healthcare are crucial in ensuring progress towards the Sustainable Development Goals (SDGs) and Universal Health Coverage (UHC) by 2030 . HealthcPatient-reported quality is an important component of healthcare quality and health service evaluation—it reflects the dimensions of quality relevant to the client , 5. PatiStudies have shown that patient experiences are related to patient satisfaction . A key cVarious methods may be used to assess client experiences and satisfaction with healthcare. These include qualitative and quantitative methods, as well as interviews, focus group discussions (FGDs), patient forums, formal complaints, observations, and informal feedback through patient advocacy groups . QuantitManary et al. highlighted three concerns with patient-reported measures . FirstlyStandardized tools for monitoring and reporting patients’ perspectives derive mostly from high-income countries . InstrumDespite some existing systematic reviews that assessed the psychometric properties of patient experience measures of care across a range of settings and diseases –22, we fA protocol for this review was registered with the International Prospective Register of Ongoing Systematic Reviews (PROSPERO) (registration number: CRD42020150438). This systematic review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines .https://www.mendeley.com/search/) for reference management and the removal of duplicates.We conducted a comprehensive literature search of the following electronic databases: PubMed , CINAHL (EBSCOHost) , and SCOPUS (Elsevier) . The search was conducted using a combination of keywords, Boolean operators, and MeSH terms. Free text terms and MeSH terms derived from or related to the selected keywords were also included in the search strategies. The following five main groups of search terms were used to develop the search strategy: (i) tool, instrument, survey, questionnaire, or scale (ii) patient or client (iii) patient satisfaction, patient experience, client satisfaction, client experience, or patient-centered care (iv) health care quality or health care assessment (v) LMICs—We modified the LMICs search filter from a previous review  and inclStudies were eligible for inclusion if they were peer-reviewed English-language articles that examined theoretical or conceptual development, psychometric properties, or the utility of instruments measuring patient experience or satisfaction with hospital-based health care (either inpatient or outpatient care). Studies were excluded if they derived from pediatric populations or high-income countries; were purely qualitative; were specific to a medical condition or procedure; or reported only Patient-reported outcome measures (PROMs).Titles and abstracts were independently screened by two reviewers (SB and NN), utilizing the eligibility criteria. Full-text copies of selected articles were retrieved for detailed examination. Articles meeting the inclusion criteria underwent data extraction and quality assessment. Disagreements between the reviewers were discussed to achieve consensus.Two reviewers (SB and NN) independently extracted data from the most recent version of the instrument using a pre-designed data extraction template, which included an assessment of: study characteristics; author; publication year; setting; country of origin; mode of administration; number of items; dimensions of patient satisfaction or experience; sample size; and psychometric properties.The quality assessment involved two reviewers (SB and NN). The Appraisal tool for Cross-Sectional Studies (AXIS) was used to appraise bias in study design. AXIS comprises 20 questions assessing the quality of study design, including aims and objectives, sample size justification, methods, and presentation of results . QuantitThe validity and reliability of the included instruments were assessed using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) . This toDiscrepancies between reviewers at the data extraction and quality assessment stages were resolved by consensus through detailed discussion. We analyzed included studies using narrative synthesis and a tabular summary of key characteristics.A total of 9658 records were obtained from the electronic search, and an additional 15 records were obtained from reference checking of relevant articles. After the removal of duplicates, a total of 7470 articles were screened. The full texts of 150 articles were assessed against the defined exclusion and inclusion criteria, of which 12 were analyzed , others by self-completion (n = 3), telephone (n = 2), and mail survey (n = 1). The number of included items varied from 16 to 52, exclusive of demographic information. The timing of administration varied between instruments designed for inpatient and outpatient care. Exit interviews were conducted for all instruments tailored for outpatient care. The timing differed for inpatient care, from surveys being conducted during admission [Most instruments were administered through face-to-face interviews  indicates a lack of correlation between items in an instrument, making summarizing items unjustified. A high estimate (≥ 0.95) indicates high correlations among items in an instrument, e.g., redundancy of items . Nine inThis systematic review identified and appraised the psychometric properties of tools measuring client experience and satisfaction with health care developed for use in LMICs. Evaluating 14 instruments within 12 studies, none had a complete assessment of all relevant measurement properties. There was a general lack of evidence for the appraisal of most measurement properties, due either to incomplete reporting or poor-quality methodology. None of the studies reported measurement error and responsiveness.Content validity assesses whether the content of an instrument reflects the construct to be measured . It is rOther frequently reported measurement properties were internal consistency and structural validity. The methodological quality of other properties, i.e., reliability, cross-cultural validity, and criterion validity, were generally fair to poor. This is likely due to the conservative nature of the COSMIN checklist, as scoring requires that overall ratings for each measurement property assessed be given according to the lowest score assigned over multiple criteria . It is iCriterion validity, which is considered when an instrument is compared with a gold standard, was reported in only three instruments. This may be because some authors lacked comparator instruments, as there are no gold standard instruments for either patient experience or satisfaction measures. According to COSMIN guidelines, a gold standard instrument for health-related patient-reported outcomes is generally impossible to find. For criterion validity, a long version of a shortened instrument can be considered a gold standard. However, if an instrument is considered a gold standard, studies comparing tools to this particular instrument provide evidence for criterion validity , 47.From a policy and practice viewpoint, for a measure to be used to benchmark performance or evaluate interventions, it is vital to understand its ability to detect change in the concept being measured , 49. OurOur findings demonstrated that most instruments utilized dimensions that were linked to elements of patient-centered care. Across instruments, common domains were communication or interpersonal aspects of care, followed by physical comfort. Although the instruments reported a wide range of dimensions, certain aspects of care, such as coordination and continuity, remain under-reported. These are important dimensions that can influence the quality of care offered to clients, as poor coordination or continuity leads to clients receiving fragmented care, often with suboptimal outcomes and a risk of harm due to inadequate communication or sharing of information from providers and duplication of interventions . As the Importantly, although patient experience and satisfaction are related, they are distinct concepts. Patient experience measures elicit feedback from patients regarding what happened before, during, and after interactions with the health care system , 52, wheThe collection of client experience or satisfaction data has become an important part of the drive towards holistic patient-centered care . It is aOur systematic review was limited by excluding grey literature and non-English articles. Missing values or insufficient reporting of psychometric properties, i.e., test–retest reliability, internal consistency, or cross-cultural validity, influenced the ratings regarding the adequacy of psychometric measures, and we did not contact authors for unpublished information. Our review is not a traditional description of diagnostic test accuracy; hence, the PRISMA guidelines were chosen over the Preferred Reporting Items for Systematic Reviews and Meta-Analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA) guidelines. Nonetheless, we have been as comprehensive as possible to ensure important details are included using the PRISMA guidelines. Further, our systematic review used a broad search strategy to identify relevant evidence on tools measuring client experience and satisfaction in LMICs. This review is limited by the paucity of available data, which is particularly acute for sub-Saharan Africa.The use of valid and reliable instruments is key to providing accurate information to inform service delivery. The review identified limitations in the validity and reliability of patient experience and satisfaction measures developed for use in LMICs. Psychometric inadequacies and/or incomplete reporting of measurement properties indicate that further development and testing of these measures or validation of previous measures developed elsewhere for use in this region is required. Future research should emphasize the evaluation of psychometric properties based on the intended use of the measure  . ImportaInstrument development should be based on good theoretical development, with item generation incorporating clients’ views. Qualitative feedback, including cognitive interviews and focus group discussions with the target population, is required to improve an instrument's content validity. We recommend applying standards such as the COSMIN checklist , 29 and Although patient experience and satisfaction have been widely studied in healthcare, gold-standard instruments have not been established , 59, 60.Patient experience and satisfaction measures are widely recognized as indicators of healthcare quality as they provide information on potential areas for improvement in healthcare delivery , 55. ForAdditional file 1. Database search strategies. The databases were accessed through Research4Life .Additional file 2. Measurement property definitions and appraisal parameters .Additional file 3. Axis appraisal results.Additional file 4. COSMIN quality assessment results.Additional file 5. Terwee’s criteria quality assessment results.


Moderate to severe paravalvular-leak (PVL) regurgitation after surgical aortic-valve replacement or after transcatheter valve implantation represents a well-known complication associated with symptoms related to heart failure, hemolysis, or both in patients with multiple comorbidities and with poor prognostic outcomes. The transcatheter closure of aortic paravalvular leaks (APVLs) is currently considered a valid alternative to cardiac surgery. Nevertheless, careful patient selection, optimal cardiac imaging for intraprocedural guidance, and expert operators are key for success. Although technically demanding, particularly in APVLs after transcatheter valve implantation, catheter-based closure is an effective, less invasive, and often the only option for high-risk patients with symptomatic PVL regurgitation. The percutaneous treatment of APVLs after conventional surgical aortic-valve replacement (AVR) or after transcatheter valve implantation (TAVI) is currently considered a valid alternative to cardiac surgery . The cliThis viewpoint is based on the author’s personal experiences in the field of structural and adult congenital interventional cardiology, particularly in transcatheter PVL closure over 10 years, X.F.R. as a co-author of Spanish Real World PVLs Closure Registry , and E.MCardiac imaging, especially two- and three-dimensional transthoracic/transesophageal echocardiography (2D/3D TTE/TEE) and cardiac angiography play an essential role in the diagnosis, guidance of intervention and subsequently in the evaluation of the outcomes of the procedure.PVLs are studied in multiple angles to document their geometry. For instance, to visualize APVLs located in the right sinus of Valsalva, fluoroscopy will be oriented in the left anterior oblique view, those located in the left coronary sinus will be in the right anterior oblique view, and non-coronary PVLs will be in the lateral view. Furthermore, fluoroscopy helps to differentiate intraprosthetics from PVL regurgitation by looking at the closing and opening prosthetic angles .TTE is very useful in identifying the APVL, particularly when the leakage is in the anterior position, as the posterior region is hidden by reverberation produced by the prosthetic annulus. The optimal views for the detection of regurgitant jets include the parasternal long axis, parasternal short axis, apical long axis, and five-chamber views. In the parasternal-short-axis view, the color flow Doppler interrogation of the sewing ring may be able to localize and define the extent of the leakage. TTE is also used to represent APVLs in a clockwise fashion . This is2D/3D intracardiac echocardiography (ICE) represents an alternative or a complementary technique to TEE; it is exclusively indicated for procedural guidance, providing a high image resolution that is useful for very sick patients in whom local anesthesia may be more desirable.Additional baseline image techniques include multidetector computed tomography angiography (MDCTA) with 3D or four-dimensional (4D) reconstruction and cardiac magnetic resonance (CMR), which are able to visualize the PVL anatomy more accurately, examining the entire circumference of the prosthetic ring on the axial oblique image plane performing precise flow-imaging and volume-based measurements. Furthermore, MDCT can provide extracardiac and coronary assessment that represents valuable help in determining the procedural risk to the patients.®system  allows unique real-time fusion of live X-ray and live echo images for intuitive guidance during PVL-closure procedures, providing live dynamic imaging and allowing the interventionalist to view catheters and devices (by fluoroscopy) and soft-tissue anatomy (by echocardiography) in the same image and orientation. The incremental value of fusion modalities is key in cases of fluoroscopically invisible bioprosthesis or anatomically hard-to-approach calcified serpiginous tracts.The integration of computed tomography with fluoroscopy (CT–fluoroscopy fusion) or echocardiography with fluoroscopy (echo–fluoroscopy fusion) in the catheterization laboratory allows operators to overcome many of the challenges posed when these imaging modalities are used individually. In particular, the novel software technology, the EchoNavigatorNowdays, there is also the potential of 3D cardiac modeling for a thorough evaluation of the anatomical structure of these defects and their relationship to adjacent structures. Furthermore, 3D-printed modeling allows for testing the device before the interventional procedure, thereby limiting residual leaks and preventing serious complications.Actually, APVLs are significantly different compared to mitral PVLs in terms of both assessment and treatment strategies. Firstly, the location of APVLs is determined by the aortic sinus position  more than the mitral-valve clockface used in mitral PVLs. Secondly, angiographic contrast injection within the affected aortic sinus might provide more anatomic information in terms of PVL location, trajectory and size than both TTE/TEE. Thirdly, since additional PVL information provided by TEE as compared to TTE or angiography is limited, less invasive approaches without general anesthesia might be considered.In contrast to mitral leakages, post-AVR APVLs require arterial access and most cases do not need an AV loop. General anesthesia can be used, but moderate procedural sedation without intubation is also acceptable. APVLs are usually crossed in a retrograde way from the aorta to the left ventricle (LV), requiring an arterial access large enough to accommodate the delivery sheath. For this reason, APVLs have been classically approached through the femoral artery with 6- to 8-Fr introducers. However, the evolution of delivery catheters and closure devices currently allow the implantation of small, medium and large devices through 4-Fr, 5-Fr and 6-Fr, respectively, which opens the possibility to treat APVLs through the radial artery. In fact, they can be effectively and safely treated in a minimally invasive approach, consisting of mild sedation instead of general anesthesia, angiographic and TTE instead of TEE guidance, and a radial instead of a femoral approach . In factComprehensive knowledge of the inner diameters of the delivery catheters is required in order to identify the largest device that can progress through every catheter.Transcatheter PVL closure was initially performed as an “off-label” indication with different occluders that have been created for other applications such as atrial septal, ventricular septal or patent ductus arteriosus closure. Those devices are not typically recommended for PVL cases due to several technical drawbacks and shortcomings .The AMPLATZER™ Vascular Plug  family is the most frequently used technology in the United States for PVL closure as plugs can progress through smaller catheters compared to other devices with the same size. In general, the AVP 3 is the preferred closure device for most operators ..21].In several cases, dedicated coronary wires are required to cross the leak. The use of more than one coronary wire as a buddy wire may help to advance catheters through the leakage. Another common finding in post-TAVR PVLs is the calcification of the path and therefore the resistance to the advancement of large delivery catheters through the leak. In fact, many reported cases describe the implantation of small or medium closure devices, as large delivery catheters cannot advance through the leak.The rate of complications from PVL closure is relatively low, especially when compared to the results of a surgical redo . PeriproUndoubtedly, APVL closure is a complex and challenging procedure with several periprocedural complications, requiring optimal patient selection and comprehensive cardiac-imaging intraprocedural guidance. Although technically demanding, strategies to increase the success rate of percutaneous closure by expert operators might increase the safety and efficacy of this less invasive treatment option for high-risk patients with symptomatic PVL regurgitation.The successful PVL reduction to mild or less results in symptomatic acute and long-lasting improvements in clinical parameters, including NYHA class, and reduces the dependency on hemolysis-related blood transfusions and the need to redo cardiac surgery.Further technological advances such as a lower profile, slippery delivery sheaths and newly designed custom-made devices will also improve procedural success and clinical outcomes. Likewise, future TAVI devices need to be designed to minimize the occurrence of PVL.


Increasing evidence suggests neuroinflammation is a highly coordinated response involving multiple cell types and utilising several different forms of cellular communication. In addition to the well documented cytokine and chemokine messengers, extracellular vesicles (EVs) have emerged as key regulators of the inflammatory response. EVs act as vectors of intercellular communication, capable of travelling between different cells and tissues to deliver selectively packaged protein, miRNA, and lipids from the parent cell. During neuroinflammation, EVs transmit specific inflammatory mediators, particularly from microglia, to promote inflammatory resolution. This mini-review will highlight the novel neuroinflammatory mechanisms contributing to the biogenesis and selective packaging of EVs. Neuroinflammation is a common feature of neurodegenerative conditions, such as Alzheimer’s and Parkinson’s diseases, manifesting early in disease pathogenesis and exacerbating progression by promoting neuronal death    are membraneous vesicles released by all cell types and encompass small EVs (sEVs) or exosomes, medium EVs (mEVs) or microvesicles, and large EVs (lEVs) or apoptotic bodies, with the former two being well documented in facilitating cell–cell communication. Despite overlaps in their functions, exosomes and microvesicles have key characteristics attributed to their unique biogenesis processes /ionomycin, a protein kinase C activator able to induce pro-inflammatory cytokine production and a calcium ionophore, respectively, sumoylating protein PTMs were identified as a critical exosome cargo sorting mechanism in inflammation (Villarroya-Beltri et al., In conclusion, EVs are emerging as critical players in the neuroinflammatory response, conveying key signalling molecules between different cell and tissue types. These are themselves regulated by neuroinflammatory mediators, highlighting the need for further study into the mechanism of EV biogenesis and cargo loading.


These functions are intimately linked to mitochondrial morphology, which is highly dynamic and capable of rapid and transient changes to alter cellular functions in response to environmental cues and cellular demands. Mitochondrial morphology and activity are critical for various physiological processes, including wound healing. In mammals, wound healing is a complex process that requires coordinated function of multiple cell types and progresses in partially overlapping but distinct stages: hemostasis and inflammation, cell proliferation and migration, and tissue remodeling. The repair process at the single-cell level forms the basis for wound healing and regeneration in tissues. Recent findings reveal that mitochondria fulfill the intensive energy demand for wound repair and aid wound closure by cytoskeleton remodeling via morphological changes and mitochondrial reactive oxygen species (mtROS) signaling. In this review, we will mainly elucidate how wounding induces changes in mitochondrial morphology and activity and how these changes, in turn, contribute to cellular wound response and repair.Mitochondria are organelles that serve numerous critical cellular functions, including energy production, Ca Mitochondria are semi-autonomous and double-membrane-bound organelles in eukaryotic cells with a well-known role in adenosine triphosphate (ATP) production via oxidative phosphorylation (OXPHOS). The ATP production machinery requires five protein complexes (Complex I-V) embedded in the inner mitochondrial membrane (IMM) and two mobile electron carriers  and can activate downstream targets to achieve multiple functions in wound repair, including inflammation and actomyosin-regulated wound repair  channels family on the plasma membrane, such as GTL-2  receptor-activated by G-protein-coupled receptor (GPCR) signaling. Regardless of the initial source, intracellular Ca2+ burst and its wave-like propagation enable rapid wound detection  within minutes , which contributes to wound healing by transiently enhancing mitochondrial reactive oxygen species (mtROS) production  mutant C. elegans where the mitochondria are constitutively fragmented  family genes, are detected in cox10 ablation causes embryonic lethality in mice, while in adult mice, cox10 deficiency shows defective angiogenic capacity near wounds  stimulation in normal cells and hyperproduction of cytokines in cells from patients with tumor necrosis factor receptor-associated periodic syndrome (TRAPS), an autoinflammatory disease (Bulua et al. Accumulating evidence suggests that mitochondrial dynamics and function respond to wounding and will lead to changes in the downstream signals that participate in the wound healing process. As one of the primary sources of ROS, mitochondria are an important player in generating these signals. ROS can directly affect protein function through posttranscriptional modification or indirectly by regulating protein expression. While mitochondria and ROS are promising targets to promote wound healing, it is essential to consider ROS's biphasic and dose-dependent roles and the different functions of mitochondria and mitochondrial ROS in various cell types. It is also important to identify more details and underlying mechanisms to achieve higher efficiency and reduction in side effects. For example, identifying the threshold level of detrimental mtROS should be helpful for personalized medicine. As wound healing is a complex process involving various cell types, it is important to explore the functions of mitochondria in the interaction between cells in addition to focusing on just one cell type. In addition, the stage-specific roles of mtROS in wound healing are still poorly defined. Furthermore, the endogenous enzymatic and non-enzymatic factors involved in antioxidant defense systems that guard against mtROS should also be considered in wound healing. Future development and application of real-time sensors to detect how mitochondria sense the wounding in model organisms such as C. elegans will further help the study of the highly dynamic wound healing process.