Respiratory and airway-protective muscle weakness caused by the blockade of neuromuscular transmission is a major cause of early mortality from snakebite envenoming (SBE). Once weakness is manifest, antivenom appears to be of limited effectiveness in improving neuromuscular function. Herein, we review the topic of venom-induced neuromuscular blockade and consider the utility of adopting clinical management methods originally developed for the safe use of neuromuscular blocking agents by anesthesiologists in operating rooms and critical care units. Failure to quantify neuromuscular weakness in SBE is predicted to cause the same significant morbidity that is associated with failure to do so in the context of using a clinical neuromuscular block in surgery and critical care. The quantitative monitoring of a neuromuscular block, and an understanding of its neurophysiological characteristics, enables an objective measurement of weakness that may otherwise be overlooked by traditional clinical examination at the bedside. This is important for the initial assessment and the monitoring of recovery from neurotoxic envenoming. Adopting these methods will also be critical to the conduct of future clinical trials of toxin-inhibiting drugs and antivenoms being tested for the reversal of venom-induced neuromuscular block. Bungarus), life-threatening paralysis occurs in more than half the patients even though the onset of signs can be delayed by many hours [The modernization of treatments for the acute- and long-term effects of snakebite envenoming (SBE) is essential to meet the WHO Roadmap goals for reducing death and disability from snakebite by more than 50% by 2030 . Weaknesny hours ), organ ny hours ). ExceptCurrently, the tools available for the standardized assessment and severity grading of neurotoxic envenoming are limited, but there is a recent resurgence in the use of the snakebite severity score (SSS) as a clinical tool originally developed for the evaluation of North American crotalid envenoming . Herein,Dendroaspis species while some rattlesnakes, for instance, induce ataxia through induction of myokymia via poorly understood peptide toxins alone or interacting with sPLA2 [Descriptions of neurotoxic snakebite are detailed in ancient texts and treatises, including the Bible, and in reference to the travels of Alexander the Great in India . The sevth sPLA2 .Neurotoxic envenoming is most often described to manifest as a “descending paralysis” progressing from small to large muscle groups. A typical descending paralysis progresses affecting smaller muscle groups and may present as ptosis secondary to weakness of the levator palpebrae as the most frequent initial sign, followed by ophthalmoplegia and then diplopia. As in myasthenia gravis, ocular muscles seem particularly susceptible to weakness . Facial As a general rule, the physical and chemical characteristics of protein and peptide-based toxins prevent them from crossing the blood–brain barrier unless there is capillary leak or hemorrhage. Nevertheless, neuromuscular weakness can have central nervous system (CNS) effects that are secondary to hypoxia and hypercarbia. This includes drowsiness, stupor, and coma. Clinicians caring for patients paralyzed by envenoming must be aware that patients are often not comatose; cerebrocortical function may be completely intact, with preserved pain sensation, auditory processing, and formation of memory. This may be particularly true of patients intubated and ventilated, who are not suffering from hypoxia or hypercarbia-induced CNS depression. The appropriate use of sedative/hypnotic medications such as benzodiazepines and propofol infusions, as well as pain relief with opioids, non-steroidal anti-inflammatory drugs, or ketamine is important. Patients who have been paralyzed and recover later relate terrifying stories of being too weak to communicate while suffering from pain and severe anxiety. Post-traumatic stress disorder after SBE is not uncommon and represents a significant cause of morbidity . ConversThe tools currently available for the standardized assessment and severity grading of neurotoxic envenoming are limited and subjective. To develop an objective clinical assessment tool, we propose that there is utility in examining methods originally developed for the safe use of neuromuscular blocking agents that are mature in the field of anesthesiology and perioperative care. Numerous similarities exist in the mechanisms of pharmacologic action between paralytic snake venom components and clinically used neuromuscular relaxant drugs. It is important to consider two categories of clinically relevant drugs: those that depolarize the postsynaptic membrane while causing weakness or paralysis and those that do not. This division groups the compounds by their clinical effects and the mechanism of action on the postsynaptic membrane. This categorization is summarized for venom components and neuromuscular blocking drugs in β-toxins produce paralysis by more complex and less well-understood mechanisms than other toxins, such as curare or three-finger toxins. A summary of the pre- and postsynaptic effects of β-toxins is presented in Currently, succinylcholine is the only depolarizing neuromuscular blocker used clinically. The short and long-term effects of succinylcholine are shown in The initial activation produces what is called a phase I depolarizing block, and the deactivation is termed a phase II block. Phase I and phase II blocks have distinctly different durations of clinical effect and produce distinctly different patterns of response to neuromuscular function monitoring (described below). The processes by which succinylcholine produce neuromuscular block are shown in The phase I depolarizing block produces visibly disorganized muscle contractions, a phenomenon known as fasciculation. Fasciculations may be barely noticed in the elderly but can be quite dramatic in young muscular patients. The contractions produced can lead to myalgias. Historically, since fasciculations can be blocked by non-depolarizing agents, small doses of curare were given before succinylcholine. However, the non-depolarizing effect will antagonize the depolarization that produces the paralysis that is the desired effects of succinylcholine, so it is not used when very rapid paralysis is required, such as in the emergency management of a difficult airway or when regurgitation and aspiration of stomach contents might occur. The combination of succinylcholine and NDNMB administration may effectively mimic elapid envenoming where there are mixed α- and β-toxin effects.The reversal of the block from depolarizing muscle relaxants (succinylcholine) occurs by the process of rapid drug metabolism and spontaneous resolution of nicotinic receptor desensitization and inactivation. Normally, plasma butyrylcholinesterases rapidly metabolize succinylcholine, reducing its duration of action to less than five minutes. However, if succinylcholine is present for a prolonged period (as when given by constant infusion or in a patient with genetic cholinesterase deficiency), receptors can remain deactivated. Therefore, patients with genetic defects resulting in the lack of plasma cholinesterase are susceptible to developing long-duration and difficult-to-reverse neuromuscular block if they are given succinylcholine. Similarly, succinylcholine can exacerbate myasthenia gravis and result in prolonged weakness. Cholinesterase inhibitors for the reversal of phase II block are contraindicated when the neuromuscular block has been caused by depolarizing agents  because additional acetylcholine in the NMJ, resulting from cholinesterase inhibition, increases nicotinic receptor desensitization, preventing reversal of the block. If reversal is attempted under these conditions, the duration of the paralysis can be prolonged because receptors are converted from a desensitized to an inactivated state. When a phase II block from succinylcholine has occurred, one must simply wait until the block resolves spontaneously, which may require more than an hour.Fasciculins comprise an interesting and lesser-known group of three-finger toxins that produce neuromuscular dysfunction. These toxins cause fasciculations by inhibition of acetylcholinesterase and uncontrolled accumulation of acetylcholine at the NMJ, an entirely different mechanism from the nicotinic receptor antagonism of other 3FTxs . The ensuing exuberant activation of nicotinic receptors causes muscle depolarization, fasciculations, and weakness. The effects of fasciculins are similar to the phase I and II neuromuscular blocks caused by succinylcholine ,25.Nerve agents produce neuromuscular weakness by inhibiting acetylcholinesterase, like fasciculins. Acetylcholinesterase inhibition causes acetylcholine accumulation and nicotinic receptor hyperstimulation, leading to receptor desensitization and inactivation. The inactivation of nicotinic receptors is analogous to receptor inactivation in succinylcholine-induced phase II block see also b, above.2βδε) leading to nerve block [The 3FTxs superfamily contains three β-chain loops that protrude as fingers. These non-enzymatic toxins act postsynaptically to competitively inhibit nicotinic receptors, similar to curare and curare-like drugs, by binding at two agonist binding sites on the adult muscle type of nicotinic receptors (α1-δ and α1-ε interface of (α1)ve block . Two subve block . Proteomve block . Snake vve block ,29 and pNon-depolarizing neuromuscular blockers (NDNMBs) are a drug category of clinically relevant compounds with curare-like actions that competitively antagonize postsynaptic nicotinic acetylcholine receptors. NDNMBs never cause fasciculations, either during initial effect or recovery. The competitive effects of NDNMBs at nicotinic receptors means that their actions can be reversed with cholinesterase inhibitors. Steroid-based neuromuscular blocking drugs were introduced in the 1960s and short- to intermediate-duration drugs are now ubiquitous in anesthesiology and critical care. Synthetic, steroid-derived drugs include pancuronium, atracurium, mivacurium, vecuronium, and rocuronium. These drugs have completely displaced curare from clinical use, although small-dose d-tubocurarine use persisted through the 1990s for use in preventing fasciculations from succinylcholine.2 retention-induced respiratory acidosis, metabolic acidosis, other medications that potentiate neuromuscular block, and the inappropriate use of cholinesterase inhibitors.Neostigmine, edrophonium, pyridostigmine, and similar agents have been used since the 1950s to reverse the neuromuscular block produced by curare-like drugs and since the early 1930s to reverse weakness from myasthenia gravis as first described by Mary Broadfoot Walker in 1935 . The basAn entirely different strategy for reversing neuromuscular block involves the use of drugs that non-covalently bind steroidal neuromuscular blockers. Sugammadex is the first drug in this class. Sugammadex is a crown ether that has a high affinity for the steroidal drug rocuronium. Reversal of rocuronium neuromuscular block with Sugammadex can be very rapid and complete .Like β-neurotoxins, Botulinum toxin (BTx) is a multi-subunit toxin that causes neuromuscular transmission blockade by interfering with arachidonic acid metabolism and vesicular release . BTx bloA fundamental difficulty in interpreting studies and case series involving treatments for paralytic envenoming is that standard measures of neuromuscular weakness have not been used. Quantitative assessment of neuromuscular weakness, such as train-of-four monitoring, has been virtually non-existent in studies of antivenom efficacy .Naja naja philippinensis) [The clinical utility of cholinesterase inhibitors for the reversal of paralysis in SBE remains controversial even fifty years after the first description of its use by Banerjee in 1972 ,31. Someinensis) ,33.not occur with neostigmine [In contrast to α-toxins, reports have described that the reversal of β-toxin-mediated paralysis does stigmine ,34. Thisstigmine ,22.Because fasciculations indicate depolarization of the muscle membrane from excessive and uncontrolled acetylcholine release, cholinesterase inhibitors such as neostigmine should be used with great caution or avoided when β-toxin effects are the primary feature of the envenoming snake or if fasciculin-containing venom is suspected ,24,34,35A recent review of the effects of standard-of-care treatment for snakebite envenoming, antivenom, reveals no randomized placebo-controlled trials of antivenom effectiveness in reversing paralysis . As wellIn contrast, studies examining paralysis caused by β-neurotoxins  suggest that antivenom does not reverse or even improve established neurotoxicity, although early administration appears to prevent neurotoxicity and might be associated with a decrease in severity for some snakes, mainly taipans . For exaNaja and Ophiophagus) for which there is great venom diversity by geographic location and, therefore, wildly differing neutralization potential of polyvalent antivenoms [Future research should include carefully controlled studies investigating whether the early administration of antivenom will prevent neurotoxicity by both depolarizing and non-depolarizing toxins, and whether antivenom can reverse α-toxin-induced paralysis. This is particularly important for venoms from the main cobra genera , although validated as a graded assessment scale in pit viper envenoming and adopted by some investigators outside North America , requireMost recently, the SSS was modified by clinical investigators to include a renal subscore and a modestly updated bedside neurological examination that has been accepted for evaluation by regulatory authorities in the US and India (NCT04996264). Unfortunately, current snakebite clinical management guidelines do not provide a sensitive tool for grading neurotoxicity, in particular for sedated, intubated patients. For treatment, the guidelines are primarily focused on the decision of when and how frequently to administer antivenom, which is generally binary depending on whether any feature of neurotoxicity (or other major toxicity) is present . For exaModernizing the SSS and developing a more detailed assessment tool specific to the neurotoxic syndromes in snakebite may not be mutually exclusive exercises and should have complementary utility. A detailed assessment tool would facilitate documentation of the development and recovery of neuromuscular function, as well as provide a quantitative basis for assessing new and older therapeutic platforms for this heterogeneous disease. Based on relatively uniform clinical descriptions of the neuroparalytic syndromes associated with snakebite envenoming, it is reasonable to imagine an expanded weakness severity scale. Such a scale would need to have components not entirely dependent upon specialized equipment or laboratory assessments. Patients on ventilator support would need to be evaluated based on additional parameters that effectively disambiguate clinically induced weakness and conveniences that might interfere with evaluation . Possible measures for the systematic assessment of toxin-induced weakness are shown in Clinical and quantitative protocols for assessment of venom-induced neuromuscular weakness and paralysis;Optimization of airway management and mechanical ventilation;Monitoring of adequacy of breathing and gas exchange;Understanding utility and limitations of drugs in reversal of weakness and paralysis.A detailed assessment tool must address four key aspects of the clinical management of snakebite envenoming:Grade 0No weakness.Grade 1Mild cranial nerve deficit  and no bulbar weakness; able to lift limbs and neck against gravity, ambulatory without assistance.Grade 2Unable to lift limbs/neck against gravity, difficulty swallowing, or inability to ambulate independently.Grade 3Severe weakness causing reduced ventilatory function, but spontaneous respiration is preserved.Grade 4Complete paralysis; reflexes absent; ventilator dependent.We propose the following hypothetical clinical tool to grade SBE induced weakness and paralysis. Following community discussion and consensus, our proposed four-point grading scale could be incorporated into the SSS as the neuromuscular function component.The distinction between grades would be based on clinically relevant deterioration or improvement that can be conveniently scored as a patient worsens or improves. For example, Grade 2 involves cranial nerve dysfunction, but there may be preserved intercostal/diaphragm muscle function, and anticipation of the need for airway protection. With Grade 3, the primary muscles of respiration are weak, with hypoventilation even when patient is protected from airway obstruction with an airway device or intervention. Grade 4 requires mechanical ventilation for survival and can be downgraded to a Grade 3 as spontaneous respiration returns. For sedated and intubated patients evolving between Grade 2 and Grade 4, the monitoring of neuromuscular weakness can at least partially overcome the limitations of clinical examination obscured by sedative hypnotics as described below. Ideally and when available, quantitative neuromuscular monitoring could help distinguish between weakness states.2 retention, increases weakness. As well, sedative medications such as propofol can increase neuromuscular block. Renal failure prolongs the half-life of neuromuscular blocking drugs, but its effects on venom clearance have not been well studied. In critically ill patients, aminoglycoside antibiotics such as gentamycin can adversely affect neuromuscular function [Studies show that the clinical assessment of neuromuscular block can be inaccurate, even when performed by very experienced clinicians. Crude assessments of neuromuscular function can be influenced by many factors, for example, inability to follow instructions or pre-existing physical disability. Patients who have received neuromuscular blocking drugs and are clinically judged to have no significant residual weakness often do have clinically significant residual weakness, to an extent that places them at risk for complications including pneumonia, aspiration, and airway obstruction after extubation ,50,51. Ifunction  and drugThere are two main types of neuromuscular monitoring: acceleromyography where muscle action is measured as the mechanical output of muscle, and electromyography (EMG), where muscle strength is measured based on the electromyogram of a muscle stimulated by a nerve. A recent paper showed that the EMG technique might be preferable in detecting block, but it is also invasive and could be less desirable for patients, families and other stakeholders otherwise encouraged to enroll in clinical studies ,54.Quantitative neuromonitoring involves the controlled stimulation of a motor nerve and observation and/or quantitative measurement of the muscular response. Clinically, this is typically carried out with four equally spaced stimuli, typically at 60 mA, 1.0 Hz, pulse width 10 ms. A typical pattern of stimulation and response is shown in For clinical trials, there is an urgent need to establish reproducible standardized outcome measures . AlthougMost patients recovering from a critical illness are gradually weaned from mechanical ventilation and may transition to non-invasive ventilation before all ventilatory support is removed. Furthermore, patients may initially tolerate a period without assisted ventilation before deteriorating and requiring a temporary period of increased ventilatory support. To overcome this, clinical trials can adopt a definition of “first successful unassisted breathing”, which is defined as continuing to breath without assistance for a period longer than 48 h ,58. ThisIn the above-proposed hypothetical snakebite weakness and paralysis scoring system, or adaptations of this tool, may provide a more sensitive outcome measure than solely relying on measures of reliance on ventilatory support. A similar tool has been successful in clinical trials in Guillain–Barré syndrome, which, like neurotoxic envenoming, can cause an acute flaccid paralysis. 1Healthy;2Minor symptoms of neuropathy but capable of manual work;3Able to walk without support of a stick but incapable of manual work;4Able to walk with a stick;5Confined to a bed or chair;6Requiring assisted ventilation; or7Dead.The “GBS disability score” at 4 weeks after randomization is an established primary outcome measure . This scOutcome measures based on physical function such as these are desirable as they are sensitive, patient centered, and clinically relevant .Oxyuranus scutellatus canni envenoming in Papua New Guinea were randomized to edrophonium, diaminopyridine, or placebo, in conjunction with atropine [Naja naja philippinensis were randomized to receive atropine and edrophonium, or placebo [EMG studies also represent a potentially valuable outcome measure for snakebite clinical trials. Only two snakebite randomized controlled trials have included electromyography as an outcome measure. In contrast to the study by Silva and colleagues using sfEMG , in the atropine . EMG was placebo . However placebo ,61.Standard clinical and quantitative neuromuscular neuromonitoring are needed to improve snake bite care. We advocate a combination of clinical assessments and quantitative neuromuscular monitoring with nerve stimulation. The specific modalities of neuromuscular stimulation include ToF and paired pulse facilitation. Types of monitors, sites for assessment , sensitivity, and specificity for different sites with depolarizing vs. non-depolarizing agents need to be clarified. The development of these tools may become essential for decreasing mortality and morbidity following snakebite and are desirable as well as likely necessary for the evaluation of therapeutics in future clinical trials.


Hematologic malignancies are a diverse collection of cancers that affect the blood, bone marrow, and organs. They have a very unpredictable prognosis and recur after treatment. Leukemia, lymphoma, and myeloma are the most prevalent symptoms. Despite advancements in chemotherapy and supportive care, the incidence rate and mortality of patients with hematological malignancies remain high. Additionally, there are issues with the clinical diagnosis because several hematological malignancies lack defined, systematic diagnostic criteria. This work provided an overview of the fundamentals, benefits, and limitations of Raman spectroscopy and its use in hematological cancers. The alterations of trace substances can be recognized using Raman spectroscopy. High sensitivity, non-destructive, quick, real-time, and other attributes define it. Clinicians must promptly identify disorders and keep track of analytes in biological fluids. For instance, surface-enhanced Raman spectroscopy is employed in diagnosing gene mutations in myelodysplastic syndromes due to its high sensitivity and multiple detection benefits. Serum indicators for multiple myeloma have been routinely used for detection. The simultaneous observation of DNA strand modifications and the production of new molecular bonds by tip-enhanced Raman spectroscopy is of tremendous significance for diagnosing lymphoma and multiple myeloma with unidentified diagnostic criteria. The Raman effect originates from the inelastic scattering of laser light, which can directly detect molecules and materials’ vibrational and rotational states . The basIn addition to its outstanding achievements in biochemistry, Raman spectroscopy is also highly known in liquid biopsy and epigenetic diagnosis. Abnormal methylation of gene promoters may be the inactivation mechanism of tumor suppressor genes. Studying cancer epigenetics and its key role in tumorigenesis through Raman spectroscopy can provide attractive epigenetic therapeutic targets and is a powerful tool for disease monitoring and prognosis estimation . The newExploring tumor pathogenesis and therapy has recently been a popular research topic. Cell senescence is an essential mechanism in preventing the proliferation of potential tumor cells, but it can also promote tumor growth. Increasing evidence has shown that cell senescence is related to the pathogenesis and development of hematological malignancies, including leukemia, myelodysplastic syndromes (MDS), and multiple myeloma (MM). Cell senescence is associated with a decline in hematopoietic stem cell function and an increased risk of hematological malignancy . It is bHistopathology is a standard method for evaluating hematological malignancies, but it has significant limitations in research and clinical settings. A patient’s bone marrow biopsy can fail to detect the heterogeneity of the disease, which may result in non-diagnostic samples; thus, this technique cannot be used repeatedly in clinical oncology . Malignain vivo needs further research. Raman spectroscopy is highly sensitive and non-destructive. CAR-T cell therapy also places the utmost importance on the probe design of CAR-T cells. Combining Raman spectroscopy and nanoprobes has made this task easier. Raman spectroscopy as an adjunct to CAR-T cell therapy is a viable option , resonance Raman scattering (RRS), tip-enhanced Raman spectroscopy (TERS), and coherent anti-Stokes Raman scattering (CARS). According to the “hot spot” phenomenon at the intersection of dimers and clusters in metal nanoparticles, which is the basis of the SERS detection method, electromagnetic solid field augmentation is produced due to aggregation. The Raman scattering signal of the adsorbed molecules is strongly amplified to 14 orders of magnitude with a highly enhanced SERS substrate when molecules are adsorbed on the surface of rough metals  or metal nanoparticles , allowing for the detection of a single molecule. SERS offers exceptionally high sensitivity and thorough fingerprint information and has developed into a potential DNA rapid identification and structural characterization method. SERS has the optimal resolution and can evaluate and classify complex spectrum data when used with chemometric techniques. Multiple target DNA detections are an important clinical application of SERS detection because of their simplicity, speed, and high sensitivity advantages. Even though SERS has great promise, its analytical performance still needs to be improved. The challenge in furthering this technology is creating a consistent process for uniformly producing SERS spanning various samples. In addition, the experimental design of clinical sample detection should be adjusted to obtain quantitative detection of analytes in complicated biological samples.In humans, the level of 5-methylcytosine (5 mC) generated by cytosine methylation is regarded as a diagnostic biomarker for early cancers and a risk assessment tool for the clinical treatment of bacterial and viral infections. Using resonance excitation of the wavelength in the UV region, RRS modifies the excitation wavelength to the absorption resonance of the target 5 mC or unmethylated cytosine at the ring absorption resonance. Raman signals can be improved without tags, and the measurement pipeline is shorter because no amplification, library formation, or other operations are required.TERS combines the chemical selectivity of the Raman spectrum with the spatial resolution (in nm) of the atomic force microscope (AFM) and scanning tunneling microscope (STM). The metal nanostructures on the AFM tip or STM tip itself (STM-TERS) alter the incident laser’s electromagnetic field and improve the Raman scattering of a few samples close to the tip. The tip of the TERS functions as a nanoantenna, which converts the electric field of the incident laser beam into local energy, thereby improving the spatial resolution of the TERS to a few nanometers under vacuum and low-temperature conditions and transforming the near field of the sample into a far-field accessible to the objective lens, thereby increasing the sensitivity to a single molecule. TERS has the benefit of observing the molecular alteration of many functional groups and DNA base pairs in the DNA skeleton as well as the development of new chemical bonds between DNA strands and various substances simultaneously. Despite many groundbreaking findings, TERS possesses excellent atomic resolution even in the strong coupling state. Many practical problems remain in cutting-edge improved nano spectroscopy’s easy and widespread deployment. TERS enhancement factors are not uniform for distinct plasma tips, even under the same excitation settings. Since their vertex size, shape, and surface roughness are slightly different, controlling them at the nanoscale is difficult. Similarly, maintaining the vector field and mode curve at the apex remains difficult.A type of unregistered non-linear chemical imaging technique called a coherent anti-Stokes Raman scattering (CARS) microscope might identify particular inherent molecular vibrations in samples. The vibration resonance of the target molecules is matched by the frequency difference between two laser beams. Without fluorescent labeling, the excitation laser in biological imaging can be tuned to resonate with the vibration of lipids, proteins, and even DNA. Living cell imaging has extensively used coherent Raman imaging, which has a high collection rate and excellent sensitivity for detecting the presence of lipids, proteins, nucleic acids, and water in cells. The sensitivity of CARS is still at the millimole level of intrinsic biomolecules despite these benefits and qualities. CARS microscopy has difficulty achieving single molecule level measurement without other enhancing techniques.in vivo detection, and biomarker detection may increase the accuracy of diagnosing precancerous lesions, aiding clinical screening, symptomatic treatment, and prognosis development  of AFM, STM, and other technologies, TERS can analyze the molecular modification of several functional groups and DNA base pairs in the DNA skeleton and detect the formation of new chemical bonds between DNA chains and various chemical substances. Clinical optical biopsies can benefit from TERS’s analysis of dynamic response changes in living cell molecules, allowing for more precise identification of different lymphoma cell types. Raman spectroscopy and RESPECT probe fingerprints compare the relative peak differences between non-Hodgkin’s lymphoma subtypes, providing diagnostic and therapeutic targets. Single-cell Raman spectroscopy has; high resolution, non-destructive, molecular specificity, and independent culture advantages. It can analyze the potential molecular differences between different leukocyte subtypes for leukemia diagnosis and detect the metabolites of leukemia cells without causing damage; when combined with flow cytometry, single-cell metabolic phenotypes can be monitored. The differential diagnosis technology of CLL and DLBCL was developed by non-invasive detection of plasma. Analyzing the 1655cmnitoring .in vitro samples, Raman spectroscopy is becoming increasingly popular for obtaining chemical images of cell samples in parasitology, pharmacology, and oncology  or metal nanoparticles , allowing for the detection of a single molecule. SERS has been widely employed in various applications, including chemical analysis, biomolecular detection, biological agent diagnosis, DNA sequence, environmental monitoring, and others because of its unmarked fingerprint recognition, high sensitivity, and quick detection capabilities. In addition, the standardization, quality assurance, and technical preparation of self-assembly methods and nano-manufacturing procedures have been rigorously assessed. Bonifacio et al. demonstrated that SERS can be a powerful tool for developing care point testing of therapeutic drug monitoring (TDM) for drugs with narrow therapeutic windows. The use of SERS in the biological analysis is shown in ructures . The SERructures .via integration with other cutting-edge analytical technologies and contemporary data processing, can now explore complex biological and environmental samples in a way that has never been possible with considerably better specificity, sensitivity, and resolution. SCRS-derived technology is superior to conventional batch measurement in environmental and biological research because of its high resolution, label-free and non-invasive nature, molecular specificity, culture independence, and application to in situ, in vitro, or in vivo studies (Single-cell Raman spectroscopy (SCRS), which has grown more complicated  studies . Some st studies .in vitro and in vivo. However, the high specificity of Raman spectroscopy comes at a cost. The acquisition rate is low, depth information cannot be directly accessed, and the sampling area is limited  combine laser tweezers and Raman spectroscopy. It is a physical instrument based on the laser mechanical effect that may be used to swiftly and non-destructively investigate individual live cells in suspension. To promptly and non-destructively identify and assess the treatment resistance of acute lymphoblastic leukemia (ALL) cells, Chen et al. developed a novel approach based on LTRS. The research contained two distinct doxorubicin-resistant parental ALL cells, BALL-1 and Nalm6. Raman spectrum variations produced by adriamycin-resistant cells may be seen using LTRS. Chen et al. demonstrated that the specificity and sensitivity of LTRS are more than 90% by using principal component analysis (PCA) and classification and regression (CRT) methods to assure the correctness of the findings. In addition, to further clarify the chemical resistance state of all cells, Chen et al. used the CRT model based on strip data and receiver operating characteristic (ROC) curve analysis to identify essential strips and strip intensity ratios with solid directional significance. Experiments have proven that the combination of LTRS analysis and multivariate statistical analysis has great potential and can become a new analytical strategy for the rapid evaluation of the drug resistance status of all cells at the single-cell level .The excessive synthesis of aberrant B-cell lymphocytes from bone marrow results in chronic lymphocytic leukemia (CLL). Slowly worsening CLL is an incurable condition. Static CLL-related cells may be seen in the bone marrow, lymph nodes, spleen, and blood. CLL cells must be highly adaptive to oxygenation and molecular cues from the matrix due to the variety of microenvironments in which they are found. For instance, lymph nodes’ non-CLL cells’ cell signal transduction affects CLL cell growth differently than elsewhere. In addition, the microenvironment in the bone marrow of CLL patients is characterized by the increased expression of mRNA and protein levels of the BCL-2 protein family, which is the crucial anti-apoptotic factor that helps maintain CLL proliferation and the basis of its drug resistance tendency so that it can be used as a therapeutic target . Amini e−1, associated with the DNA phosphate group stretching mode, is very sensitive to proton beam exposure. As a result, it may be used to diagnose genetic abnormalities and mutations in AML and as a spectral marker of cytogenetic damage , a set of various myeloid disorders marked by peripheral blood cell loss. Men over the age of 50 and those who have had cytotoxic treatment in the past are more likely to develop myelodysplastic syndromes. At the bone marrow sample and gross inspection time, morphological evidence of dysplasia was used to diagnose MDS. The comprehensive diagnostic analysis of information usually obtained from karyotype, flow cytometry, molecular genetics, and other studies has certain limitations in the clinical application . To diagAlthough MDS includes heterogeneous subclasses, they share a common origin in hematopoietic stem cells and progenitor cell compartments. The degree of haemocytopenia partly determines the subtypes of MDS, but some MDS and mixed MDS/myeloproliferative tumor (MPN) subgroups may show increased leukocyte, monocyte, and platelet counts. In addition, patients with mild or marginal anemia can be diagnosed with early MDS if there are apparent morphological or cytological changes . Anemia + and CD8+ T cells from the control group and LPS-treated mice during acute inflammation. The difference could be seen 10 days after LPS injury. At the post-acute stage, CD4+ and CD8+ T cells from treated and untreated mice could not differentiate again, indicating that the T cells had largely recovered their original state. The biological information obtained from Raman spectroscopy is consistent with the immune reading, meaning that Raman spectroscopy is a very suitable label-free method that can be used to track the activation of splenic T cells in systemic inflammation from the acute to chronic stages to track the changes in the autoimmune system in some MDS patients . Quantitative measurements were made of the likelihood, penetration force, and viability of cell membrane perforation using the force-distance curve acquired during the indentation process. They also looked at the potential for visualizing cells using TERS. This imaging is functionalized by using silver nanoparticles in a home-built Raman system combined with an inverted microscope through AFM probes, which successfully demonstrated that TERS imaging is capable of visualizing noticeably different features in the Raman spectrum between the nucleus and cytoplasm of a single living cell and of analyzing the dynamic behavior of biomolecules in living cells , which are also normal cells in most B-cell non-Hodgkin’s lymphomas. Although they share the same GC B-cell precursor, these lymphomas originate from cells at different stages of GC reaction and develop through other pathogenic mechanisms . Monitorng cells .2 tissue area images containing thousands of Raman spectra. Partial least squares discriminant analysis was used to create a lymph node classification model to distinguish benign and malignant tissues and to distinguish cancer type, grade, and BCL2 protein expression. This study provides a new idea for developing a clinical optical biopsy tool for diagnosing lymph node cancer using Raman spectroscopy  accounts for approximately 10% of all hematological malignancies. Although MM is still considered a single disease, it is a collection of several malignant plasma cell tumors with different cytogenetics. Almost all MM patients will eventually relapse. The choice of the treatment plan is very complex when relapse occurs. It is affected by many factors, including recurrent t-type insertion, previous treatment adaptability, recurrence severity, and performance status . ImmunotNucleic acid biomarkers for cancer immunotherapy have been expanded to include SERS-active nanomaterials. SERS-active nanoparticles have been created for immunotherapy layering and SERS immunomarker sensing . SERS usAlthough some patients have experienced a long remission or recovered after functional treatment, others still have early recurrence or receive ineffective treatment. To improve the treatment and prognosis results, it is necessary to comprehensively analyze the information on molecular abnormalities that lead to differences in these results and use biomarker-driven personalized treatment methods. To achieve this goal, biomarkers must be measured robust and repeatable manner. The progress of biomarker monitoring technology helps identify and validate treatment-related biomarkers of myeloma, such as biomarkers that can predict the outcome of patients’ disease according to differences (prognostic biomarkers) or biomarkers that can target the patient’s cell subsets according to a specific molecular pathology (predictive biomarkers) . Raman setc. They identified the spectrum distinctions between dormant and active B cells and evaluated their relationship to recognized intracellular biological changes.SERS nanotags can also achieve targeting functions through biomolecular detection and can simultaneously detect various biomarkers. This indicates that the technology has significant advantages in cancer detection and diagnosis with the simultaneous detection of multiple biomarkers . The devThe limitations of conventional molecular biology technology may be supplemented by Raman spectrum analysis, which offers a potent tool for examining gene mutations. It also provides a technique to trace the dynamics of the biochemical composition of a single cell . PrecisiA novel supplementary tool for illness diagnostics is Raman spectroscopy. However, there are still certain drawbacks, such as substances’ unsatisfactory spontaneous Raman spectrum signal. They have a limited application range, low sensitivity, and are susceptible to fluorescence interference. Resonance Raman scattering was developed to identify cytosine methylation without labeling, amplification, library construction, or other operations. It does this by enhancing the material’s Raman spectrum signal, which significantly improves the sensitivity limitation of traditional Raman spectroscopy. The resolution of Raman spectroscopy is precise in creating intermolecular chemical bonds, and the strong coupling state of atoms may also be identified; Coherent Raman imaging is applied to live cell imaging to determine intracellular lipid, protein, nucleic acid, and water levels with great sensitivity.Raman spectroscopy provides clear benefits over conventional hematological tumor diagnosis techniques. Its main advantages are that it can produce a Raman fingerprint without causing any damage, is specific, and has high sensitivity. Moreover, it does not require any sample preparation or fluorescent or isotope labeling during the detection process, which perfectly satisfies the demands of quick and real-time clinical detection. Raman spectroscopy may also provide precise discrimination and micro-detection with minor sample damage, which is very important for analyzing the course of a disease and its prognosis after therapy. Of course, combining Raman spectroscopy technology with conventional biochemical evaluation techniques may be optimal for its clinical application. Raman’s distinctive spectral peaks provide accurate identification. As additional tools for laboratory diagnosis, biochemical detection markers are used. The two, taken together, will significantly increase clinicians’ ability to make accurate diagnoses. For instance, exactly how most blood system cancers form and occur is still unclear. Low clinical diagnosis efficiency is caused by biochemical markers of the blood system that can be impacted by other primary diseases and have complex changes that frequently require medical expertise to interpret and appraise. Hematological tumors can be identified and treated, and the prognosis can be determined using Raman scattering and its registration techniques. Raman spectroscopy is increasingly being used in healthcare settings.


Although US tobacco use trends show overall improvement, social disadvantage continues to drive significant disparities. Traditional tobacco cessation interventions and public policy initiatives have failed to equitably benefit socially-disadvantaged populations. Advancements in mobile digital technologies have created new opportunities to develop resource-efficient mobile health  interventions that, relative to traditional approaches, have greater reach while still maintaining comparable or greater efficacy. Their potential for affordability, scalability, and efficiency gives mHealth tobacco cessation interventions potential as tools to help redress tobacco use disparities. We discuss our perspectives on the state of the science surrounding mHealth tobacco cessation interventions for use by socially-disadvantaged populations. In doing so, we outline existing models of health disparities and social determinants of health (SDOH) and discuss potential ways that mHealth interventions might be optimized to offset or address the impact of social determinants of tobacco use. Because smokers from socially-disadvantaged backgrounds face multi-level barriers that can dynamically heighten the risks of tobacco use, we discuss cutting-edge mHealth interventions that adapt dynamically based on context. We also consider complications and pitfalls that could emerge when designing, evaluating, and implementing mHealth tobacco cessation interventions for socially-disadvantaged populations. Altogether, this perspective article provides a conceptual foundation for optimizing mHealth tobacco cessation interventions for the socially-disadvantaged populations in greatest need. Efforts to reduce tobacco use in the US have failed to equitably benefit many socially-disadvantaged populations. Decreased tobacco use over the past two decades is largely because well-resourced, socially-advantaged populations have responded well to public policy efforts and tobacco cessation interventions, reaching endgame levels (<5%) of tobacco use , 2. MeanIncreased recognition of access barriers has led many tobacco experts to turn to digital modalities as a delivery channel for equitable reach. Smartphones, in particular, have become ubiquitous, providing internet connectivity even for those who lack broadband connectivity , 10. TheIn this paper, we provide our perspectives on the current state of the science surrounding mHealth interventions to promote health equity in cessation of tobacco use. We will review research on how social determinants of health (SDOH) contribute to tobacco use disparities. Against that backdrop, we propose a conceptual model that can guide the development of mHealth tobacco cessation interventions to address SDOH. In that manner, we hope to ensure that mHealth interventions for tobacco cessation serve the socially disadvantaged populations with greatest need.It is now accepted that health disparities, including those related to tobacco use, are driven by an interplay of factors that function within and across multiple levels of influence. These factors are commonly referred to as social determinants of health (SDOH). Although widely used, the term SDOH has different meanings based on one's field and scientific background. The term SDOH was originally used as a “catch-all” to designate all health influences that originate and function outside of explicit “medical care.” Even though this usage persists in some sectors today, SDOH are now conceptualized with greater nuance , 16.Most current definitions share two unifying themes. First, modern definitions tend to place greater emphasis on extra-individual rather than intra-individual influences. Second, SDOH are now conceptualized less as a collection of independent influences, and more as factors that function interdependently to influence health across various domains  and levels  .A substantial body of research links various SDOH with tobacco use through direct and indirect mechanisms. Below, we provide a brief, non-exhaustive overview of particularly well-studied SDOH and the mechanisms by which they are thought to influence tobacco use.The most substantially researched SDOH are probably those that contribute to individual-level socioeconomic status (SES). The primary SES factors that have been studied include education, income, occupational status, and insurance status . FindingIncreasingly, it is recognized that individual SES may be a proxy for extra-individual influences on tobacco use. Businelle et al.  modeled via numerous mechanisms. Upstream neighborhood-level factors in low-SES neighborhoods include greater density of tobacco marketing . Race and ethnicity are also, in and of themselves, independent reflections of all the numerous potential exposures that one's identity encapsulates. Estimates consistently show that cigarette use is most prevalent among American Indian/Alaska Natives (23%), followed by African Americans/Blacks (15%) and Non-Hispanic Whites (15%), Hispanic/Latinx (10%), and non-Hispanic Asians (7%) . HoweverMultiple SDOH contribute to the association between tobacco use and racial and ethnic background. Experiences of discrimination are associated with greater dependence on tobacco products among multiple racial and ethnic minority populations . AdditioAlthough research in mHealth tobacco cessation intervention has grown exponentially, this body of evidence is still in its infancy. A recent systematic review of mHealth tobacco cessation interventions identified 18 trials, of which the majority were identified as pilot or feasibility trials . AlthougSDOH Targeting Approach, researchers select a specific, underrepresented group . Then, they leverage models of SDOH to create a customized mHealth intervention package designed to engage individuals who match the demographic and socioenvironmental context of interest. For example, a researcher may take an existing mHealth intervention designed for the general population, and use a SDOH framework [e.g., Cultural Accommodation of Substance Abuse Treatment framework . That progression leaves many important questions unanswered about the impact and cost of the intervention's components, their ability to accommodate and address SDOH, and the scalability of the full intervention package.We propose that these risks can be minimized by creating an intervention development pipeline that integrates community-centered methods, SDOH framework(s), and a translational research framework. This conceptual model is depicted in Perhaps one of the most novel and conceptually promising opportunities to promote health equity enabled by mHealth intervention technologies is the potential for real-time intervention that adapts dynamically to context . Such interventions, termed just-in-time-adaptive-intervention (JITAI), leverage intensive longitudinal data collected by smartphones and wearable sensors to characterize an individual's real-time context, and then deliver an intervention in moments of elevated need or receptivity . Recent In one study, we randomly delivered a digital stress management intervention prompt during minutes when a recently quit smoker was stressed vs. not stressed. The resulting JITAI will be the decision rule that specifies the optimal temporal context (stressed or not stressed) in which the digital intervention should be delivered to maximize protection against smoking relapse . We beliTo illustrate, we apply our proposed conceptual model to this line of intervention development research aimed at developing a stress management JITAI to protect against smoking relapse. In Multiphase Optimization Strategy is particularly well-equipped to handle the complexity of SDOH and to build interventions that are both effective and scalable enough to tangibly redress tobacco disparities. MOST requires systematic preparation phase work that culminates in measurable objectives and a sound conceptual model to guide subsequent optimization and evaluation. Laying a sound research foundation that links intervention components to SDOH is particularly valuable for developing interventions to promote health equity and eventual uptake. MOST is also specifically used for building interventions that are multicomponent to target different determinants of a risk behavior. To address specific SDOH, researchers may need to systematically add new components, as well as remove or restructure existing components, tasks for which MOST is particularly well-suited.In our hypothetical intervention development example depicted in In this article, we provided a current perspective on the science surrounding mHealth interventions to promote equitable intervention for tobacco cessation. We provided a non-exhaustive overview of how SDOH contribute to tobacco use disparities. Against that backdrop, we reviewed current mHealth tobacco cessation intervention research, highlighting that much of this work is in the early intervention development phase , and pointing out important considerations to ensure that intervention development pipeline outputs interventions that tangibly work to redress tobacco use disparities. We propose a conceptual model for developing interventions that uses community-centered methods to systematically integrate SDOH framework(s) with a suitable translational research framework. We close by suggesting several benefits of using MOST as a translational research framework, including capacity to integrate SDOH framework(s) and community-centered methods, and adept handling of multicomponent interventions. We also elevate the JITAI for its potential to support intervention that dynamically accommodates upstream, contextual SDOH exposures.Despite burgeoning research support for mHealth in tobacco cessation, from the lens of health equity, many limitations may yet be uncovered. Given the relative novelty of mHealth, we may not necessarily know at this stage whether mHealth creates additional barriers or complications to intervening on traditionally marginalized tobacco users. Although mHealth technologies have become increasingly ubiquitous, questions remain regarding their acceptability and feasibility across society's most socially-disadvantaged populations. Indeed, numerous barriers may disproportionately impact socially-disadvantaged populations, including limited technology and internet accessibility, low digital literacy, and linguistic barriers , 62. ForThe original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.SB led the conceptualization, drafting, and editing of this manuscript. AP, KK, AH, DC, and BS assisted with conceptualization, drafting, and editing. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The brain has limited innate ability to promote repair, regeneration and functional recovery following injury, disease, or developmental disorder. Although cell and gene therapies have significant potential in the brain, no single treatment is likely to succeed in isolation. Here we discuss the current state of the art in cell and nucleic-acid-based neurotherapeutics and argue for the development of combination therapies that use biomaterials to help overcome the current limitations of cell and gene therapies alone. For many of the most chronic and debilitating neurological disorders, such as brain injury, neurodegenerative disease and congenital disorders of the brain, no robust preventative measure or effective disease-modifying therapy is currently available. With an ageing global population, these unmet needs will only become more pressing.Amongst the most promising new therapeutic candidates are cell and gene therapies. To date, 18 cell or gene therapies have been approved by the European Medicines Agency (EMA), under the designation of “Advanced therapy medicinal products” (ATMPs). 11 have a current marketing authorisation at the time of writing: 7 gene therapies and 4 cell therapies. Only 2 of these target the central nervous system (CNS) – the gene therapies Zolgensma®, for spinal muscular atrophy, and Skysona®, which targets an inborn error of metabolism that results in cerebral adrenoleukodystrophy. A recent study estimated that only 11 new neuro/neuromuscular cell and gene therapies were currently being investigated in clinical trials The EMA defines Combination ATMPs as therapies that use a cell or gene therapy to achieve their effects alongside a component that does not rely on pharmacological, immunological, or metabolic means to exert its effect – This includes devices such as biomaterial cell scaffolds or nanoparticles for gene therapy delivery.The definition of “biomaterial” in the context of Combination ATMPs is broad-ranging, encompassing both natural and synthetic materials in various forms such as gels, particles, and more structurally complex constructs that aim to restore aspects of normal tissue architecture from subcellular to gross anatomical scale. Many biomaterials have inherent therapeutic utility in addition to their ability to support cell and gene therapies, as is discussed further below. However, the European Union (EU) clinical trials register currently lists no combination ATMP trials for neurological applications. Combination ATMPs for the brain, therefore, represent an underutilised approach. The utility of these systems will depend on the design of appropriate biomaterials for specific uses within the brain.Biomaterials for the brain must meet several general requirements. Ideally, the material should match the mechanical properties of the administration site, as softer materials tend to be less stable and stiffer materials may result in gliosis Restoring structure and function in the brain will require fine control over tissue architecture from subcellular to gross anatomical scale. Parkinson's disease is an instructive example – In Parkinson's disease, dysfunction and loss of dopaminergic neurons connecting the substantia nigra and striatum results in multi-centimetre scale lesions. Slowing disease progression and restoring function would require promotion of endogenous axonal growth and synaptogenesis or engraftment of cells capable of functional integration. Biomaterials such as growth-factor laden collagen scaffolds can help “bridge” these gaps by providing biochemical and physical guidance cues over relevant distances Biomaterials can provide structural cues essential for restoring brain architecture. Recent advances in inkjet, micro-extrusion and laser-assisted bioprinting have shown that fine control over biomaterial structure is achievable while maintaining strong cell survival and tuneable mechanical properties. Additionally, electrospinning of fibres allows for anisotropic, patterned materials to be generated that provide topographical cues for directed cell growth, such as axon or neurite guidance Many natural biomaterials have intrinsic bioactive effects in and of themselves – For example, fibrin, collagen, laminin, and hyaluronic acid bear versatile binding sites that allow them to interact with both grafted cells and host brain tissue and provide chemotactic cues for the migration, invasion, and retention of graft/host cells Cell therapies are divided by the EMA into somatic-cell therapy medical products (sCTMPs) and tissue-engineered products (TEPs). In sCTMPs, engrafted cells are not intended to replace/regenerate lost tissue directly. Instead, they act through the pharmacological, immunological, or metabolic action of their cells or tissues. Tissue-engineered products use engrafted cells or tissues to regenerate, repair or replace damaged host tissue .Fig. 1.CThe adult brain has only a small resident population of stem cells, which show limited ability to proliferate or migrate within the brain to regenerate cells and tissues lost to injury or disease Cell therapies face several key challenges. As for any neurotherapeutic, delivery to the brain is complicated by significant losses due to the blood-brain barrier. Even when locally administered, the dysfunctional brain is a hostile environment for transplanted cells due to the presence of toxic metabolites, inflammation and disruption of normal tissue architecture in the form of a glial scar or cyst. Where restoration of function depends on the integration of grafted cells into host neuronal networks, cells may need substantial pre-treatment, genetic modification, or pharmacological manipulation to promote axon outgrowth and synaptogenesis in this environment For example, following stroke, a large fluid-filled cavity remains, bounded by a glial scar and dysfunctional  cells. Chronic inflammation and catastrophic loss of tissue architecture  make this a uniquely challenging site for cellular regeneration Recombinant nucleic acids are used to regulate, repair, add or delete a gene sequence in this approach. Nucleic-acid therapies are a promising therapeutic option in cases with a robust inheritable component, such as Huntington's disease, Amyotrophic lateral sclerosis (ALS) or Parkinson's disease.Nucleic-acid therapies aimed at correcting loss-of-function gene defects primarily rely on adeno-associated viruses (AAVs) delivered to the brain intracerebrally or intrathecally Nonviral vectors avoid or lessen many of the risks associated with viral vectors, typically at the cost of lower transfection efficiency. Nonviral gene delivery approaches are inherently reliant on biomaterials, such as nucleic-acid carriers, to mitigate against degradation of the payload during delivery and promote uptake into target cells. These include inorganic nanoparticles such as gold, calcium phosphate or silica, cationic lipid nanoparticles, emulsions, peptide-based carriers, and polymers For either approach, viral or nonviral, the main challenges of gene delivery to the brain are the rapid degradation of the genetic payload, insufficient gene dose at the site of administration, off-target gene expression and transient expression of therapeutic genes Biomaterials have strong potential as an enabling technology for cell and gene therapies. We propose that the current lack of combined ATMP approaches in clinical trials represents a significant opportunity for biomaterials researchers to contribute to the development of effective neurological therapies. The development of new medical devices incorporating cell, gene and biomaterial approaches may help address the complexity of neurological disease, and we anticipate increased use of multimodal approaches in clinical trials over the coming years.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Liver metastases occur in almost half of patients with colorectal cancer, either at the time of presentation (synchronous) or eventually as a metachronous recurrence of the disease. Approximately one quarter of patients with metastasis to the liver receive surgical resection with curative intent but recurrence is frequent and related to tumor biology. Understanding cancer biology is crucial to improve outcomes. In an attempt at unveiling novel targets for treatment, this paper investigates and summarizes current knowledge of the distinct growth patterns of tumor cells at the interface with normal liver tissue, defined as the histopathological growth pattern, and their interaction with immune cells in the microenvironment. Almost half of all patients with colorectal cancer present with or eventually develop metastasis, most frequently in the liver. Understanding the histopathological growth patterns and tumor immune microenvironment of colorectal liver metastases may help determine treatment strategies and assess prognosis. A literature search was conducted to gather information on cancer biology, histopathological growth patterns, and the tumor immune microenvironment in colorectal liver metastases, including their mechanisms and their impact on clinical outcomes. A first consensus on histopathological growth patterns emerged in 2017, identifying five growth patterns. Later studies found benefits from a two-tier system, desmoplastic and non-desmoplastic, incorporated into the updated 2022 consensus. Furthermore, the tumor immune microenvironment shows additional characteristic features with relevance to cancer biology. This includes density of T-cells (CD8+), expression of claudin-2, presence of vessel co-option versus angiogenesis, as well as several other factors. The relation between histopathological growth patterns and the tumor immune microenvironment delineates distinct subtypes of cancer biology. The distinct subtypes are found to correlate with risk of metastasis or relapse, and hence to clinical outcome and long-term survival in each patient. In order to optimize personalized and precision therapy for patients with colorectal liver metastases, further investigation into the mechanisms of cancer biology and their translational aspects to novel treatment targets is warranted.  Almost half of all patients with colorectal cancer present with or eventually develop metastatic disease, with the liver being the most frequent site of metastasis . As systLong-term survival at 5 years can be achieved in up to 50% of patients undergoing surgical resection of liver metastasis. Importantly, long-term survival is linked to actual cure in selected patients operated for liver metastasis ,11,12,13Several attempts have been made at establishing prognostic models to predict outcome or likelihood of benefit from liver surgery, usually taking into account features such as size, number, and location of metastasis, as well as the time sequence from primary tumor treatment to development of liver metastasis . RecentlIn this study, we investigate the current knowledge of the histopathological growth patterns at the liver–tumor interface and the tumor immune microenvironment in resected colorectal liver metastases.The structured evaluation by microscopy of resected liver specimens has evolved over time, mostly with a focus on confirming the diagnosis and assessing resection margins. However, over the past decade, a keen and evolving interest in specific tumor growth patterns of liver metastases and their prognostic role has emerged. Indeed, a key 2013 paper coined the question, “Histopathological evaluation of liver metastasis: what should be done?” . The autThe prognostic significance of HGPs has been established in several studies, showing superior overall survival in patients with desmoplastic growth pattern ,34,35,36The first consensus work on HGP of liver metastases emerged in 2017 . The conIn this first consensus work, 12 independent observers scored a set of 159 liver metastases. With regards to interobserver variability, the investigators found good-to-excellent correlations with the experts’ gold standard, with intraclass correlation coefficient values >0.5 for replacement and desmoplastic HGP. In a second set, an independent cohort of 374 patients with colorectal liver metastases, the impact of HGPs on overall survival after liver resection was assessed. A cutoff of >50% of the length of the tumor–liver interface was set, placing the patients in categories according to dominant HGP. A significant difference in survival was found in favor of desmoplastic HGP. Dividing patients into four categories based on the predominant growth pattern: desmoplastic, replacement, pushing, and mixed , was proA second, updated consensus guideline emerged in 2022 with the main goal of implementing histological growth patterns into the clinical decision process for treatment of patients with liver metastases . The updHGP and the anti-tumor immune response are related and may reflect the immune system’s ability to fence off cancer growth in the liver ,33,42. TDesmoplastic HGP is associated with an inflammatory phenotype, which may explain the superior treatment response compared with the other growth patterns . In one Replacement HGP is, on the other hand, associated with a non-immune phenotype and has a shorter recurrence-free survival . The preClaudin-2 was found to be predominant in liver metastases of patients with replacement HGP and was associated with poor overall survival in primary CRC and metastasis-free survival, as well as with the consensus molecular subtypes CMS 1 and CMS 3 . In contDesmoplastic, and the more rare pushing HGP, induce angiogenesis and endothelial proliferation at the tumor–liver interface . Many caCancer cells in the replacement type HGP obtain their blood supply by vessel co-option . Vessel Although several working hypotheses of tumor biology and the microenvironment of the different histopathological growth patterns have been proposed ,44,47,61Several factors seem to influence the histopathological growth of metastases, including cancer cell implantation site, presence or absence of coagulation and inflammation, response to liver injury with either fibrosis or regeneration, transcriptional reprogramming in replacement type metastases that express liver-specific genes, cancer cell motility, and angiotropic migration. Moreover, spatiotemporal and single-cell analyses demonstrate metabolic alterations and impact on immune-cell activation related to chemotherapy in the liver metastasis microenvironment . Based on immunohistochemical analysis mapping spatial phenotypes of epithelial and stromal cells, two new theories have emerged . First, One study of 29 paired primary and metastatic CRC cases investigated whether molecular changes in the primary tumor could predict HGP in liver metastasis, comparing primary CRC with desmoplastic HGP and replacement HGP liver metastases . The invNo significant correlation has been found between tumor budding scores in primary tumors and their corresponding metastases in the liver . Both tuThe desmoplastic HGP seems to be associated with increased anti-tumor immune response in both the originating primary CRC and corresponding CRLM. A recent study looking at the relationship between primary cancer and HGPs of their corresponding metastases observed high-tumor-infiltrating lymphocytes (TIL) densities and Crohn’s disease-like lymphoid reaction in desmoplastic CRLM . The presence of KRAS and SMAD4 mutations in CRLM suggest an initiating phenomenon in oligo-metastatic disease, defined as an indolent and long-term survival course of disease when it comes to comparing the molecular constellation of primary and metastatic CRC. Accumulation of mutational changes, mostly mutations in PI3KCA and BRAF, is observed in poly-metastatic disease. In addition, high counts of GrzB+ T cell-subsets have been documented in the tumor core of the metastases with an oligo-metastatic disease .The Consensus Molecular Subtype (CMS) classification describes four CRC subtypes with distinct biological characteristics that show prognostic and potential predictive value in clinical setting . SeveralPreoperative chemotherapy usually induces various degrees of treatment response assessed histopathologically by attributing a tumor regression grade (TRG). Notoriously, TRG has shown poor interobserver agreement independent of which grading system has been used . The updOne study proposed that chemotherapy induces desmoplastic growth in patients with replacement type CRLM, based on higher incidences of desmoplastic HGP in patients who received preoperative chemotherapy compared with chemo-naive patients in a randomized phase III clinical trial . HoweverSeveral studies suggest that systemic therapies may interfere and change histological growth patterns of CRLM ,36,75,76In an Italian cohort, the replacement type was associated with local recurrence and a higher risk for margin invasion, suggesting that a wider resection margin (at least >1 mm) should be attempted in this setting . The autIn the last 10 years, multiple studies have looked at assessing HGP as a prognostic biomarker. These studies have included both untreated patients with resectable metastatic disease and patients with preoperative chemotherapy. In both chemo-naïve and in preoperatively treated patients, the desmoplastic pattern has consistently emerged as the HGP with the most favorable outcome. Furthermore, any amount of non-desmoplastic growth negatively impacts outcome. However, remarkable progress has been made in biomarker-driven therapies for unresectable metastatic colorectal cancer, supporting re-evaluation of these patients. In addition to chemotherapy regimens used in CRLM, biological agents such as anti-VEGF, anti EGFR-antibodies, multikinase inhibitors, and immunotherapy with checkpoint inhibitors in patients with microsatellite instability (MSI-H) are now treatment options for primarily non-resectable CRLM. Only a few studies have investigated the role of HGP in the era of new biological agents, leaving prospects for future clinical validation studies on patients treated with novel preoperative strategies. Currently, assessing histopathological growth patterns in CRLM provides information from a single time point in a selected group of patients with resectable/potentially resectable disease. In order to test the plasticity of growth patterns and identify optimal future treatments, a non-invasive, preoperative method that would allow determination of growth patterns at different timeframes is required. This would enable selection of patients with exclusively desmoplastic metastases for curative surgical resection alone, thus avoiding the undesirable side-effects of adjuvant chemotherapy. Moreover, patients with angiogenic desmoplastic growth pattern could be candidates for anti-angiogenic therapy in a neoadjuvant setting. Further insights in interactions between cancer cells and different components of the tumor microenvironment might be elucidated by single cell-RNA sequencing. This could provide a better understanding of particular cellular subsets with specific functions and spatial localization. Given the variation in the tumor immune microenvironment of each HGP, the selection of immunomodulatory therapy might need to be adapted to the growth pattern, resulting in treatment strategies for inoperable patients.As the field of digital pathology is expanding and many pathology services are becoming increasingly digitized, implementing machine learning and artificial intelligence-based algorithms may become an aid in assessing HGPs and even finding novel relevant clinicopathological features . Until nThe field of spatial transcriptomics will allow further exploration of the mechanisms, cell-to-cell interactions and temporal alterations noted from primary to metastases, the involvement and contribution of the tumor microbiome, and the effects of chemotherapy on a complexity scale hitherto not possible ,81,82. SIn order to better understand tumor biology and test treatment options specific to each HGP, patient-derived xenografts and organoids were obtained. Although with the lack of adaptive immune response, these will not deliver complete information about the immune microenvironment associated with the different growth patterns. However, patient-derived explants maintain both histological architecture and immune response generated in human tumors. Several novel avenues for research are to be explored , includiExtended evidence supports integrating HGP in the pathological assessment of CRLM. Adhering to current guidelines for scoring growth patterns is key, as standardized methodology and nomenclature enables studies on large patient cohorts on the biological mechanisms of HGP. Eventually, increased insight into the mechanisms of cancer biology may yield new avenues for targeted and tailored patient treatment in CRLM.


Autophagy is a process that degrades endogenous cellular protein aggregates and damaged organelles via the lysosomal pathway to maintain cellular homeostasis and energy production. Baseline autophagy in the kidney, which serves as a quality control system, is essential for cellular metabolism and organelle homeostasis. Renal fibrosis is the ultimate pathological manifestation of progressive chronic kidney disease. In several experimental models of renal fibrosis, different time points, stimulus intensities, factors, and molecular mechanisms mediating the upregulation or downregulation of autophagy may have different effects on renal fibrosis. Autophagy occurring in a single lesion may also exert several distinct biological effects on renal fibrosis. Thus, whether autophagy prevents or facilitates renal fibrosis remains a complex and challenging question. This review explores the different effects of the dual regulatory function of autophagy on renal fibrosis in different renal fibrosis models, providing ideas for future work in related basic and clinical research. Autophagy, first introduced in 1963 by Christian de Duve, is a Greek term meaning “self-eating” . From yeAutophagy is affected by a broad variety of factors, including extracellular factors such as nutrients in the outside world, ischemia and hypoxia, and concentration of growth factors, and intracellular factors such as metabolic stress, senescent or broken organelles, and misfolded or aggregated proteins. Because of the regular presence of these factors, cells maintain a low, basal autophagic activity to preserve self-stability. The level of autophagic activity is regulated by multiple signaling pathways, among which the mammalian target of the rapamycin (mTOR) pathway, AMP-activated protein kinase (AMPK) pathway, P53 pathway, acetylation modifications, phosphatidylinositol 3 kinase (PI3K)/protein kinase B  pathway, and p62 play key roles. mTOR negatively regulates autophagy , and mTONumerous studies have shown that autophagy is widely present in cells of various tissues in the human body and is significant for maintaining normal physiological functions of the heart, liver, kidney, and other organs . DysreguTherefore, autophagy has a dual role in preventing and exacerbating injury in most organs. In the kidney, autophagic activity is of great importance to maintain the stability, viability, and physiological function of the renal cellular internal environment . In expeFibrosis is a phenomenon in which organs and tissues such as the lung, heart, liver, kidney, and skin show an increase in fibrous connective tissue and a decrease in parenchymal cells. Long-term fibrosis can lead to organ and tissue hypofunction and even functional failure. Autophagy is involved in the occurrence and development of fibrotic diseases. The effect of induced autophagy on fibrotic diseases has been demonstrated in most organs . ReactivRenal fibrosis, characterized by excessive deposition of ECM in the glomerular and tubulointerstitial matrix, is a common pathological feature of progressive chronic kidney disease (CKD). The pathogenesis of renal fibrosis involves an extremely complex interplay of multiple cellular events, including fibroblast overproliferation and activation, increased ECM deposition, inflammatory cell infiltration, tubular atrophy, glomerulosclerosis, and sparse microvasculature . It is nThe effect of autophagy on renal fibrosis varies in different tissues and settings, with some studies suggesting that autophagy has a protective effect on cells  and otheAcute kidney injury (AKI), caused mainly by nephrotoxic drugs, renal ischemia–reperfusion (IR), and sepsis, is a major renal disease with poor clinical outcomes in both the short term  and long term (development of CKD and ESRD) . The patin vivo and in vitro models, autophagy occurs as a response to IR injury , a synthetic vitamin D analogue, has revealed that OCT + IR-injured rats exhibit significantly increased autophagy and reduced cell cycle block compared with IR-injured rats. Moreover, OCT may induce autophagy through the Janus kinase/signal transducer and activator of transcription (JAK/STAT) pathway–induced phosphorylation of the Bcl-2–Beclin-1 complex to activate autophagy , attenuaA recent study assessed autophagic activity during IR injury and recovery phases. Li et al. generated CAG-RFP-EGFP-LC3 mice under chicken b-actin control using the differential sensitivity of red fluorescent protein  and enhanced green fluorescent protein  to pH, so as to distinguish between early autophagic vesicles and autolysosome . BecauseNormal EPO/EpoR signaling in renal tubules is involved in the regulation of tubular autophagic flux; high EpoR activity in the kidney reduces AKI in the acute phase; and low EpoR activity makes IR injury more likely in the acute phase. Upregulation of EPO/EpoR signaling pathway in the early phase can reduce renal injury, and downregulation of EPO/EpoR signaling after the acute phase can reduce autophagic flux, maintain autophagy–apoptosis balance and peritubular capillary integrity, and promote recovery from renal injury, thereby inhibiting renal fibrosis . These rIn IR injury models, autophagy enhances cell survival during initial tubular injury as a response to AKI, but hinders normal repair during reperfusion. The long-term pro-fibrotic effect of autophagy may be due to its cytoprotective role. Activation of autophagy in response to AKI helps delay the progression of renal fibrosis in most cases, while defective autophagy during the recovery period after injury may promote renal tubular cell reparation to improve renal fibrosis. In addition, the specific timing and extent of autophagy activation after IR injury may either promote or prevent the progression of renal fibrosis; the specific regulation depends on the activation factors and the different signaling pathways .To date, most studies on the role of autophagy in renal interstitial fibrosis have been performed using the unilateral ureteral obstruction (UUO) model. UUO is currently a more classical animal model of renal interstitial fibrosis , which cSeveral studies have proposed that autophagy has antifibrotic effects in UUO-associated renal fibrosis. Autophagy decreases ECM deposition and renal tubular atrophy, thereby reducing the extent of renal fibrosis . ValproiInterestingly, the activation of autophagy in UUO model renal interstitial of myofibroblasts promotes the progression of fibrosis. Protein kinase Cα (PKCα) is one of the major subpathways of mTORC2, and the Rictor/mTORC2 signaling pathway is involved in TGFβ1-induced fibroblast activation and renal fibrosis . PreviouIn addition, recent studies have revealed a profibrotic role of autophagy downregulation or defect in UUO-associated renal interstitial fibrosis. Using a proximal tubule-specific ATG5 knockout mice model, Li et al. proposed that autophagy deficiency promotes G2/M cell cycle block and accelerates renal interstitial fibrosis after UUO . A recenin vitro. OI ameliorates renal fibrosis by inhibiting activation of the TGF-β/Smad and nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) pathways, reducing ROS production and inhibiting autophagy  and wild-type (WT) C57BL/6 mice UUO. Rab7 is involved in the formation and transport of autophagosomes and subsequent fusion with lysosomes . The expOverall, in UUO-induced renal fibrosis, the improvement of fibrosis by upregulation of autophagy is mainly manifested by the inhibition of inflammatory signals during fibrosis, degradation of the cellular matrix and regulation of the cell cycle by autophagy. The pro-fibrotic effect of autophagy is mainly due to the shrinkage of tubules and lipid accumulation caused by sustained activation. Differences in the mode of induction to autophagy and the timing of autophagy activation, the molecular mechanisms mediated and the signal pathways, result in a possible dual role of autophagy in the regulation of renal fibrosis. Sustained activation of autophagy may lead to tubular atrophy and thus promote renal fibrosis, whereas autophagy-mediated degradation of excess collagen may prevent fibrosis .Diabetic kidney disease (DKD) is a glomerular disease, and tubulointerstitial fibrosis (TIF) always occurs early in DKD . TIF is in vitro and in vivo, which can be abrogated by selective AMPK inhibitors and ERK activators. It has been suggested that Klotho exhibits its effects in renal protection by activating autophagy in renal tubular cells through AMPK and ERK pathways and participating in the fibrotic process  is an herbal plant from China. Triterpenic acids-enriched fraction from CP (CPT) increases AMPK phosphorylation and decreases phosphorylation of its downstream effector mTOR, which in turn activates autophagy and improves thylakoid stromal fibrosis -52E cells, overexpression of miR-22 inhibits autophagic flux and induces expression of Col IV and α-SMA, leading to increased renal fibrosis . Under hIn summary, autophagic integrity is critical for cellular homeostasis and its alteration can lead to cellular damage or death. DKD is associated with severe dysregulation of autophagy. In DKD models with the same pathways mediating autophagy, differences in the inducing factors may result in activation or inhibition of autophagy, which in turn exerts a mitigating effect on renal fibrosis. Furthermore, the same type of factor-induced autophagy may bring about activation or inhibition of autophagy owing to differences in the molecular mechanisms and signaling pathways that mediate autophagy. Therefore, we may infer that the regulatory role of autophagy in renal fibrosis may be bidirectional in the DKD model .+ T cell proliferation, and increases the percentage of regulatory T cells in an autophagy gene-dependent manner. These results emphasize the role of autophagy in reducing the post-injury inflammatory response and maintaining proximal tubular cell self-tolerance, both of which contribute to the amelioration of renal fibrosis , podocytes and glomerular endothelial cells (GEC). Renal tubular epithelial cell injury is a central event in the pathogenesis of CKD . RECT auhropathy . Howeverhropathy . Using afibrosis . These rfibrosis . On the fibrosis . These rfibrosis . TherefoAutophagy plays an important role in maintaining podocyte homeostasis, and its dysfunction may be associated with the renal fibrosis process. Clinical and experimental evidence suggests that dysfunction of the autophagy-lysosome pathway leads to severe podocyte injury, podocyte loss, massive proteinuria, and renal fibrosis . In addiThrough the above study we found that both high or low autophagy in RTEC and GMC may play a role in protecting renal fibrosis. Knockdown of different autophagy genes, or defective autophagy in different segments of RTEC, may lead to different renal fibrosis outcomes. However, autophagy in podocytes and GEC plays a predominantly protective role in maintaining cellular integrity and inhibiting renal fibrosis. They do so mainly through intercellular synergism, modulation of relevant signaling pathways, and regulation of relevant cellular processes. In addition, there are fewer studies related to the role of autophagy in other kidney resident cells as well as in infiltrating cells in promoting or inhibiting renal fibrosis.in vivo models of acute and chronic kidney injury, the role of autophagy in renal fibrosis is multifaceted. Depending on the experimental conditions, autophagy may be protective or detrimental. In IR injury models, activation of autophagy slows the progression of renal fibrosis in most cases, but defective autophagy later in the course of the disease may contribute to ameliorate renal fibrosis. In the UUO model, differences in how autophagy is induced also produce different regulatory outcomes in renal fibrosis. In the DKD model, different inducers of the same pathway may activate or inhibit autophagy and exert a mitigating effect on renal fibrosis. Moreover, in different experimental models of renal fibrosis, differences in injury methods, cell types, the timing and intensity of autophagy induction, and the diversity of signaling molecular mechanisms lead to contradictory effects of autophagy on renal fibrosis (Autophagy is an evolutionarily conserved degradation process whose basal level plays a critical role in the stability of the internal environment. The role of autophagy in the pathogenesis of renal disease may be multifactorial and complex, and its biological effects can differ considerably depending on the pathological location of the diseased tissue. From the above findings discussed in this review, it is clear that autophagy is a double-edged sword. Based on fibrosis . TherefoA large body of evidence supports an important role for autophagy in renal physiology and pathology. Despite these advances, many unanswered questions remain. For example, while studies have now reported negative regulation between autophagy and some classical pathways in the kidney, whether there is positive regulation remains to be further explored. It is well known that autophagy plays different roles in different diseases or stages of the same disease, and whether the differential mediating autophagy triggers play different roles on renal fibrosis in different periods of renal disease, such as early, middle and late stages, needs to be further elucidated. In addition, at this stage, some animal and cellular experimental studies have demonstrated that drugs can reduce renal fibrosis by regulating autophagy, but whether they can be extended to clinical treatment remains open. In many cases, autophagy may interact with other cellular processes to influence the development of renal disease, and it is also important to investigate such interactions and the regulatory mechanisms involved. Additionally, the evidence supporting autophagy malfunction in renal illnesses that is now available comes from hypothesis-driven research and is still absent from unbiased studies like omics research.Autophagy is a dynamic process, and it is difficult for a single regulatory mechanism to complete this complex process, and the organism works through a complex regulatory network to maintain orderly intracellular autophagy. Therefore, the complex connection between autophagy and multiple signaling molecules should be considered synergistically from multiple targets. At present, it is not clear how autophagy affects renal fibrosis through signaling molecule interactions in a dynamic equilibrium. It is believed that through more detailed studies of the autophagic process in the future, multi-targeted intervention of autophagic signaling pathways, intermittent control of autophagic activation time and intensity, and constant changes of autophagy-inducing factors can be achieved to control autophagy in a moderate range, and targeted autophagy will become a new strategy for delaying renal fibrosis.


This paperoutlines the arguments for why PAC should remain as the standard of care in AL, instead ofswitching to twice-weekly SBM. Arguments put forward in favour of PAC are the strength ofevidence for its safety, cost-effectiveness and adaptability, and its adoption by multipleinternational guidelines as standard of care. The potential implications of PAC for druginteractions and antifungal resistance are also discussed. The drawbacks of twice-weeklySBM are appraised, including missed or delayed diagnoses, unnecessary investigations,deferral of systemic anti-cancer therapy and increased pressure on laboratoryservices.Primary antifungal chemoprophylaxis (PAC) is the widespread strategy of choice for theprevention of invasive fungal disease in patients with acute leukaemia (AL). Twice-weeklymonitoring of the serum biomarkers (SBM) galactomannan and 1,3-β- This paper argues that twice-weekly serumbiomarker monitoring (SBM) with GM and BDG should not replace PAC as the primary IFDprevention strategy in AL.Individuals undergoing systemic anti-cancer therapy (SACT) for acute leukaemia (AL) are athigh risk of developing invasive fungal disease (IFD), a group of infections associated withsignificant morbidity and mortality.5 Mould-active PAC was subsequently shownto be even more efficacious than fluconazole for this indication, demonstrating theimportance of a PAC agent with activity against both Candida species andmoulds in vulnerable patients.7 The diagnostically challenging nature ofIFD means that it cannot be known with certainty whether these findings apply to allcentres, as the incidence of IFD in AL may vary geographically, and true IFD rates aredifficult to establish without widespread use of post-mortem diagnosis. Given the severeconsequences of IFD, however, current evidence suggests that PAC should be regarded as thepreferable option unless reliable, well-powered local data prove otherwise.The evidence to date well illustrates the spectrum of threats that IFD presents to patientswith haematological malignancy and HSCT, and the efficacy of PAC in combating them. Whendeployed in randomized controlled trials, fluconazole PAC significantly reduced theincidence of IFD and associated mortality in neutropenic cancer patients and bone marrowtransplant recipients.8–10 Therapeutic drug monitoring (TDM) is also available in most developedhealthcare settings either locally or via a regional reference laboratory to help optimizeeffectiveness and prevent concentration-dependent therapeutic failure. Economic analyseshave revealed posaconazole PAC to be cost-effective, an effect driven by avoidance oftreatment costs and increased length of hospital stays associated with IFD.11 Potentially severe drug interactionscan prevent concomitant use of posaconazole with some SACT agents such as vincristine anddasatinib, but echinocandins, polyenes and isavuconazole are alternative PAC options withevidence for their efficacy.12–15 An increased global focus on antifungal stewardshipmeans that the question of whether PAC could increase the prevalence of antifungal-resistantorganisms is relevant. Importantly for antifungal stewardship programmes, however, thelimited evidence that does exist for increasing triazole resistance is both conflicting andprone to reporting bias.16–18 When breakthrough IFD on prophylaxis is suspected, diagnosis isparticularly challenging because the presence of PAC is likely to reduce the sensitivity ofserum fungal biomarkers.19 Giventhe extensive experience of most centres in using PAC, however, diagnostic algorithms oftenaccount for this by using pre-emptive, fever-driven treatment approaches.Posaconazole is now, therefore, the most widely used PAC agent in AL and HSCT. The agent iswell absorbed and well tolerated following oral administration and serious adverse eventsare rare.20Diagnostic accuracy of serum GM in immunocompromised patients varies with optical densityindex (ODI) cut-off; 0.5 ODI yielded 82% and 81% sensitivity and specificity, respectively;1.0 yielded 72% and 88%; 1.5 yielded 61% and 93%.21 Deployment of the tests in parallel as twice-weekly SBMmay improve overall performance, but combining them is under-studied in this cohort, and isstill likely to result in missed diagnoses. This is as much due to test design asperformance; serum GM does not detect Candida and neither test detectsMucorales22 Conversely, falsepositives are likely to result in unnecessary delays to crucial SACT,23 and unnecessary investigationsexposing the patient to ionizing radiation through CT scanning or invasive procedures likebronchoscopy.In patients with cancer, the accuracy of serum BDG and GM for diagnosis of IFD have variedin meta-analyses owing to the significant heterogeneity of included studies. The bestsensitivity and specificity outcomes for serum BDG in meta-analysis of IFD diagnosis havebeen 80% and 63%, respectively.24 Clinical pressures may also favour the use of PAC; asclinical pressures on healthcare systems continue to increase with population, earlydischarge of stable but vulnerable patients may be a necessity. In that scenario, clinicalteams may be reluctant for patients to be discharged or managed at home without cover forenvironmental fungal pathogens that are more abundant in the community.25The utility of SBM is also likely to be limited by laboratory resource pressures,particularly given that a strategy of SBM is likely to increase the number of BDG and GMtests being requested. Many local microbiology laboratories rely on transporting samples toregional reference mycology laboratories for such tests, a process that incurs additionalcost, prolonged turnaround time and inefficiency. Even where such tests are offered inhouse, laboratories are under increasing clinical pressure to deliver a range of tests thatcompete for staff time and resources. The overall outcome in both scenarios is increasedturnaround times, potentially negating the benefit of early detection and missing theopportunity to implement timely antifungal treatment.There is an evidence base for the cost-effectiveness of BDG as an antifungal stewardshiptool, with savings predominantly driven by minimizing antifungal use. This evidence,however, pertains to enabling earlier discontinuation of pre-emptive antifungal treatmentrather than as an alternative to PAC. It is therefore unknown whether the pharmacy saving ofreducing PAC prescribing would be sufficient to offset increased laboratory costs inaddition to the investigation, management and prolonged hospitalization of patients with IFDmanaged reactively rather than preventatively.Preventing IFD using PAC has proven to be a safe, cost-effective and adaptable strategy inneutropenic patients with haematological malignancy and/or bone marrow transplant, with astrength of evidence reflected by its support in international guidelines. Replacing PACwith twice-weekly SBM in AL may expose patients to increased risk through missed or delayeddiagnoses, unnecessary investigations and deferral of SACT, as well as putting increasedpressure on laboratory services already experiencing unprecedented demand. The strategy isalso yet to be proven to be cost-effective or to reduce the selection of antifungalresistance, and it is less practical for patients being managed in the community. Patientswith AL should continue to be administered PAC to prevent IFD instead of twice-weekly serumGM and BDG monitoring.