Exosomes are a typical subset of extracellular vesicles (EVs) that can be transmitted from parent cells to recipient cells via human bodily fluids. Exosomes perform a vital role in mediating intercellular communication by shuttling bioactive cargos, such as nucleic acids, proteins and lipids. Long noncoding RNAs (lncRNAs) are transcripts longer than 200 nucleotides without protein translation ability and can be selectively packaged into exosomes. Accumulating evidence indicates that exosomal lncRNAs have a critical role in tumor initiation and progression through regulating tumor proliferation, apoptosis, invasion, metastasis, angiogenesis, treatment resistance and tumor microenvironment. Increasing studies suggest that exosomal lncRNAs have great potential to be served as novel targets and non-invasive biomarkers for diagnosis and prognosis in non-small cell lung cancer (NSCLC). In this review, we provide an overview of current research on the disordered functions of exosomal lncRNAs in NSCLC and summarize their potential clinical applications as diagnostic and prognostic biomarkers and therapeutic targets for NSCLC. Lung cancer is one of the most common malignancies and the leading cause of cancer related death around the world with more than 2 million new patients and 1.76 million deaths annually Extracellular vesicles (EVs) are a kind of small membrane vesicles with phospholipid bilayer structure Fig. 1. For the first step, the cell membrane sinks inward and forms vesicles carrying substances from the cell surface and extracellular space. The vesicles then fuse with a cell structure named early endosome and move along special protein tracks As one of the main types of EVs, exosomes can be released by a majority of cells and play critical roles in cell-to-cell crosstalk under diverse pathophysiological conditions Exosomes are a fascinating new research field attracting the attention of many researchers. It was originally thought that exosomes were used to remove unwanted waste produced by cells Fig. 2.lncRNA research is a rapidly expanding field of genomics. lncRNAs are a large and diverse class of RNA transcripts longer than 200 nucleotides in length and hardly translated into proteins The most well-known mechanism of lncRNA-mediated chromatin architecture regulation and chromatin remodeling is related to dosage compensation. lncRNA Xist can recruit various proteins in an orderly manner during the early stage of embryonic development, triggering gene repression of the entire X chromosome, which ultimately leads to chromosome condensation into an inactive Barr body lncRNA is capable of regulating the stability of mRNA through diverse mechanisms to affect mRNA expression level. For example, lncHUPC1 functions as competitive endogenous RNAs (ceRNAs) to absorb miR-133b, thereby regulating SDCCAG3 expression in prostate cancer lncRNA is also involved with translation regulation and post-translational regulation Fig. 3 and Table 1.lncRNA can modulate biological activities of recipient cells by being transferred in the form of exosomes. Accumulating evidence indicates that dysfunctions of exosomal lncRNAs occur in a variety of malignancies, which is involved with tumor growth, progression, angiogenesis, and therapy resistance. It is of importance to comprehend the underlying mechanisms how exosomal lncRNAs function to regulate tumor development. In this section, we specially discuss about the dysfunctions of exosome-derived lncRNAs in NSCLC and potential molecular mechanisms, as shown in The promoting function of lncRNA-contained exosomes on tumor proliferation has been widely reported. For instance, exosomes derived from serum samples of NSCLC patients are enriched in metastasis-associated lung adenocarcinoma transcript 1 (MALAT-1) Invasion and metastasis are critical phases of cancer progression, contributing to cancer mortality in diverse mechanisms Angiogenesis is an important condition for tumorigenesis, growth and progression. Increasing evidence shows that exosomes from tumor cells participate in regulating tumor angiogenesis through diverse mechanisms With the in-depth research of tumor-related mechanisms and the development of cancer treatment, tumor targeted therapy has become a hot spot, the application of which in NSCLC patients has achieved notable efficacy. However, acquired resistance to tumor targeted therapy inevitably occurs after initial effective response, leading to inferior therapeutic effect and poor prognosis lncRNA H19 is a widely accepted oncogene in multiple cancers. Its role in NSCLC targeted therapy resistance has been evaluated, which indicates that H19 can act as a facilitator of resistance to gefitinib, a representative first-generation tyrosine kinase inhibitor, by hnRNPA2B1-mediated incorporation in exosomes Tumor microenvironment (TME), a complex integrated system which is composed of tumor cells, inflammatory cells, immune cells, stromal cells, other cellular components and non-cellular components Tumor-associated macrophages (TAMs) are the main tumor-infiltrating immune cells, which are usually induced by tumor cells to promote tumor immune escape, tumor growth, metastasis, drug resistance and angiogenesis Table 2.Although tissue biopsy is the gold standard for NSCLC diagnosis in clinical practice, the method has several limitations, such as tissue volume, repeatability and inability to characterize tumor heterogeneity, resulting in a lack of an accurate and complete disease status diagram Due to remained poor prognosis of NSCLC patients, early diagnose of NSCLC before major clinical events is of great importance, which can effectively reduce the related mortality. Several exosomal lncRNAs have been demonstrated as novel diagnostic biomarkers in NSCLC. Compared with healthy controls, serum exosomal lncRNA GAS5 is significantly downregulated in NSCLC patients, and its low expression is associated with advanced TNM stage and larger tumor size of NSCLC patients Exosomal lncRNA TBILA and AGAP2-AS1 are suggested as potent biomarkers for diagnosing NSCLC Lung squamous cell carcinoma (LSCC) is one of the pathological types of NSCLC. Exosomal SOX2-OT appears to be a reliable biomarker for LSCC diagnosis. Teng et al. indicate that the expression level of exosomal SOX2-OT is significantly upregulated in plasma of LSCC patients and descended after surgical resection of LSCC patients Overall, all these findings suggest that exosomal lncRNAs are a class of promising biomarkers for NSCLC diagnosis. More research is needed to confirm the diagnostic value of these molecules before real clinical application.Han et al. estimate the clinical potential of exosomal lncRNA SNHG15 for early diagnosis and prognosis of NSCLC In conclusion, exosome-derived lncRNAs have great potential in providing new insights into NSCLC diagnosis and prognosis dependent on liquid biopsy. Although the current understanding of exosomal lncRNAs-related liquid biopsy is more in-depth than before, molecular research, large-sample multicenter retrospective and prospective studies are still warranted to verify its clinical value. Of note, the final cut-off value of exosomal lncRNA also needs to be further clarified.Although chemotherapy following surgical resection remains a standardized treatment for NSCLC, the overall survival of patients with advanced NSCLC has not been prolonged. Thus, it is necessary to explore novel therapeutic approach. Emerging evidence confirms that exosome-derived lncRNAs play vital roles in mediating targeted treatment of NSCLC, indicating the potential of exosomal lncRNAs as therapeutic targets for NSCLC. lnc-MMP2-2 contained in TGF-β-mediated exosomes promotes the invasion and migration of NSCLC by regulating MMP2 expression, and enhances the brain metastasis of NSCLC by increasing BBB permeability, suggesting that exosomal lnc-MMP2-2 may be a novel therapeutic target for NSCLC treatment In contrast to free lncRNAs in the circulating system, lncRNAs loaded into exosomes are more stable and freer from the degradation by RNA enzymes. Exosomes wrapped by lipid bilayer membranes which is capable of protecting the loaded drugs from degradation can be considered as natural drug delivery carriers First, it is difficult to isolate exosomes from human body fluids. So far, there is still no standardized technique for exosome isolation in a high purity and efficient manner, and the core challenge mainly comes from high heterogeneity in size of exosome Exosomal lncRNAs can be decorated to carry specific sequences or molecules functioning as tumor suppressors, achieving precise treatment of NSCLC with the assistance of nanotechnology, which has great clinical application potential. However, the therapeutic efficiency and safety of exosomal lncRNAs-mediated drug treatment system in NSCLC have not been fully investigated. Once injected into the human body, exosomal lncRNAs may cause cytotoxicity, which involves major safety issues Although a variety of exosome-derived lncRNAs have been proved to play a crucial role in the occurrence and development of NSCLC, there is still a lack of large-scale prospective studies In recent years, remarkable progress in our understanding of exosome-derived lncRNAs has been made, and a clearer landscape of the characteristics and versatile functions of these molecules is emerging. Tumor-related regulatory processes, non-invasiveness, and real-time assessment of tumor status endow exosomal lncRNAs with considerable potential as reliable diagnostic biomarkers and for dynamic monitoring of disease progression and therapeutic intervention. In this review, we primarily summarize the dysfunctions and clinical value of exosomal lncRNAs in NSCLC, and highlight the main challenges that hinder their clinical application. In fact, only a small fraction of exosome-derived lncRNAs have been studies. Therefore, more rigorous research is needed to elucidate how exosomal lncRNAs affect the complicated physiological processes in NSCLC, so as to more comprehensively understand their acting patterns. Addressing relative challenges in the coming years will bring robust diagnosis and prognosis, effective and precise treatment associated with optimal outcomes of NSCLC patients, in an exosomal lncRNAs-dependent manner.


To review recent international and domestic definitions, considerations, and treatment algorithms for statin intolerance, and specifically, statin-associated muscle symptoms (SAMS).Multiple organizations around the world have produced guidance documents to aid clinicians on managing statin intolerance. A common theme resides among all the guidance documents that most patients can tolerate statins. For those patients who cannot, healthcare teams need to evaluate, rechallenge, educate, and ensure adequate reduction of atherogenic lipoproteins.Statin therapy remains the cornerstone of lipid-lowering therapies to reduce atherosclerotic cardiovascular disease (ASCVD) and reduce mortality and morbidity. The common theme throughout all these guidance documents is the importance of statin therapy to reduce ASCVD and continual adherence to treatment. Because adverse events occur and inhibit patients from achieving adequate lowering of their atherogenic lipoproteins, trial and rechallenge of statin therapy, as well as addition of non-statin therapies, especially in high-risk patients, is also undisputed. The main differences stem from laboratory monitoring and the classification of the severity of the adverse effect. Future research should focus on consistently diagnosing SAMS so that these patients can be easily identified in the electronic health records. Reducing levels of atherogenic lipoproteins has been shown to decrease risk of clinical atherosclerotic cardiovascular disease (ASCVD). Statin therapy remains the cornerstone of lipid-lowering therapy and is generally well tolerated; however, occasionally patients experience adverse effects, often called statin-associated muscle symptoms (SAMS). These symptoms include, but are not limited to, muscle pain, weakness, cramps, and fatigue. The incidence of these symptoms has been reported to be as high as 5-30% in the literature –3. In clThis review provides an overview of statin intolerance guidance documents from Latin America, Europe, Canada, and the USA. Table In 2016, the Luso-Latin American Consortium (LLAC) released a consensus definition, and guidance on the management of SAMS (Table The guidance reports the seven SAMS standards (SAMS 0 to SAMS 6) ranging from asymptomatic increases in creatinine kinase (CK) < 4× upper limit of normal (ULN) to necrotizing autoimmune myositis [The LLAC endorses that for all patients with CK elevations and/or muscle symptoms, the highest tolerated dose of statins should be kept, and ezetimibe should be the first therapeutic addition. If statin and ezetimibe therapy is insufficient to achieve specific lipid targets, complementary therapy with bile acid sequestrants, fibrates, or phytosterols may be considered. However, the LLAC does not endorse either the use of niacin as add-on lipid-lowering therapy or intermittent statin dosing. The LLAC noted that variability in low-density lipoprotein cholesterol (LDL-C) with intermittent statin dosing was associated with increased cardiovascular mortality and therefore found the recommendation inadequate. This guidance was published prior to the outcome data for proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibodies.Patient centeredness has been a central component of managing SAMS, especially when attempting to avoid the “nocebo” effect to prevent negative expectations and to counter existing bias. The LLAC guidance references that previous studies have shown that the “nocebo” effect is attenuated when multiple choices of treatment are made available to the patient, and patients are given the opportunity to choose the option they most prefer. The LLAC was effectively able to detail SAMS, while providing guidance to maximize statin adherence and mitigate the risk of muscle injury.In 2015, the European Atherosclerosis Society (EAS) Consensus Panel released recommendations for assessing, evaluating the cause of, and managing patients with SAMS  goals, then other additional therapies should be employed. The panel suggests a vegetarian diet, ezetimibe, nutraceuticals including psyllium and plant stanols, bile acid sequestrants, and fibrates. This guidance was published prior to the outcome data for proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibodies. This guidance discusses the possible underlying pathophysiological causes of SAMS. While current research indicates that it is possible statins decrease mitochondrial function, attenuate energy production, and alter muscle protein degradation, the EAS Consensus Panel suggests that further research into the pathophysiology of SAMS could present new therapeutic potential •.In 2017, the EAS Consensus Panel provided an update to their statement on SAMS, where they further stressed the importance of allocating adequate time to managing patients at high risk of cardiovascular events who are also experiencing muscle symptoms . Time isIn 2016, the Canadian Consensus Working Group (CCWG) published a comprehensive statin-intolerance definition that integrates a practical concept of “goal-inhibiting statin intolerance” (GISI)  as a phenomenon in patients who do not achieve expected benchmarks of lipid lowering through the use of maximally tolerated statin doses. The differentiation of these terms helps explain when a lack of statin efficacy (GISR) prevents achievement of lipid-lowering goals, whereas situations when patients do not reach lipid-lowering benchmarks due to statin-associated adverse effects are defined as GISI. Figure Common throughout the CCWG statement is the theme of establishing trust with patients during the entirety of assessment for statin use and subsequent management. The first pillar to goal-inhibiting statin intolerance management is identifying and explaining the strong indications that exist for statin use. Once indication for therapy is established, the group emphasized the importance of understanding risk factors that may predispose patients to experience statin-associated adverse effects and limit statin use, while continually integrating lifestyle modification goals into the overall management of the patient. Non-modifiable risk factors that may predispose patients to statin-associated adverse effects include ages above 80 years old, female sex, family history of myopathies with or without statin therapy, and Asian ethnicity •. ModifiIn 2014, the National Lipid Association (NLA) created a definition of statin intolerance that included the concept of “real or perceived,” which at the time, was missing from other definitions . In 2022The guidance further described other therapeutic options to decrease atherogenic lipoproteins. As well as described the “nocebo” effect as a possible reason for intolerance, however, according to the writing group, should not be a reason to delay additional therapy, especially in high-risk patients. However, once additional therapy is initiated, finding a tolerable statin regimen should still be a goal of care, as complete statin intolerance is very rare.In 2022, the NLA published a guidance on SAMS ••. It deAn overview of the similarities and differences among the statin intolerance guidance documents is available in Table The common theme throughout all these guidance documents is the importance of statin therapy to reduce ASCVD and continual adherence to treatment. Because AEs occur and inhibit patients from achieving adequate lowering of their atherogenic lipoproteins, trial and rechallenge of statin therapy, as well as addition of non-statin therapies, especially in high-risk patients, is also undisputed. The main differences stem from laboratory monitoring and the classification of the severity of the adverse effect. A common theme resides among all the guidance documents that most patients can tolerate statins. For those patients who cannot, healthcare teams need to evaluate, rechallenge, educate, and ensure adequate reduction of atherogenic lipoproteins.


Nanotechnology is the use of materials that have unique nanoscale properties. In recent years, nanotechnologies have shown promising results for human health, especially in cancer treatment. The self-assembly characteristic of RNA is a powerful bottom-up approach to the design and creation of nanostructures through interdisciplinary biological, chemical and physical techniques. The use of RNA nanotechnology in therapeutics is about to be realized. This review discusses different kinds of nano-based drug delivery systems and their characteristic features. A branch of nanotechnology called RNA nanotechnology involves designing, studying, and utilizing synthetic structures based on RNA. This review discusses different kinds of nano-based drug delivery systems and their characteristic features. It aims to provide an overview of nanoparticles as a delivery system for gene therapy to treat diseases such as cancer. In order to enhance nanoparticle efficacy, these systems should be designed with this in mind in order to develop and test delivery systems rationally and scientifically. There is a broad spectrum of nanoparticles (NPs) with dimensions ranging from 1 nm up to 100 nm that have emerged as an amazing class of materials. The physical and chemical properties of nanoparticles have made them useful in a wide range of scientific and technological applications. Advanced nanotechnology is often considered a universal technology due to its potential to impact almost all aspects of society and industries significantly. Its impact is significant in medicine, healthcare, biotechnology, and information technology . This arMany NPs had been developed based on fatty components. NPs formed of solid fat and named solid lipid nanoparticles (SLNs) are fat-based colloidal mixture systems with a solid pattern at the body temperature. Lipid-based NPs, often known as lipid nanoparticles (LNPs), are a subclass of organic NPs. They consist of at least one lipid bilayer encircling at least one interior aqueous compartment, and are typically spherical platforms. As a delivery vehicle, lipid-based NPs have a number of benefits, such as easy formulation, self-assembly, biocompatibility, high bioavailability, capacity for large payloads, and a variety of physicochemical properties that can be tuned to influence biological features. LNPs, which differ from conventional liposomes in that they form micellar structures within the particle core and can have different morphologies depending on the formulation and synthesis conditions, are frequently utilised for the transport of nucleic acids. The most prevalent class of FDA-approved nanomedicines is lipid-based NPs . The comMany polymer-based NPs (PNPs) have been used to fabricate self-assembled polymer-based NPs as delivery systems. The use of nanotechnology in the medical profession is known as nanomedicine, and it involves the use of nanoparticles with sizes in the nanoscale range. As a field of study in science, drug delivery systems are becoming more and more significant. Polymers are increasingly being used more frequently, and controlled-release systems and drug-targeting systems offer an alternative to conventional delivery nanoparticles . They caAnother polymer type is the organic polymers or biopolymers. Living species generate those polymers and are made of proteins and polysaccharides that make them biocompatible and non-immunogenic . ProteinA very well-known polymer-based gene carrier is the Chitosan–DNA complex NPs. Cationic polymers like chitosan can manage the release of antibiotics, proteins, deoxyribose nucleic acid, vaccines or proteinaceous drugs. These abilities enabled cationic polymers to be used in the pharmaceutical industry and research. Cationic polymers have also been studied extensively as non-viral deoxyribose nucleic acid vectors for genetic transmission and medication. Chitosan can make firm electrostatic interconnections with deoxyribose nucleic acid and anionic mucosal surfaces. The adhering proficiency of chitosan depends on its de-acetylation degree and molecular mass. Some studies reported that some chitosan grades could be utilized for organic approaches such as immunization .A type of radially symmetric, nanoscale molecules known as dendrimers have a distinct, homogenous, and monodisperse structure. They have an exterior shell, an inner shell, and a center that is normally symmetric. Several dendrimers are effective delivery or carrier systems for medicines and genes because they have intrinsic pharmacodynamic characteristics. However, some dendrimers' cytotoxicity prevents them from being used in medicine. Unlike most linear polymers, dendrimers can be synthesized with a degree of control that yields essentially monodisperse, globular macromolecules with a significant number of peripheral groups. Numerous uses for dendrimer prodrugs can be found in developing novel medications . Dendrim2) as well as semiconductors like silicon and ceramics are examples of inorganic-based nanomaterials. Inorganic NPs are employed in a variety of applications including catalysis, water treatment, medicine, electronics, agriculture, chemical catalysis, the food industry, and many more because of their special qualities. Additionally, some metal NPs have special thermal, magnetic, and biological characteristics, making them valuable building blocks for nanodevices with a variety of physical, chemical, biological, medicinal, and pharmacological uses  oxide (FeO), and magnetite ferrosol ferric oxide (Fe3O4)  oxide (Fe (Fe3O4) . SPIONs  (Fe3O4) . To prevum salt) .Semiconductors incorporate NPs are tiny nanoscale crystals of magnitude ranging from 1 nm to hundred nanometers . Mainly In vitro gene silencing has been achieved with high efficiency and particularity using various interface techniques and ribonucleic acid molecules; however, in vivo, the proficient transmission of medicinal ribonucleic acids to particular cells still faces obstacles.Recently, several kinds of clinical ribose nucleic acid NPs have been produced and extensively investigated for their potential use in diverse disease management. The polyvalent ribonucleic acid NPs represents a delivery system that is characterized by the elasticity for making polyvalent transmission machines that can transmit up to six different types of molecules to particular cells involving drugs, analytical molecules or therapeutics . In thisDelivery of the drug to a diseased tissue through NP technology mainly depends on the nanometer range particle size of the formed system . AccordiSome answers and prospects are provided herein for the diversity of problems involving synthetic and thermal behaviours uncertainty, short biological half-life, low productivity and expensive manufacturing techniques, possible adverse effects, and a breakout of endosomes .in vivo was not a priority due to fine-tuning that makes a difference in looking for an area that can be adjusted with negligible inconvenient impact. Besides, it has appeared that vulnerable sites where RNA degradation in serum occurs are frequently fine-tuned by mutation or alteration ; modification of the C at two prime  , capped teration .The debasement of medicinal compounds within the passage of endocytosis is a major issue in DNA or protein delivery. Endosomal escape is the most significant obstacle in the ligand-based cellular capture for particular transmission of small interfering ribonucleic acid or clinical ribonucleic acid NPs Oligomerization properties of promoter-associated RNAs (pRNAs) can move the conveyance of clinical compounds in forming a network with endosome debating operators, which can disturb endosomes and consequently intercede endosome elude of therapeutic molecules. Imperfect or psoralene-unfunctional adenovirus components have significant endosomatic action . PolymerThere are several strategies to help endosomal elude. These strategies incorporate the utilization of chemically prepared polymers to make small interfering ribonucleic acid or polymer polyplex, the linking of small interfering ribonucleic acid with fats to make NPS of fat or the small interfering ribonucleic acid affiliation with the proteinaceous material that pierce cells (cell-penetrating peptides) or synthetic material that disturb membrane-bound vesicles (endosomes). The arrangement of small interfering ribonucleic acid or polymer polyplex for discharge from endosomes and genetic quieting effectiveness has design considerations that have been, as of late, checked ,48.Regarding acid-splittable binders, the positively charged end of the polymer's multiplexes gained protonation beneath the impact of pH <7 of the membrane-bound vesicle (endosome). Consequently, the membrane-bound vesicle (endosome) is destabilized, employing the proton sponge impact. In addition, the acid hydrolysis followed by the loss of the cationic branches comes about within the decreased interconnections between small interfering ribonucleic acid and polymer, which in turn, leads to the discharge of the small interfering ribonucleic acid for endoribonuclease dicer or helicase processing .Cell penetrating peptides [CPPs] speaks to other technique for small interfering ribonucleic acid transmission and disordering of endosomes. Since CPPs ordinarily convey small interfering ribonucleic acid into the cells in a similar pathway as small interfering ribonucleic acids or polymer polyplex and NPs containing fat. After interaction with negatively charged small interfering ribonucleic acid, positively charged proteinaceous material carries siRNA beside them and enters the cell through endocytosis. Amphipathic peptides procured the most centre for nucleic acid delivery because they are brief and contain a large number of histidine and leucine buildups.  They allA later report examined the pH reliance of endosome elude employing an economically accessible peptide (having properties of both polar and non-polar components) called endo-porter that has been utilized to provide various contents of nucleus material (DNA and RNA) to the cells of mammals . Endo-poin vivo [Despite their various sorts, there is still a significant challenge related to using NPs capable of endosomal disturbance in therapeutics . The neein vivo . Focusinin vivo . This naClearly, nanotechnology has improved healthcare by facilitating advances in the biotechnology, pharmaceutical, and medicinal industries. Cancer targeting has been improved with RNA nanotechnology, but efforts are required to boost delivery efficiency and specificity to individual cancer cells. In addition, combining RNA with other chemical polymers to augment endosomal escape has faced the obstacles of undefined structure, stoichiometry, and nanoparticle accumulation in normal organs.Nanoparticles are a vital delivery system in the field of gene therapy for managing diverse diseases like cancer. The self-assembly characteristic of RNA can be considered as a powerful bottom-up approach for the design and creation of nanostructures through the interdisciplinary of biological, chemical, and physical techniques. Many research groups, including ours, are working to solve the endosome escape issues. Once these challenges are overcome, the field of RNA nanotechnology and therapeutics will move into clinical reality.Nanoparticles (1–100 nm) are capable of treating cancer due to their specific advantages, such as biocompatibility, low toxicities, excellent stability, increased permeability and retention, and precise targeting.Pharmaceutics has been utilizing nanoparticles for decades to reduce side effects and toxicity.in vivo is necessary.Establishing an effective, non-pathogenic and practical nanosized gadget for different clinical delivery Therapeutic RNAs have been developed, and their potential for treating diseases is just beginning to be explored.A major hurdle in pursuing RNA as a therapeutic remains specific targeting and endosome escape.Pharmaceutics has been utilizing nanoparticles for decades to reduce side effects and toxicity.The use of nanoparticle delivery systems could improve the treatment of many diseases.Field of RNA nanotechnology and therapeutics will move into clinical reality once solving the endosome escapes issues.A rapid spread of nanotechnology in medicine, specifically drug delivery, is expected.For clinically approved RNA nanoparticles to be optimized, the immunostimulation by these nanomaterials will need to be overcome.


The cerebellum’s role in affective processing is increasingly recognized in the literature, but remains poorly understood, despite abundant clinical evidence for affective disruptions following cerebellar damage. To improve the characterization of emotion processing and investigate how attention allocation impacts this processing, we conducted a meta-analysis on task activation foci using GingerALE software. Eighty human neuroimaging studies of emotion including 2761 participants identified through Web of Science and ProQuest databases were analyzed collectively and then divided into two categories based on the focus of attention during the task: explicit or implicit emotion processing. The results examining the explicit emotion tasks identified clusters within the posterior cerebellar hemispheres , the vermis, and left lobule V/VI that were likely to be activated across studies, while implicit tasks activated clusters including bilateral lobules VI/Crus I/II, right Crus II/lobule VIII, anterior lobule VI, and lobules I-IV/V. A direct comparison between these categories revealed five overlapping clusters in right lobules VI/Crus I/Crus II and left lobules V/VI/Crus I of the cerebellum common to both the explicit and implicit task contrasts. There were also three clusters activated significantly more for explicit emotion tasks compared to implicit tasks , and one cluster activated more for implicit than explicit tasks (left lobule VI). These findings support previous studies indicating affective processing activates both the lateral hemispheric lobules and the vermis of the cerebellum. The common and distinct activation of posterior cerebellar regions by tasks with explicit and implicit attention demonstrates the supportive role of this structure in recognizing, appraising, and reacting to emotional stimuli.The online version contains supplementary material available at 10.1007/s12311-022-01459-4. The cerebellum has long been associated with motor domain functions such as gait control and movement adaptation. In recent years, however, studies increasingly have identified functions of the cerebellum that extend beyond the motor domain and encompass a multitude of cognitive functions, as well as, notably, affective processes , 72, 85.Current theories propose that the cerebellum produces a modulatory signal that arises from the construction of an internal model of the outcome of actions or thoughts based on the individual’s current state , 57, 86.Early evidence for the role of the cerebellum in emotion processing arose from clinical observations that when the structure is damaged by disease or injury, affective symptoms occur. Initial case studies of dysfunction impacting non-motor cerebellar regions lead to recognition of a “dysmetria of thought” and the cerebellar cognitive affective syndrome , 66, 67.Clinical findings further suggest that the location of the cerebellar lesion might explain some differences in the observed affective symptoms, according to the type of response or cognitive labelling of the emotion that is required . AccordiMany previous neuroimaging studies of emotion in healthy adults have been conducted using functional magnetic resonance imaging (fMRI) and positron emission tomography (PET). Yet most studies focused on the role of the amygdala or prefrontal cortex in generating or regulating emotional responses , 59, 84.Several studies have investigated the diverse functional roles of the cerebellum in multiple domains, including a study  that looWhile such studies of large samples or multiple time points offer detailed information about a few tasks or individuals, a meta-analysis of existing studies of emotion offers a complementary means of building upon and synthesizing findings from multiple tasks and diverse participants to identify common foci of activation supporting a particular functional domain. Previous meta-analyses have investigated non-motor activations within the cerebellum , 71, 80 Building on the existing evidence of the cerebellum’s role in emotion processing, the current work aims to update previous meta-analytic findings and compare emotion studies utilizing explicit or implicit allocation of attention to identify common and distinct areas of activation. The present analysis considers studies utilizing broad stimulus classes  that assess emotion recognition and experience, but excludes studies of social cognition , emotion regulation, and pain. Based on prior findings , it was A literature search was finalized in May 2021 using Web of Science (webofknowledge.com) and ProQuest  with the search terms: fMRI OR PET AND cerebel* AND emotion* OR affect* OR arousal OR motivation* OR apathy OR depression OR anxiety OR mood OR amimia OR aprosodia OR dysprosod* OR "action tendencies" OR "subjective feeling" OR cognition. Additional studies were then extracted from reference lists of prior work to expand study inclusion. This search yielded 881 articles from Web of Science, 740 articles from ProQuest, and 322 articles from previous citations. Details of the screening process are reported in Fig. Studies or contrasts were excluded if they were reviews or meta-analyses, utilized only connectivity, region of interest (ROI), independent/principal components or multivariate pattern analyses (ICA/PCA/MVPA), or if the analysis focused on motor function, social cognition, emotion regulation, pain or sexual arousal. Studies could contribute multiple contrasts/experiments, but redundant contrasts that utilized the same task within a study  were excluded .Ultimately, 80 peer-reviewed studies that had been conducted between 1997 and 2021 and included 2761 total participants were selected as meeting the inclusion criteria and addressing the contrasts of interest. Tasks included viewing emotional faces or scenes, smelling pleasant/unpleasant odorants, rating emotional experiences, reading emotional text, and recalling personal emotional memories. Emotions covered by the studies included both positive and negative valence , including specific labels such as happiness, amusement, surprise, sadness, anger, grief, disgust, and fear. The emotional stimuli typically expressed or evoked high arousal and were compared to a neutral or other control condition. Details on the complete list of studies and tasks are provided in Table Subsequently, study tasks and contrasts were categorized according to the attentional allocation: explicit  or implicit (attention directed to another task or feature of the stimulus), with four contrasts excluded from this secondary analysis for combining both types of attentional tasks. Whole brain coordinates were transformed into MNI space when necessary using GingerALE’s built-in conversion tool. Extracted data is available upon request; this meta-analysis was not pre-registered.The meta-analysis was performed on the selected studies using an activation likelihood estimation (ALE) approach with the program GingerALE, version 3.0.2 , 22, 77.p < 0.01, and cluster level family-wise error correction threshold of p < 0.05, a method which accounts for multiple comparisons and the spatial dependence of neuroimaging data [p < 0.05 with 10,000 permutations and minimum cluster size of 100 mm3. A less conservative threshold was implemented for the cerebellum analysis compared to the whole brain analysis based on our a priori hypotheses regarding this region’s contribution to emotion processing and interest in differentiating locations that are most likely to be activated for each emotion category within the cerebellum.In the analysis of whole brain coordinates from all emotion studies, the ALE probabilities were tested for significance against a null distribution using non-parametric testing with 5000 permutations, a voxel level threshold of ing data . SubsequThe classification of study contrasts that met inclusion criteria and addressed the research questions of interest resulted in a total of 139 contrasts from 80 studies on 2761 participants yielding 1404 foci across the whole brain for the combined emotion analysis. The results from the whole brain GingerALE meta-analysis revealed six clusters that were likely to be activated during all emotion studies in the combined analysis: bilateral amygdala, right middle frontal gyrus, bilateral inferior occipital cortex extending to the superior cerebellum, and left parahippocampal gyrus/thalamus , these clusters may be within areas that belong to whole brain functional networks including: executive control, default mode , somatomotor, ventral attention/salience, and limbic networks . Briefly, several clusters in the cerebellum were significantly likely to be activated by one or both categories including bilateral lobules VI, Crus I, Crus II and the vermis Figure , similarIn the current meta-analysis of affective functions in the cerebellum, activation foci from 80 neuroimaging studies were combined to identify regions likely to be activated by explicit and/or implicit emotion processing tasks. Whole brain results identified common emotion-related activation in the bilateral amygdala, insula, occipital cortex, superior cerebellum, and right inferior/middle frontal gyrus, consistent with prior reports. The analysis of activation within the cerebellum for explicit emotion tasks identified clusters within the posterior cerebellar hemispheres , the vermis, and left lobule V/VI that were likely to be activated across studies, while implicit tasks activated clusters including bilateral lobule VI/Crus I/II, right Crus II/lobule VIII, anterior lobule VI, and lobules I-IV/V. A direct comparison between these categories identified five clusters in the cerebellum for the conjunction of both explicit and implicit tasks, as well as three clusters activated significantly more for explicit emotion tasks compared to implicit tasks, and one cluster activated more for implicit than explicit tasks.Based on the observed pattern of results, these findings do not support the predicted dissociation of activation in the lateral hemispheric lobules vs. the vermis for emotion tasks requiring explicit attention or implicit attention, respectively. Rather, the present study supports and updates previous meta-analyses indicating distributed activation of the posterior cerebellum during both types of emotion processing in regions that may be associated with neocortical networks supporting cognitive/executive functions, mentalizing, and salience processing. This work highlights the need for researchers to ensure neuroimaging coverage of the cerebellum and to discuss cerebellar activations with respect to the affective and cognitive processes involved in the task (rather than only considering motor function) in order to better characterize how the cerebellum shapes healthy and clinical affective functioning.The results of the meta-analyses for both explicit and implicit emotion studies yielded several clusters in bilateral posterior hemispheric lobule VI and Crus I/II. Additionally, some clusters for each category included portions of the vermis, which in previous task-based and clinical studies has been identified as a crucial region for emotion processing and associative learning  that is supported by structural connections with limbic subcortical regions and the brainstem , 55, 65.Another cluster located in left lateral Crus I that was identified in the current meta-analysis of both explicit and implicit tasks, also has been associated with emotional tasks in previous studies , 71. TheOther clusters in the separate explicit and implicit attention analyses included activation bilaterally in lobules VI, Crus I, and Crus II. In addition to the ventral attention network mentioned above, these clusters were located in regions previously associated with the executive control and default mode neocortical networks , 87. SpeFurther insight into the affective functions of the cerebellum can be gained by comparing the current results to two previous meta-analyses that addressed this topic , 71. TheThe second previous meta-analysis  includedWhile the current meta-analysis did not include timing or other cognitive domains, by focusing on emotion studies only, the present meta-analysis offers greater detail on the nature of affective processing in the cerebellum by highlighting the similarities and differences between tasks with explicit and implicit attention . Whole brain results also indicate regions of co-activation that include the amygdala, insula, occipital cortex, and prefrontal cortex, with more widespread clusters for implicit attention tasks. With the current updated and expanded study list, our work has improved power and greater diversity of tasks and participants to confirm and expand prior findings of emotion-related activation not only in the vermis, but also in bilateral posterior lobules VI, Crus I, and Crus II of the cerebellum.In consideration of the impact of context on emotional performance, the hypothesis of the current study focused specifically on activation differences between explicit and implicit emotion tasks. Tasks in the former category required explicit attention to the emotion shown or elicited by the stimulus, while tasks in the latter category directed attention to a non-emotional stimulus feature so that emotional information was only processed implicitly. Our direct comparison of studies using explicit versus implicit attention identified clusters that were common to both task types as well as unique to one category or the other. When compared to each other, explicit emotion tasks yielded significantly greater likelihood of activation in three clusters including right lateral lobule VI, the vermis, and left lateral lobule VI, whereas implicit emotion tasks yielded greater activation in only one cluster in left posterior lobule VI. Furthermore, the conjunction analysis identified regions of overlap between the two categories in primarily the posterior and lateral hemispheric lobules.These findings, therefore, did not support the hypothesis of a dissociation between explicit and implicit attention tasks in which explicit emotion tasks uniquely recruited regions of the posterior cerebellum  and implicit tasks recruited the vermis (that has connections with the limbic system) , 70. InsEmotional stimuli are likely processed with higher priority than neutral stimuli regardless of the attention instructions that participants receive for a given task, and are automatically appraised for novelty and personal relevance , 84, resOne limitation of the findings from the current meta-analysis is that the imaging field of view varied across studies, surely impacting the degree to which the cerebellum was covered during the functional scans and biasing results towards the superior cerebellum. Similarly, individual differences in brain shape and size also make it likely that coverage differed across participants, although the degree of this problem cannot be determined from group maps. Future studies, therefore, should strive to fully include whole brain coverage that is not limited to the neocortex, in order to better estimate the contribution of the inferior cerebellum, which has been shown to contain similar representational maps and connectivity as the superior cerebellum .Another limitation of the current analysis of explicit and implicit studies is that tasks utilizing all individual emotions of both positive and negative valence were included. This choice was made to maximize the number of included studies and examine the effects of explicit and implicit attention regardless of the specific emotion elicited. Nonetheless, there may be differences in how the cerebellum processes individual emotions or valence, perhaps according to the type of behavioral response that is motivated by these categories Below is the link to the electronic supplementary material.


Over the past few decades, brain-computer interfaces (BCIs) have undergone significant expansion, driven by innovative methodologies and technological advancements. Among the emerging methodologies that promote new BCI models, brain connectivity stands out. These systems hold the potential to completely reshape the interactions with technology and, importantly, to redefine our approach to addressing neurological conditions. BCIs are primarily distinguished by their invasive or non-invasive recording methods, such as electroencephalography (EEG), magnetoencephalography MEG, functional near-infrared spectroscopy (fNIRS), functional magnetic resonance imaging (fMRI) and stereo EEG, as well as their targeted applications.communication and neurorehabilitation, aiming to restore the ability to communicate or recover abilities that have been lost. This mission is particularly important in the rehabilitation context, where interfaces can be used to facilitate central functional recovery, especially for individuals recovering from stroke  with physiotherapy, creating a synergy between technology and recovery methodologies. The central focus was to probe whether the impact of MI-BCI varies with patient severity and if it provides universal recovery benefits. To unveil the effectiveness of this innovative approach, the researchers recruited a cohort of hospitalized ischemic stroke patients who exhibited motor deficits. They used standard tests before and after the rehabilitation along with non-contrast CT scans to assess the effects of high-density signs on the prognosis of stroke. The dynamic changes in neural activity after stroke were mapped out using brain topographic maps. The findings highlighted the superior performance of MI-BCI compared to conventional rehabilitation methods.In the medical field, BCIs hold a crucial role in de Seta et al.. The authors have established a novel approach to enhance post-stroke motor rehabilitation by focusing on cortico-muscular coupling (CMC) within a h-BCI. Through a pseudo-online analysis involving both healthy and stroke subjects, the study optimizes CMC computation and its translation into movement detection. This refinement, including adjusting CMC calculations every 125 ms and collecting two predictions before making a final decision, greatly enhances both accuracy and speed, no matter the type of movement. Importantly, the attempts and actual movements of stroke patients are both classified using CMC-based detection, achieving high accuracy and rapid classification. These findings lay the groundwork for a novel non-invasive h-BCI design, leveraging combined EEG and EMG connectivity patterns during upper limb movement attempts.BCIs should accommodate individual needs, using residual signals that can originate not only from the brain but also from the muscles. These innovative technologies, called hybrid BCIs (h-BCIs), bridge the gap between cerebral and muscular signals, as described by the work of Dillen et al. aims at making a step forward in this respect and proposes different data-driven approaches to investigate the feasibility of lower limb BCI in participants with an amputation and able-bodied participants performing lower limb movements. Different machine learning (ML) methods are tested, such as random forest, logistic regression, and linear discriminant analysis, each combined with a series of features based on power spectral density, common spatial patterns and xDAWN algorithm. The authors demonstrate that EEG can be reliably used as a control signal for lower limb prostheses in BCIs, with random forest methods appearing as the best classifier choice in most of the cases and common spatial patterns as the most suitable feature extraction method. Further integrating EEG with other signals (as EMG) could be of high interest for designing accurate h-BCI systems targeting lower limb prosthetic device control.While most of the ongoing research is focusing on upper body movements, as demonstrated by the previously discussed studies, it is important to mention that BCI techniques can also target lower extremities, although decoding lower limb movements from EEG brain signals is more challenging. As such, EEG for lower extremity prosthetic control is currently rare  features from simultaneous EEG and fNIRS recordings to predict participants' performance in an fNIRS-based affective neurofeedback task on healthy participants. Their results provide evidence of the feasibility of using multimodal FC predictors for neurofeedback performance, revealing good prediction accuracy and demonstrating good agreement between resting-state FC connectomes derived from different functional modalities.Connectivity-based features are also relevant in neurofeedback training applications. These allow self-regulation of one's own brain activity by providing feedback and reward signals, representing one of the earliest and simplest applications of BCI systems  is highly relevant, allowing users to better understand how models make decisions and increasing confidence in the system. However, the efficacy of AI-based approaches comes with a caveat. They require a large amount of data for training, and this may represent a substantial challenge within the BCI context, especially in clinical and rehabilitative applications. In these scenarios, limited samples sizes and the need to adapt the system to each user are peculiar. To overcome such limitations, several potential solutions could be considered. For instance, leveraging publicly available data could partially mitigate the data scarcity issue. Similarly, using approaches such as transfer learning could be useful in addressing this problem allowing the transfer of knowledge from domains with a large amount of data to those with more limited datasets  methods appear promising for such purpose and for dealing with high dimensionality, the intrinsically noisy, sparse, and non-stationary nature of EEG data imposes several limitations. Moreover, many ML/DL approaches often lack transparency and frequently remain as “black boxes”, generating results without explanations. Therefore, the current development and use of To conclude, brain connectivity analysis, dimensionality reduction, modeling of non-linear interactions, integration of different data sources for h-BCI, individually-tailored systems and the pursuit of transparent AI represent essential topics to further explore that all converge in current BCI research, with a greater challenge lying in achieving real-time implementations.IBG: Writing—original draft, Writing—review and editing. LT: Writing—review and editing. AM: Writing—review and editing. SS: Writing—original draft, Writing—review and editing, Conceptualization.


Non-covalent Bruton’s tyrosine kinase inhibitors (ncBTKi) are being investigated for the treatment of B-cell malignancies, including chronic lymphocytic leukemia (CLL). These agents hold promise for the treatment of CLL, especially CLL requiring treatment after prior discontinuation of covalent Bruton’s tyrosine kinase inhibitors such as ibrutinib, acalabrutinib and zanubrutinib for either intolerance or progression of disease. This review outlines current preclinical and clinical data for the use of ncBTKi in CLL. Recently reported data has shown durable responses for the ncBTKi pirtobrutinib in CLL patients previously treated with a covalent BTKi with a median PFS of 19.6 months. We also discuss recently discovered mechanisms of resistance to ncBTKis, including acquired mutations in the BTK protein not in the C481 position. In addition, we highlight ongoing clinical trials that are incorporating ncBTKis in CLL as monotherapy or in combination therapies with other agents. The results of these trials as well as ongoing research regarding mechanisms of resistance to ncBTKi and covalent Bruton’s Tyrosine Kinase inhibitors will be important to determine where ncBTKi may fit into the treatment of CLL. Covalent Bruton’s tyrosine kinase inhibitors (cBTKi) have led to a paradigm shift in the treatment of chronic lymphocytic leukemia (CLL). These targeted oral therapies are administered as standard treatments in both the front-line and relapsed and/or refractory settings. Given their administration as a continuous therapy with a “treat-to-progression” strategy, limitations of their use include discontinuation due to toxicity or from progression of the disease. Non-covalent Bruton’s tyrosine kinase inhibitors (ncBTKi) distinguish themselves by binding reversibly to the BTK target, which may address the limitations of toxicity and acquired resistance seen with cBTKi. Several ncBTKis have been studied preclinically and in clinical trials, including pirtobrutinib and nemtabrutinib. Pirtobrutinib, which is now FDA approved for relapsed and/or refractory mantle cell lymphoma (MCL), has shown outstanding safety and preliminary efficacy in CLL in phase 1 and 2 clinical trials, with phase 3 trials underway. This agent may fill an unmet medical need for CLL patients requiring treatment after a cBTKi. Pirtobrutinib is particularly promising for the treatment of “double exposed” CLL, defined as CLL requiring treatment after both a cBTKi and venetoclax. Some patients have now developedacquired resistance to pirtobrutinib, and resistance mechanisms (including novel acquired mutations in BTK outside of the C481 position) have been recently described. Further study regarding the mechanisms of resistance to pirtobrutinib in patients without prior cBTKi exposure, as well as the potential for cross-resistance between cBTKi and ncBTKis, may be important to help inform where ncBTKis will ultimately fit in the treatment sequencing paradigm for CLL. An emerging clinical challenge is the treatment of CLL after ncBTKi discontinuation. Novel therapeutic strategies are being investigated to address the treatment of patients following disease progression on ncBTKis. Such strategies include novel agents  as well as combination approaches incorporating a ncBTKi  that may help overcome this acquired resistance. The covalent Bruton’s tyrosine kinase inhibitors (cBTKi) ibrutinib, acalabrutinib and zanubrutinib are now widely utilized standard treatment options for both the initial treatment of CLL and relapsed and/or refractory chronic lymphocytic leukemia (CLL) ,4,5,6,7.Despite outstanding clinical outcomes seen with ibrutinib, a subset of patients must discontinue ibrutinib due to toxicity or due to disease progression . RetrospHowever, while acalabrutinib and zanubrutinib have addressed some toxicity concerns withthe cBTKi ibrutinib, therapy discontinuation due to disease progression and acquired resistance remains a limitation of the cBTKi class ,18. MutaThere is no conclusive understanding as to what causes the development of resistance mutations to cBTKi. Current research has hypothesized that resistance mutations can arise in patients from evolutionary development of a BTK or PLCG2 mutant clone that allows an escape from BTK inhibition. In addition, it has been proposed that resistance arises from the competitive selection or outgrowth of drug resistant mutant clones already present at treatment initiation ,19. In gNon-covalent BTK inhibitors (ncBTKi) reversibly bind to BTK, and hold promise to address some of the limitations of toxicity and resistance posed by cBTKi ,24. HereAs described above, cBTKis directly bind to the cysteine at residue 481 of BTK in the ATP binding pocket, effectively blocking the autophosphorylation of BTK tyrosine residue 223 (Y223). In contrast, ncBTKis interact with BTK using hydrogen bonds, ionic bonds and hydrophobic interactions . This meDespite the differences in the methods of inhibitor binding, structural studies of BTK with both cBTKi and ncBTKi show similarities in their required interactions with residues around 410, 430, 480, and 540, in addition to inhibitor-specific interactions. The ncBTKis ~26–29) have a slightly higher number of interactions than cBTKis (~19–22), possibly due to the size of the molecule, and due to the fact that more interactions are required for these inhibitors to achieve the affinity necessary for a reversible drug . The wea have a sThere are several ncBTKis in development. These drugs have the potential to transform the treatment of B-cell malignancies, including CLL, and fill an unmet medical need for therapies in patients who are resistant or intolerant to treatment with cBTKis. In this review, we discuss ncBTKis, including vecabrutinib, fenebrutinib, nemtabrutinib, and pirtobrutinib, as well as discussing what is known regarding resistance mechanisms for ncBTKis.50 3nM). In addition to BTK, vecabrutinib also targets BLK, IGF1R, ITK, LCK, and TEC  but not epidermal growth factor receptor (EGFR), thereby reducing EGFR toxicities seen previously in covalent BTKi . InIn a recent study, Qi et al. generated BTKi resistant Rec-1 cell lines through long-term exposure to covalent (ibrutinib) and non-covalent  BTKi . They idAnother group studying resistance to ncBTKi performed a whole exome sequencing of samples from two patients with disease progression while taking pirtobrutinib, so as to provide evidence of resistance through multiclonal alternative site BTK mutations . In the While the exact signaling mechanism of resistance in these inactivating ncBTKi mutations requires further study, recent articles have reported a noncatalytic scaffolding function of BTK with HCK or LYN or dependencies of kinase-deficient BTK mutants on TLR9, UNC93B1, CNPY3 ,49,50,51Given the clinical promise of ncBTKi, the recent identification of acquired resistance mutations to ncBTKi that negatively affect the kinase activity of BTK (rendering it kinase deficient/dead) highlights a crucial unmet need for understanding the noncatalytic function of BTK in BCR signaling. Additional studies are also required to functionally characterize those gain-of-function PLCG2 mutants  identified from ncBTKi resistance  46,47,4,447,48.While pirtobrutinib was recently granted accelerated approval by the FDA for patients with MCL, pirtobrutinib and other ncBTKis remain investigational for patients with CLL. As a monotherapy, pirtobrutinib holds promise to fill an unmet need for patients with not only progression after cBTKi treatment, but also for patients needing CLL therapy after treatment with both a cBTKi and venetoclax. This patient population of “double exposed” CLL patients who have been treated previously with both classes of targeted agents marks an area of great unmet need for patients with CLL ,57,58,59Pirtobrutinib has also been studied in combination with other agents, including venetoclax and rituximab. The phase Ib portion of the BRUIN study evaluated the safety of pirtobrutinib + venetoclax, and pirtobrutinib + venetoclax + rituximab in patients with relapsed/refractory CLL . The comWhether pirtobrutinib will be moved into earlier lines of therapy, including front-line therapy or prior to the use of cBTKi, remains an unanswered question. There is an ongoing trial of pirtobrutinib versus ibrutinib in previously untreated CLL  found that for CLL patients who are venetoclax-naïve, venetoclax has excellent clinical activity following ncBTKi discontinuation . Standard therapies (including CIT and PI3Ki) had low overall response rates and responses were not durable, while patients treated with CAR T-cell therapy and allogeneic stem cell transplant had higher ORRs .There are ongoing trials of several different classes of agents that may hold promise after ncBTKi discontinuation. These novel strategies include, but are not limited to, BTK degraders  have improved patient outcomes, their use may be limited by toxicity as well as by resistance. The non-covalent BTKi pirtobrutinib has demonstrated outstanding early tolerability and clinical activity, including durable responses in relapsed and/or refractory patients previously exposed to covalent BTKi or BCL2i. While these ncBTKi show promising efficacy in CLL, a subset of patients has developed resistance due to BTK and PLCG2 alterations. Long-term safety and efficacy data remain unknown. An emerging clinical challenge will be the treatment of patients after acquiring resistance to ncBTKi. Longer follow-ups from the early clinical trials of ncBTKis, as well as randomized studies of ncBTKis versus current standards of care, will help inform where these agents will fit into the CLL sequencing paradigm. More research is required regarding the mechanisms of acquired resistance to cBTKis and ncBTKis, as well as the potential for cross-resistance between cBTKi and ncBTKi. In addition, preclinical and clinical studies of novel combination approaches and novel therapeutic strategies such as BTK degraders, bispecific antibodies and PKC-beta inhibitors will be essential for improving patient outcomes.


Tissue regeneration is a complex molecular and biochemical symphony. Signaling pathways establish the rhythmic proliferation and differentiation cadence of participating cells to repair the damaged tissues and repopulate the tissue-resident stem cells. Sensory proteins form a critical bridge between the environment and cellular response machinery, enabling precise spatiotemporal control of stem cell fate. Of many sensory modules found in proteins from prokaryotes to mammals, Per-Arnt-Sim (PAS) domains are one of the most ancient and found in the most diverse physiological context. In metazoa, PAS domains are found in many transcription factors and ion channels; however, PAS domain-containing Kinase (PASK) is the only metazoan kinase where the PAS sensory domain is connected to a signaling kinase domain. PASK is predominantly expressed in undifferentiated, self-renewing embryonic and adult stem cells, and its expression is rapidly lost upon differentiation, resulting in its nearly complete absence from the adult mammalian tissues. Thus, PASK is expressed within a narrow but critical temporal window when stem cell fate is established. In this review, we discuss the emerging insight into the sensory and signaling functions of PASK as an integrator of metabolic and nutrient signaling information that serves to balance self-renewal and differentiation programs during mammalian tissue regeneration. In electronics, a “sense relay” typically refers to a type of relay that is used to monitor or sense certain parameters or conditions within a circuit. A sense relay is often employed to provide feedback or control based on the status or measurement of the monitored parameter. Thus, sense relays are often integrated into automation control systems or protection schemes to ensure the safe and efficient operation of electrical equipment and systems. Sensory kinases provide similar functional advantages in the cellular context by sampling the environment and relaying appropriate responses for timely decision-making. In stem cells, sensory information is critical to establish lineage identity and self-renewal or differentiation decisions. Thus, protein kinase signaling plays a pivotal role in controlling cell identity, pluripotency, and self-renewal of stem cells ,2,3. StePAS Kinase (PASK) consists of two tandemly arranged Per-Arnt-Sim (PAS) domains, terms PAS-A and PAS-B, respectively, and a catalytic domain within the CAMK family of protein kinases ,10 Figu. The solUnder normal physiological conditions, PASK mRNA and proteins are nearly absent in adult human and mouse tissues ,14. TherAnalysis of bulk RNAseq datasets revealed a positive correlation between the undifferentiated state of mouse ESCs and the mRNA levels of PASK. In contrast, induction of neurogenesis of mESCs or an embryoid body formation resulted in a progressive decline in PASK expression in tune with differentiation kinetics . SimilarDespite increased expression during iPSC reprogramming, the catalytic inhibition of PASK did not affect the iPSC reprogramming efficiency, indicating that PASK may not play a significant role during iPSC reprogramming . On the Muscle satellite cells, or muscle stem cells (MuSCs), offer a unique biological context to dynamically study the regulation and function of PASK during mammalian tissue regeneration. Uninjured quiescent MuSCs cycle infrequently and are metabolically less active . Damage PASK is not expressed in adult skeletal muscles, and its protein levels are absent from quiescent muscle stem cells. However, myofiber injury rapidly induced PASK expression, which peaks 3 days post-injury, a temporal point during regeneration when activated myoblast population is building  13]. Su. Su13]. The increase in PASK expression in regenerating muscles coincides with the influx of macrophages in the niche. Through the action of macrophages, fibroblasts, and other muscle resident cells, the regenerating niche is enriched with signaling peptides, hormones, and nutrients that guide temporal transition through cell fate and establish a heterogeneous myoblast progenitor population. During regeneration, PASK is activated by insulin and amino acids such as leucine via direct phosphorylation by the mechanistic Target of Rapamycin (mTOR) protein kinase . mTOR plMechanistically, the mTOR phosphorylation of PASK at the onset of differentiation strengthens the interaction between PASK and its substrate, Wdr5 . We discAs described below, Wdr5 phosphorylation is a requirement for the induction of the Myogenin promoter and induction of the myogenesis program in response to insulin signaling.The earliest evidence that PASK is required for induction of Myogenin (Myog) transcription came when we recapitulated a classic MyoD transdifferentiation assay in C3H/10T1/2 cells . In thisPASK is primarily localized into the cytoplasm of undifferentiated cells. Interestingly, in freshly isolated primary myoblasts, we noticed that the cytoplasmic localization of PASK is restricted to cytoplasmic granules. However, at the onset of terminal differentiation, PASK is released from these granules and is translocated into the nucleus . As Wdr5In an experimental model of muscle regeneration where chemical or freeze injury to the myofiber network is induced, near-complete myofiber destruction releases MuSCs from their muscle niche, resulting in their activation. Quiescent MuSCs utilize fatty acids, perform beta-oxidation, and cycle infrequently ,28. ActiMitochondrial metabolism of glucose and glutamine generates co-factors of epigenetic enzymes, such as alpha-ketoglutarate, succinate, and acetyl-CoA, which play critical roles in establishing stem cell fate ,31. IntrSelf-renewal is a stem cell proliferation feature that preserves stem cell identity and differentiation competence. Thus, the stem cell cycle is uniquely poised to re-establish the stem cell identity at the end of each mitotic cycle. In one mechanism for re-establishing cell identity at the end of the mitotic cell cycle, Wdr5 was shown to recruit mitotic anaphase-promoting complex/cyclosome (APC/C)-Cdc20 to histones of genes regulating ESC identity . APC/C iKOPask animals showed defective regenerative myogenesis and showed the expansion of Pax7+ myoblast numbers throughout the regeneration [KOPask animals appear indistinguishable from WT animals, and the numbers of Pax7+ MuSCs are not different under normal homeostatic conditions. These points to either developmental compensation of PASK function by other kinases or that PASK may not be required for the developmental myogenesis program. Future studies involving conditional MuSCs-specific loss of PASK will be instructive in answering some of these questions.Thus, biochemical disruption of Wdr5-APC/C interaction by PASK is required for building a heterogenous myoblast population and generating differentiation-competent progenitors. PASK expression peaks at 3 days post-injury  and adult muscle stem cells. There exists a great interest to preserve and extend the self-renewal potential of adult stem cells in vitro. Our results suggest that PASK inhibition might be an important strategy to achieve that goal. At the same time, the in vivo application for targeted inhibition of PASK might benefit organismal metabolism (see above) and likely boost stem cell function, albeit with the caveat of poor differentiation performance. However, since PASK targets two mechanistically distinct pathways to regulate self-renewal and differentiation, it might be possible to develop strategies that promote self-renewal without affecting differentiation performance.As with any new signaling pathways, many questions about PASK functions in stem cells remain to be answered. For example, additional substrate targets and transcriptional regulators of PASK expression in activated stem cells and at the end of myogenesis programs remain unknown. Furthermore, as most studies of PASK have been conducted in the context of muscle regeneration, it remains unknown if PASK plays similar functional roles in other adult stem cell systems. Nevertheless, emerging studies suggest that PASK plays important role in regulating muscle stem cell function and metabolism, and further studies are needed to fully understand the molecular mechanisms by which PASK regulates muscle stem cell differentiation and energy metabolism and to investigate the potential therapeutic applications of PASK modulation in muscle disorders and aging.


Innate immunity is the primary host mechanism of protection against infectious diseases in humans and animals. This broad and non-specific response fends off the initial infection and facilitates the establishment of pathogen/antigen-specific adaptive immunity. Thus, innate immunity is crucial in determining the outcome of host-pathogen interactions. Vaccination with non-infectious molecular components of pathogens boosts the host immunity to respond effectively against infectious pathogens. However, pathogens of humans and animals have evolved with mechanisms to counteract the hostility and persist within the infected host. Ultimately, the combined innate, adaptive, and vaccine-induced immunity impacts the host-pathogen interactions and subsequent course of infection. In this Research Topic, five research articles and a mini review are presented on various host-pathogen factors and vaccine components that affect bacterial and viral pathogenesis in humans and animals.Aggregatibacter actinomycetemcomitans (Aa) is an etiological agent of localized aggressive periodontitis (LAP) in humans -based vaccine for S. Enteritidis infection and tested its protective efficacy in a murine model. Specifically, the authors have created mutants of S. Enteritidis defective for tolR (ΔtolR), a gene that codes for the inner membrane protein, and rfaQ (Δ rfaQ) that codes for a transferase involved in keeping the stability of the outer membrane and evaluated their OMV production, compared to the wild type (WT) bacteria. It should be noted that previous studies have shown that a mutant S. Enteritidis rfaQ was defective for virulence in model systems, while a tolR mutant displayed elevated expression of OMVs in other Salmonella species  against the recombinant outer membrane protein P2 (rOmpP2) of various Haemophilus parasuis genotypes, which causes Glasser’s disease in pigs , the causative agent of porcine high fever disease  during mycobacterial infections. Since pathogenic mycobacteria can exploit the host cell lipid metabolism for survival and infection, understanding the immune-modulatory role of LDs on immune cells through various mechanisms is crucial for identifying potential targets to control mycobacterial infections.Finally, the mini review by In summary, this Research Topic includes articles on the molecular immunological determinants of host-pathogen interactions using various model systems of bacterial and viral infections. The concepts and findings presented in these articles would provide a platform for devising better and improved interventions for infectious diseases.SS: Writing – original draft, Writing – review & editing.


MYC, a key member of the Myc-proto-oncogene family, is a universal transcription amplifier that regulates almost every physiological process in a cell including cell cycle, proliferation, metabolism, differentiation, and apoptosis. MYC interacts with several cofactors, chromatin modifiers, and regulators to direct gene expression. MYC levels are tightly regulated, and deregulation of MYC has been associated with numerous diseases including cancer. Understanding the comprehensive biology of MYC under physiological conditions is an utmost necessity to demark biological functions of MYC from its pathological functions. Here we review the recent advances in biological mechanisms, functions, and regulation of MYC. We also emphasize the role of MYC as a global transcription amplifier. The Myc gene was first identified in the early 1980s as a cellular homolog of the retroviral v-Myc oncogene . Its disThe MYC family of proteins consists of three paralogs, MYC (c-MYC), MYCN (N-MYC) and MYCL (L-MYC) . AlthougUpon binding at promoters, the transregulatory domains of MYC and its isoforms, are believed to project its influence onto target genes through patches of amino acids that share high sequence homology among the three MYC isoforms. These patches are referred to as MYC boxes (MBs). From the amino-to carboxyl terminus, there are six conserved MBs: MB0, I, II, IIIa, IIIb, and IV. They are generally unstructured and can adopt specific conformations induced upon partner-protein binding. The degree of plasticity for each MB upon complexing with different partners has not been explored. The inventory and functional roles for MB-interacting partners that have been most intensively investigated are involved in transcription and chromatin process, or control MYC turnover, has recently been reviewed .A sampling of the MYC-interactome shows MB0 interactions with general transcription factor TFIIF . MBI andTranscription activation involves the binding of transcription factors to specific DNA sequences, which recruit the transcriptional machinery, coactivators, and chromatin modifiers to form a transcriptional complex that initiates gene transcription. Transcription factors can recruit coactivators such as CBP/p300, which possess histone acetyltransferase activity and can acetylate histones to promote an open chromatin structure that allows for gene transcription. In addition, transcription factors can recruit chromatin modifiers such as SWI/SNF, which can remodel chromatin to allow access to the transcriptional machinery . Unlike When viewed a transcriptional activator, the expectation and goal were to identify specific, direct MYC target genes to provide insights into the crucial downstream targets and biological processes responsible for mediating the physiological functions and oncogenic pathology of MYC. Numerous studies were undertaken to identify MYC-regulated genes by employing techniques such as microarray or next-generation sequencing to compare RNA expression profiles and genome-wide mapping of MYC-bound chromatin. The notion that MYC and MYC-MAX complexes regulate a limited and well-defined set of target genes for their various roles has been largely challenged . StudiesThe complexity of transcription amplification can be influenced biologically by input signals, cis-elements, other transcription factors, and analytically by the algorithms and pipelines used for analysis. These factors can highlight or obscure the relationship between MYC binding and promoter output in omics studies. To exclude such interfering or biased factors, minimal promoter and the reporter-based assay was designed to interrogate MYC function . Basal rAlthough, it has been suggested that the binding of transcription factors to enhancer elements, super-enhancers, or other regions that drive the recruitment and activity of the transcription machinery plays a critical role in the non-linear mode of transcriptional amplification , the dirin situ hybridization (smFISH) in fixed cells and MS2-tagging of RNA in live cells were used to assess the immediate impact of MYC on transcription bursting. The findings demonstrate that MYC influences the length of time that other core transcriptional factors reside at promoters. Elevated MYC levels uniquely influence the dwell time of various transcriptional machinery complexes. The glucocorticoid receptor (GR) remained unchanged, while SPT5, TBP, and RNAP II exhibited increased dwell time, and MED1, a mediator component, showed decreased dwell time. Elevated MYC enhanced RNA output from its target genes and alterations in burst duration were attributed to changes in the residency of transcriptional machinery and hence altered transcription output. Overall, MYC universally extended the duration of transcriptional bursts , without altering their frequency  or SP1 that recruit corepressor, or changes in chromatin accessibility driven by epigenetic modifications which lead to the displacement of DNA-bound coactivators to ultimately achieve gene repression . FurtherAs discussed above, MYC is an integral part of transcription progression, acting as a global amplifier, it is indispensable for both embryonic development and the maintenance of self-renewing tissues in adults . MYC proSKP2 ubiquitin ligase complex, which direct the phosphorylation, degradation, and proteasome-mediated turnover of p27  and DNA damage . ThroughMYC has been shown to regulate rDNA transcription. MYC interacts with components of the SL1 complex, enhancing the association of TBP and TAF complex with the promoter and recruiting HATs to facilitate RNAP I recruitment and transcription at rDNA promoters. Consequently, the upregulation of UBF expression mediated by MYC positively influences the transcriptional activity of RNAP I, ultimately resulting in enhanced rRNA synthesis . SumoylaMYC proteins are intrinsically disordered proteins (IDPs). They tend to interact with different proteins simultaneously and has been speculated that MYC forms liquid-liquid phase separation when present at high concentration . It has myc mRNA transcripts, while the P2 promoter accounts for 75%–90% of the transcripts . The MYC-TAD harbors a multitude of super-enhancer regions that intricately regulate the expression of the MYC  led to a ∼50% reduced MYC level  regulates the expression of MYC by binding to ∼50 kb downstream of the enhancer   within the IDR region of MYC, thereby reducing the thermal stability of MYC-MAX dimerization and subsequently its function . MYC funMYC protein is a crucial transcription regulator that plays a central role in regulating gene expression in different cellular situations. Its capacity to amplify transcriptional responses contributes to the precise control of cellular processes and the maintenance of a balanced state within cells. It is not known whether MYC exerts its pathological action from an augmentation of its normal transcription amplifier role or whether MYC neopathologic functions are elicited at supraphysiological levels. It is important to understand mechanistically how MYC regulates different kinetic steps of transcription by all three RNAPs. A deeper understanding of the mechanisms through which MYC amplifies transcription, and the factors that influence this process in physiological and pathological conditions will enhance our knowledge of gene regulation and offer valuable insights for developing targeted therapeutic approaches for MYC-related disorders.


Asymptomatic esophageal eosinophilia (aEE) is a rare presentation, where patients have increased eosinophils in esophageal mucosa but lack any esophagus-related symptoms. Cases of aEE have only been documented in adults, and little is known about its clinical significance and whether treatment is warranted. We report a case of an 11-year-old patient with uncontrolled severe persistent asthma who underwent flexible bronchoscopy and upper endoscopy as a part of complete aerodigestive evaluation. Elevated intraepithelial eosinophils in the esophageal mucosa were noted, suggesting an aEE-like presentation. This case documents a pediatric patient with aEE and highlights the importance of combined aerodigestive assessment with pulmonology and gastroenterology teams for the evaluation of severe asthma. Atopic diseases, such as atopic dermatitis and allergic asthma, are increasing in prevalence worldwide –3. TheseIn the pediatric patient population, EoE is increasing in prevalence alongside atopic disease as a whole –3, 7, 8.The long-term complications of untreated EoE are clear: persistent allergic inflammation leading to fibrosis and esophageal strictures over time, resulting in permanent damage to the esophagus . HoweverAn 11-year-old male patient with uncontrolled severe persistent asthma and allergic rhinitis underwent an upper gastrointestinal endoscopy and flexible bronchoscopy. A diagnosis of asthma was given six years prior following repeated episodes of cough, chest tightness, shortness of breath, and wheezing triggered by viral respiratory infections and exercise. Sneezing and coughing following exposure to environmental allergens was also noted. At this time, patient was already on Step 5 inhaled corticosteroid-long acting beta agonist (ICS-LABA) therapy montelukast, and as needed short acting beta agonist for rescue treatment . ResponsConcurrently, this patient was also being followed by gastroenterology for functional constipation, where initial efforts to treat with polyethylene glycol were unsuccessful. The patient reported abdominal discomfort and ultimately discontinued its use without resolution of constipation. Coordination between gastroenterology and pulmonology teams concluded that a bronchoscopy and an upper endoscopy were required for further evaluation to rule out other factors in the pathogenesis of respiratory symptoms.Bronchoscopy revealed that the airway mucosa had evidence of inflammation and friability, consistent with uncontrolled severe persistent asthma. Bronchoalveolar lavage (BAL) was performed in the lingula and right middle lobe, and upon gross observation, the BAL specimen was clear; however, microscopy revealed the presence of hemosiderin-laden macrophages, indicating bleeding into the airway . Upper endoscopy revealed esophageal mucosal changes in the mid and distal esophagus, including linear erosions without hemorrhage, often seen with esophagitis. Four biopsies were obtained from the middle esophagus and distal esophagus. Microscopic analysis revealed 35 eosinophils per HPF in both areas with microabcesses and degranulation, confirming the histopathologic criterion for a diagnosis of eosinophilic esophagitis.GERD and asthma are often found as coexisting conditions, and GERD is recognized as a trigger in many cases of severe asthma . HoweverIt is unclear whether the persistent, subclinical inflammation of aEE has similar long-term adverse effects. Few studies have aimed to investigate the molecular differences between eosinophilic inflammation in aEE compared to EoE. Using immune markers of eosinophilic inflammation , a study performed by Kitamura et al. identified no significant differences between aEE and EoE at the cellular level, supporting the hypothesis that aEE and EoE have similar pathophysiologic processes . ImportaThis case documents aEE in a pediatric patient in the context of severe persistent asthma, which raises interesting questions about the etiology of aEE in the pediatric population. Although our patient lacked esophageal symptoms, the number of eosinophils per high-powered field >35) was consistent with a diagnosis of EoE  was cons, mepolizThe co-occurrence of aEE with severe persistent asthma in this 11-year-old patient brings to question several aspects of clinical management for consideration: (1) what is the significance of aEE in the pediatric population; (2) is treatment for aEE warranted; and (3) should upper gastrointestinal endoscopy be incorporated into routine clinical workup for pediatric patients with severe asthma even in the absence of esophageal symptoms. We suspect many patients with severe allergic asthma have some level of aEE that may warrant treatment and may need to be considered for a full evaluation by pulmonary and gastroenterology teams, despite the absence of symptoms for traditional EoE.