Striving to optimize surgical outcomes, the Enhanced Recovery After Surgery (ERAS) pathway mitigates patients’ stress through the implementation of evidence-based practices during the pre-, intra-, and postoperative periods. Intestinal flora is a sophisticated ecosystem integrating with the host and the external environment, which serves as a mediator in diverse interventions of ERAS to regulate human metabolism and inflammation. This review linked gut microbes and their metabolites with ERAS interventions, offering novel high-quality investigative proponents for ERAS. ERAS could alter the composition and function of intestinal flora in patients by alleviating various perioperative stress responses. Modifying gut flora through multiple modalities, such as diet and nutrition, to accelerate recovery might be a complementary approach when exploring novel ERAS initiatives. Meanwhile, the pandemic of COVID-19 and the availability of promising qualitative evidence created both challenges and opportunities for the establishment of ERAS mode.  Medicine; Surgery; Microbiology; Microbiome The past decade has marked an explosion of exciting discoveries linking the composition and function of indigenous microorganisms to human health and disease. Especially, culture-independent genomic techniques allow a comprehensive classification and evaluation of the gut microbiome, which has dramatically increased our understanding of the extensive changes in microbial composition.Because Danish professor Kehlet first proposed the concept of fast-track surgery in the 1990s,ERAS could alter the composition and function of intestinal flora in patients by relieving various stress responses during the perioperative period. This affects the metabolism of the host, thus achieving the purposes of reducing postoperative complications, shortening hospital stay, and promoting rehabilitation. This review summarized the role of gut microbiota in ERAS, and how intestinal flora might regulate the metabolic processes to accelerate rehabilitation. Lastly, we explored future directions that merit consideration in basic and clinical translational studies.In the human gut, trillions of microorganisms  coexist with human surfaces and inside every cavity of the body. The gut microbiome are nearly 1,000 more genes than in the human genome .Generally, a healthy gut ecosystem is characterized by a diverse array of taxa, high gene richness, and stable functional cores in microbes. Despite a distinguished interindividual variation in gut microbiota composition and dynamics, it is redundant for clear persistence of conserved metabolic functions across multiple phyla. The most abundant among these core pathways include genes encoding glycosaminoglycan degradation, short-chain fatty acids (SCFAs) synthesized from complex polysaccharides, and specific lipopolysaccharides (LPS), as well as the biosynthesis of vitamins and serval essential amino acids.The physiological and metabolic properties in both healthy and diseased states are inevitably affected by the intestinal flora. The first evidence for the mechanistic involvement of intestinal flora in metabolic regulation was shown in 2004, where it was found that intestinal flora regulated the host’s acquisition and storage of energy from the diet in rats.,SCFAs butyrate, propionate, and acetate, primarily fermented from complex carbohydrates , might be metabolically protective. Specifically, SCFAs activate G protein-coupled receptors (GPCRs) and inhibit histone deacetylases, which are the principal energy sources for intestinal epithelial cells.Various tissues respond to bile acids that regulate lipid and glucose metabolism as well as inflammation. Primary bile acids are synthesized in hepatocytes from cholesterol and transformed into secondary bile acids by intestinal flora.Butyrivibrio crossovers and Eubacterium siraeum.The branched-chain amino acids (BCAAs), leucine, isoleucine, and valine represent among the nine essential amino acids which are manufactured by intestinal bacteria. Elevated circulating concentrations of BCAAs are powerful biomarkers of insulin resistance and type 2 diabetes (T2D).Intestinal microbiota metabolizes dietary nutrients such as L-carnitine, phosphatidylcholine, and choline, to generate trimethylamine (TMA), which is assimilated in the gut and turned into trimethylamine-N-Oxide (TMAO) by flavin-containing monooxygenase 3 in the liver.Indole and its derivatives are synthesized directly from dietary tryptophan by the metabolism of intestinal microorganisms. Several of them serve as aryl hydrocarbon receptor (AhR) ligands. Emerging evidence indicates that reduced microbial capacity to produce AhR activating metabolites might be a crucial element of the metabolic syndrome. The mechanism could be related to gut permeability and LPS transposition caused by diminished secretion of GLP-1 and IL-22, which is responsible for chronic inflammation, insulin resistance, and hepatic steatosis.In conclusion, structural constituents and metabolites released by bacteria that deal with both dietary and host-derived molecules regulate metabolic inflammation via myriad regimes. This raises prospective targets for exploring innovative therapeutic vehicles for metabolic diseases. It is noteworthy that metabolic inflammation and gut microbiota assembly are dominated by other parameters. Modifications in the intestinal flora could moderate and perpetuate the constitutive health of the organism, which establishes the foundation for a range of interventions in ERAS.Currently, the microbiota has been categorized as the largest “endocrine organ” in the human body.ERAS is implemented on the foundation of evidence-based medicine and optimizes clinical trajectories involving perioperative interventions through multidisciplinary collaboration among surgery, anesthesia, nursing, nutrition, etc. Kehlet et al. first discovered that in elderly high-risk patients receiving colonic surgery, substantial progress in postoperative recovery could be accomplished through early and aggressive perioperative care.Ruminococcus gnavus, Bacteroides vulgatus, etc.Parabacteroides goldsteinii, that ameliorated smoking-induced lung disease via the gut-lung axis.,,Smoking compromises microbial community function, especially the metabolism of amino acids, carbohydrates, propanoate, and indoles. It was demonstrated that smoking cessation for more than 4 weeks before surgery significantly shortened the postoperative hospital stay and reduced the rate of overall complications.Likewise, 4 weeks of preoperative abstinence from alcohol significantly decreases the incidence of postoperative complications whereas 2-week withdrawal from alcohol markedly enhanced platelet function and shortened bleeding time.,The intestinal microbiota exerts a decisive role in diverse categories of chronic pain, especially visceral pain. Appropriate pain manipulation in the perioperative period could efficiently diminish stress and insulin resistance, as well as facilitate the early restoration of intestinal function in patients.Anesthesia and surgery could provoke perioperative neurocognitive dysfunction (PND), which is probably attributable to modifications in intestinal microecology. The administration of certain general anesthetics could result in a depletion of microbiome diversity as well as neurologically relevant metabolite variations.Enterococcus faecalis which contributed to the anastomotic fistula.Prolonged opioid treatment has been linked to microbial imbalances among humans and mice. Low-opioid multimodal analgesic strategy in ERAS could mitigate the detrimental effects of opioids on anesthetic awakening and postoperative bowel functions. Opioids administered for pain management have been demonstrated to induce expansion of pathogenic bacteria, bacterial translocation, immune dysregulation, and sustained inflammatory responses.Dietary changes could optimize surgical outcomes through effects on the gut microbiota. ERAS recommends preoperative oral carbohydrate beverages, nutritional condition improvement, and early postoperative reinstatement of transoral diet. Hyoju et al. have revealed that a short-term low fat/high fiber diet could prevent the detrimental impact of long-term HFD feeding on intestinal flora and anastomotic healing in mice.Intestinal flora serves an imperative role in dietary interventions to mitigate postoperative insulin resistance and catabolism. A dietary intervention study revealed a considerable increment of microbial pathways producing acetate and butyrate in patients with T2D after 12 weeks of consumption on a diet rich in combinatorial fiber mixture.Abiogenesis intrinsic taxa are engaged in ERAS to mediate the host response to inflammatory triggers, whereas the inflammatory reaction conversely exacerbates intestinal flora dysbiosis. Excessive inflammatory responses could originate during the perioperative period for manifold factors, including trauma, infection, intraoperative ischemia/reperfusion (I/R) injury, as well as imbalance in systemic oxygen supply and demand because of improper anesthetic management or circulatory instability. Perioperative inflammation management interventions in ERAS could optimize postoperative regression and long-term survival of patients.Lactobacillus and Ruminococcaceae were signatures of ecological misalignment because of I/R injury and were accompanied by a decrement in SCFAs levels, intestinal inflammation, and enteric leakage.A distinctive bifurcated correlation exists between intestinal flora and I/R injury.Clostridium difficile toxin A in Caco-2 cells via TLR-4 pathway.Moreover, ERAS recommended that all patients undergoing elective colorectal surgery should be considered for oral antibiotics (OAB). A multicenter, pragmatic, randomized controlled trial demonstrated that OAB prophylaxis the day before colon surgery could remarkably decrease the incidence of surgical site infections.Microbiota, comprising hundreds of bacterial strains, constitute an ecological network with more or less favorable status, which could be a formidable way to fulfill the commitment of precision medicine. Therefore, we envisioned targeting the unique microorganisms in each individual to avail personalized interventions for ERAS, especially in those patients suffering from metabolic and tumor diseases, which are intimately intertwined with intestinal flora .Figure 3Permissible techniques to modulate the microbiome comprise dietary interventions, probiotics or prebiotics, bacterial consortia, and fecal microbiota transplantation (FMT). Among them, diet, a key determinant of microbial community structure, is the most modifiable and relatively innocuous factor for perioperative patients. It has been established that personalized diets could successfully modify postprandial blood glucose elevation and consistent alterations to gut microbiota configuration.,The implementation of the ERAS strategy should be not only constrained to surgery but also integrated into the treatment of patients with malignancies to enhance prognosis and survival. Intestinal flora influences the mobilization of the immune system, facilitate cancer-related inflammation, and eventually affect the tumor response to therapy. Gut microbiota serves as a reservoir factor in moderating the anti-tumor immune response to chemotherapy,,,,Furthermore, there is accumulating evidence that microorganisms are also integral to the tumor tissue itself, with potential bacterial transfer from the intestine to the peritumoral milieu.C. difficile infection compared to MBP alone.This was the original collaboration between ERAS and intestinal microecology, which indicated that there was still a substantial gap in this field. The mediating ramifications of intestinal flora in the partial ERAS measures were synthesized, gaining novel insights into ERAS. However, challenges and controversies might also emerge with the lapse of time and the availability of new high-quality evidence. For instance, the ERAS guidelines recommended against the utilization of mechanical bowel preparation (MBP) in colonic operations. Nevertheless, a thorough meta-analysis recently demonstrated that the coadministration of OAB with MBP dramatically lowered the prevalence of global complications without an increase in The COVID-19 pandemic has brought unmissable opportunities and challenges for ERAS evolution. Formulating adequate perioperative nursing care for patients in need of acute and intensive caution related to COVID-19 infection is an urgent task. Gut microbiota might contribute to the magnitude of COVID-19 by registering the host immune response,in vitro, which are unable to reproduce the actual milieu of the gut, and hence neglect the cross-feeding network constituted by the intestinal microbiota and the host response. Notwithstanding these limitations, the availability of large and comprehensive datasets as well as the employment of computational tools portend a promising scenario for microbiome exploration. Over the forthcoming decade, we anticipated that preclinical and pertinent clinical studies would offer exhilarating new insights into how ERAS moderates immunometabolic phenotypes in host and distant tissues via the gut flora, leading to further enhancements for patients and health systems.Currently, most investigations covering the interactions between ERAS, microbiome, and human physiology remained pertinent, whereas only a few studies have delineated the underlying mechanisms of these three entities. In human experiments, a considerable group of participants is required to surmount the tremendous individualized variability among microbiomes. Moreover, functional research on bacterial metabolism are generally implemented in monocultures


Diffuse pulmonary ossification (DPO) is a rare condition of DLD (diffuse lung disease) characterized by the presence of metaplastic ectopic bone in the lungs and is less frequent in patients without a clear background of lung diseases. DPO is characterized by very small calcific nodules, often with bone mature located in both lungs and often in peripheral areas of the lungs. Two patterns of DPO have been recognized dendriform and nodular. The dendriform type is less common and is characterized by a coral-like network of bone spiculae along the alveolar septa and is often related to interstitial fibrosis or chronic obstructive lung disease . Recent  A 41-years-old male was referred to our hospital for persistent bronchitis. No significant anamnestic findings were evident: no history of smoking, environmental allergen exposure or infective disease, or family history of lung disease or connective tissue disease. Serology almost complete for panel of auto-antibodies was negative . On physical examination his vital signs were normal. For diagnostic completeness, the patient carried out an ECG trace and an echocardiography which were substantially within the normal limits. Chest examination was negative. Laboratory exams, including complete blood count, electrolyte analyses, and inflammatory markers were normal and also kidney function was normal. The functional tests detected a normal respiratory function but the DLCO/VA was moderately reduced (67% predicted). Arterial Blood gas analysis on room air shows normal blood oxygen and Co2 values in a normal range. Broncho-alveolar lavage (BAL) performed two days after admission, was normal. A chest X-ray (CXR) showed multiple pulmonary small nodules localized in both lungs from the upper fields to the lower fields, with a greater anatomical profusion in the middle fields . To furtDiffuse pulmonary ossification (DPO) is an unusual condition described for the first time by Luschka and colleagues in 1856, defined by the widespread presence of metaplastic bone in the lungs . HistoriThrough the literature review (Scopus-PubMed), the analysis of the reported cases, overall, demonstrates that DPO is a prevalent pathological phenomenon most commonly occurs in men in their 40–60s, but in rare cases, it has also been described in younger men and women ,18. The Since patients with PDO cannot benefit from specific therapy, the recommendation to treat and control any co-morbidities present is considered necessary, due to the potential fibrosing interstitial evolution linked to this rare disease.


Portal hypertension is responsible of the main complications of cirrhosis, which carries a high mortality. Recent treatments have improved prognosis, but this is still far from ideal. This paper reviews new potential therapeutic targets unveiled by advances of key pathophysiologic processes.Recent research highlighted the importance of suppressing etiologic factors and a safe lifestyle and outlined new mechanisms modulating portal pressure. These include intrahepatic abnormalities linked to inflammation, fibrogenesis, vascular occlusion, parenchymal extinction, and angiogenesis; impaired regeneration; increased hepatic vascular tone due to sinusoidal endothelial dysfunction with insufficient NO availability; and paracrine liver cell crosstalk. Moreover, pathways such as the gut-liver axis modulate splanchnic vasodilatation and systemic inflammation, exacerbate liver fibrosis, and are being targeted by therapy. We have summarized studies of new agents addressing these targets.New agents, alone or in combination, allow acting in complementary mechanisms offering a more profound effect on portal hypertension while simultaneously limiting disease progression and favoring regression of fibrosis and of cirrhosis. Major changes in treatment paradigms are anticipated. Portal hypertension (PH) is a major consequence of liver cirrhosis (LC) where its complications are key determining prognosis . These cPH becomes clinically significant (CSPH) when the porto-caval pressure gradient, measured clinically by the hepatic vein pressure gradient (HVPG) is equal or above 10 mmHg . PatientCirrhosis of the liver is responsible of about 90% of cases of PH in western countries, so we will focus on this disease. Cirrhosis is the result of a prolonged and progressive scarring process (liver fibrosis), caused by chronic injury and inflammation. Fibrosis leads to marked architectural liver disturbances, which are aggravated by loss of parenchymal cells due to vascular occlusion and ensuing tissue collapse, which makes that attempts of regeneration lead to the formation of regenerating nodules separated by fibrous tracts, which represents the hallmark of cirrhosis. Impaired liver regeneration and continued fibrogenesis further aggravate the process. Recent evidence suggests that cirrhosis is potentially reversible, but is not yet defined if, why, and when cirrhosis reaches a point of no-return . ReversiTreatment of PH at early stages is based primarily on controlling the etiological cause of the liver disease, to enhance the chance of reversing the architectural disturbances leading to PH. In addition, several studies have highlighted the role of relatively simple measures such as a safe lifestyle   and pro-inflammatory cytokines, activation of hepatic stellate cells (HSCs), and macrophages. These processes can be targeted with specific drugs, which is a relevant area of research.Splanchnic vasodilation and increased portal inflow represent the main extra-hepatic factor aggravating PH. This is mediated by increased NO availability , decreasIn addition to structural abnormalities (fibrosis and disruption of liver vascular architecture), an increased liver vascular tone further increases IHVR and is thought to represent about 30–35% of the total IHVR. So, interfering with this component has the potential to decrease portal pressure by over 30%, which should be enough for preventing most complications from PH , which iThe mechanisms leading to endothelial dysfunction are interconnected with those causing HSCs activation and fibrogenesis due to crosstalk between LSECs and HSCs, thus explaining how drugs improving endothelial dysfunction may also improve fibrogenesis (as it happens with statins and antioxidants). Moreover, some extrahepatic stimuli, specifically from the gut-liver axis, are also involved in activation of HSCs and explain the beneficial effects of Farnesoid X Receptor agonists, such as obeticholic acid. Hepatocytes finally undergo necroptosis; cell death stimulates the release of pro-inflammatory elements and contributes to HSC activation . The vasUnder these driving forces, the liver undergoes dramatic changes, the percentage of fibrotic tissue increasing at the expense of the functional parenchymal mass. Disrupted microcirculation generates areas of the parenchyma that become less perfused and together with parenchymal extinction progressively worsens IHVR. As stated before, initial progression of PH is dominated by structural elements, while thereafter extrahepatic factors increasingly contribute to aggravate PH by increasing both the portal blood inflow and the hepatic vascular tone .The complications of PH do not appear until the HVPG reaches values ≥ 10 mmHg . During Current drugs used for clinical management of LC patients are based on general therapy (lifestyle intervention), control of etiological factors, and use of drugs that counteract the splanchnic and systemic vasodilation. Up to now, this is achieved mainly by the oral administration of non-selective beta-blockers (NSBB)  for long-term therapy or somatostatin and analogs (mainly octreotide), and vasopressin derivatives such as terlipressin for short-term administration . The most recent therapeutic innovation is carvedilol, a NSBB that has intrinsic anti-adrenergic activity, this makes that it decreases portal venous inflow, but also the intrahepatic vascular tone, resulting in an enhanced reduction in HVPG even at low doses. This makes carvedilol the NSBB of choice , 18, 36.In this section, we discuss promising strategies to reduce structural and functional alterations leading to IHVR; a detailed list of drugs that act on these processes is shown in Table Structural changes and fibrogenesis contribute to progression of LC and PH. Although there is still not any approved antifibrotic drug, numerous efforts have been spent in developing candidate agents over the last decade. These efforts made it possible to clarify targets and pathways involved in liver fibrogenesis. Transforming growth factor β1 (TGF1) is a major contributor to HSCs activation, for which many different strategies have been proposed in the past. Monoclonal antibodies such as fresolimumab, currently in phase II clinical trial, can neutralize all isoforms of TFGβ . Lysil-oIndirect strategies for HSCs deactivation have raised considerable attention; antidiabetic drugs showed antifibrotic activity by reducing oxidative stress, inflammation, and consequently HSCs activation, such as antibodies against leptin receptor , metformOther drugs also have pleiotropic effects, including antifibrotic activity. Peroxisome proliferation-activated receptors  are nuclear hormone receptors which regulates cholesterol synthesis, whose deregulation is involved in inflammation, insulin resistance, and fibrogenesis. Re-activation of these receptors showed encouraging results in reversing liver fibrosis, inflammation, steatosis, and extrahepatic complications of chronic liver disease , 118–123Recently, the cannabinoid receptors CB1 and CB2, which mediate glucose and lipid metabolism and insulin signaling, and are overexpressed in hepatic fibrosis , have bevβ3-mediated HSCs apoptosis, may decrease liver fibrosis and reduce IHVR [Structural and functional changes are intimately linked. Strategies against functional alterations such as reversing the changes in LSECs phenotype could contribute to deactivation of HSCs via crosstalk. For instance, soluble guanylyl cyclase (sGC) which is highly expressed in most liver cells, causes vasodilation via cyclic guanosine monophosphate (cGMP) production , 128. sGuce IHVR . This tyuce IHVR .Thromboxane is a vasoconstrictor molecule which contributes to the increased vascular tone in advanced chronic liver disease (ACLD). Terutroban , an eicoOcclusion of small hepatic veins as a result of endothelial injury is thought to cause parenchymal extinction contributing to tissue collapse and architectural distortion during the progression of cirrhosis . This isStatins are drugs with pleiotropic effects on vascular biology that go beyond their lipid lowering capacity. Statins have been shown to act on several pathways, including Rho/ROCK and KLF2 , causingPDE5 is an enzyme which converts vasodilating cGMP into its inactive form and is increased in the cirrhotic liver. Its modulation using PDE5-inhibitors may have potential in the treatment of ACLD, as highlighted in a recent review . In the Tetrahydrobiopterin (BH4) is a cofactor for NO synthesis which is downregulated in cirrhotic livers. However, a trial of a synthetic analog of BH4, sapropterin, did not demonstrate any beneficial hemodynamic or functional effect over 2 weeks of treatment .LSECs inflammation and injury are accompanied by increased oxidative stress which contributes to LSECs capillarization. Oxidative stress via ROS production in all liver cells decreases the bioavailability of NO  by scaveInhibitors include angiotensin-converting-enzyme inhibitors (ACEIs), angiotensin-receptor blockers (ARBs), and aldosterone antagonists (AAs). In advanced cirrhosis, after developing a hyperkinetic circulation, RAAS is activated in response to splanchnic and systemic vasodilation and contributes to sodium and water retention. Moreover, angiotensin II is a powerful vasoconstrictor that in HSCs has profibrotic effects . SpironoThe FXR is a nuclear transcription factor responsive to bile acids. It is normally expressed in the liver but also in the intestine and kidney . In precIn PH progression, angiogenesis is stimulated by several stimuli. Impaired microcirculation due to distorted intrahepatic circulation and sinusoidal pseudo-capillarization, and fibrosis stimulates expression of hypoxia-inducible factors (HIFs) and inflammation, with ensuing release of vascular endothelial grow factor (VEGF) and other angiogenic factors  and platelet-derived growth factor (PDGF)). The elevated pressure causes LSECs stretching and phenotypic dysregulation and activation of the Raf/MEK/ERK pathway , 172. AmRho-kinase (ROCK) activity is correlated with activation of HSCs and endothelial dysfunction . A cliniEndothelin is a potent vasoconstrictor molecule produced by the endothelium, which is increased in patients with cirrhosis. Moreover, in cirrhosis, there may be a change in the distribution and responsiveness of the different endothelin receptors . This miThere are promising strategies to modulate extrahepatic targets that may influence PH, either by means of decreasing the portal blood flow or by modulating extrahepatic mechanisms that finally influence liver disease Table .Table 2ERelaxin is a vasodilatory and antifibrotic protein that is produced mainly by the ovary and breast in females and in the prostate in males. Important vasodilatory and antifibrotic properties have already been shown in pre-clinical studies –194, incSerum albumin is produced by the liver and is markedly decreased in decompensated LC. Moreover, it is structurally and functionally abnormal, jeopardizing its antioxidant, scavenging, and immunomodulatory non-oncotic properties . ConsequBacterial translocation is a frequent event in decompensated cirrhosis with ascites. Translocation may cause endotoxemia and may be preceded by translocation of bacterial products, DAMPs and PAMPs, with associated pro-inflammatory responses that may enhance progression of the liver disease, cause systemic inflammation, and in the case of bacterial translocation result in sepsis or severe bacterial infections, such as spontaneous bacterial peritonitis.The increased levels of endotoxin and pro-inflammatory cytokines contribute to endothelial dysfunction and vasoconstriction via ET-1 and vasoconstrictory prostanoids . LimitinLiver regeneration and fibrogenesis occur in parallel in chronic liver disease, although if liver injury continues, the process leads to the formation of cirrhosis, with regenerating liver nodules surrounded by fibrotic tracts, with a profoundly disturbed liver vascular architecture and IHVR. LSEC as well as quiescent HSCs and their crosstalk are important elements in support of the regenerative process. Cell therapy based on bone marrow transplantation was a promising approach to stimulate regeneration . Bone maA recent clinical trial studied the infusion of mature autologous monocyte-derived macrophages in patients with compensated cirrhosis with a change in MELD score at 90-day as primary outcome . Cell thKnowledge of the PH mechanism underwent continuous development since the concept of splanchnic vasodilation contributing to increase portal pressure was introduced in the 1980s, providing for the first time a rationale for using splanchnic vasoconstrictors for the complications of PH. Since then, understanding the molecular mechanisms of disease progression and careful clinical observations have allowed identifying multiple targets to improve treatment and patients’ management. This has been paramount to ameliorate short and long-term prognosis of patients with cirrhosis, for which we now have disease-modifying therapies. While the current therapy and management are mainly focused on the prevention of the complications of PH and the decompensation of cirrhosis, the novel strategies are centered in reducing the IHVR and in preventing/reversing fibrosis.Future therapy for PH is likely to involve multiple strategies aimed at acting on different mechanisms that act together and frequently synergistically promoting cirrhosis progression. New therapies that have shown promising results include the following: (i) statins, PPAR agonists, GLP-1 agonists, sGC activators and stimulators, enoxaparin, ribaroxaban, and dual or pan-FXR receptor agonists. Multiple RCTs are in progress, which makes the field of PH and cirrhosis a fascinating one, where rapid changes in management and prognosis are expected soon.


Pulmonary combined large-cell neuroendocrine carcinoma (CLCNEC) is a rare neuroendocrine tumor pertained to lung large cell neuroendocrine carcinoma (LCNEC) with aggressive behavior and poor prognosis generally. The clinical features of CLCNEC are not specific including cough, expectoration, chest distress, chest pain, etc., which are prone to have different manifestations of the mixed components. Owing to the low incidence, there are few related small-scale retrospective studies and case reports. Currently, the treatment regimen of CLCNEC mainly refers to LCNEC that complete surgical resection is preferred in the early stage and according to previous researches, platinum-based small cell lung cancer (SCLC) standard treatment regimen showed promising results in postoperative and advanced CLCNEC as compared to that of non-small cell lung cancer (NSCLC). Adenocarcinoma-CLCNEC more likely harbor driver gene mutation, and may benefit from targeted therapy. As for immunotherapy, more clinical trial data are needed to support its benefits. This article will fill the gap and will provide new insight into the clinical characteristics, pathological diagnosis and treatment endeavors of CLCNEC. Originating from argyrophilic cells in the mucosa of lung and bronchus , 2, lungIn 2015, world health organization (WHO) grouped typical carcinoid (TC), atypical carcinoid (AC), small cell lung cancer (SCLC) and LCNEC into neuroendocrine tumors (NETs)  and clasInstead of focusing on specified analysis of pure or combined parts, current studies on CLCNEC generally take all components as a whole , 18. By The diagnosis of CLCNEC is divided into two parts. Pathological manifestations of LCNEC part are complicated and volatile. The observation of the cell and tissue morphology through light microscopy combined with immunohistochemical (IHC) features and neuroendocrine particles under electron microscopy are required for precise and accurate diagnosis . The patAndo T et al. analyzedp = 0.112). The first-line group exhibit significantly longer median progression-free survival (PFS) for SCLC-based regimens than for NSCLC-based regimens . Additionally, median OS (mOS) was non-significantly shorter for CLCNEC than pure LCNEC (p = 0.083) due to limited sample size and potential follow-up bias. This result point out SCLC regimen as more appropriate choice as either first-line or adjuvant chemotherapy, when compared to the NSCLC regimen for LCNEC treatment. CLCNEC should be managed in a multidisciplinary setting, confirming the adjuvant chemotherapy  paramount importance to improve patients’ outcome [Currently, the common treatment regimen of CLCNEC mainly refers to LCNEC that complete surgical resection is preferred for limited-stage (I-IIIA) according to the NSCLC guidelines announced by The National Comprehensive Cancer Network (NCCN). The SCLC-like or NSCLC-like postoperative adjuvant chemotherapy selection for advanced or metastatic CLCNEC is remained controversial. Recent clinical studies reported the prognosis of LCNEC patients receiving SCLC chemotherapy regimen was more effective as compare to that of NSCLC –36. Zhan outcome .In the last decade, immunotherapy has dramatically changed the natural history of NSCLC optimizing OS and life quality of patients . PrelimiCLCNEC presented a higher probability of driver gene mutations than pure LCNEC due to its NSCLC part , 42. Wanp < 0.001). Comparing mOS of pure LCNEC with CLCNEC, the latter was found more aggressive (p = 0.083). Handa Y et al. [p = 0.020) and pathological stage  to be independent prognostic factors of OS. There is no statistical difference in 5-year OS rates and 5-year recurrence-free survival (RFS) rates of CLCNEC and pure LCNEC . Therefore, the researchers concluded that the prognosis of CLCNEC patients were equivalent to that of pure LCNEC. The differences in OS between CLCNEC and LCNEC patients in the above literatures may be caused due the limited data availability in retrospective studies with selective bias.CLCNEC exhibit a high degree of malignancy with relatively poor prognosis. Wang Y et al.  conducteY et al.  collecteA growing evidences proved that CLCNEC is a neuroendocrine carcinoma with high-grade morphological and biological heterogeneity and aggressive tumor malignancy. Due to lack of definitive evidences, the CLCNEC is short of standardized treatment strategy and follow LCNEC diagnosis and treatment strategies more evidently the complete surgical resection is preferred in early stages of I and II. In postoperative and advanced stages, SCLC-like standard chemotherapy is advised to be the best option as compared with NSCLC chemotherapy. The CLCNEC patients rarely benefit from immunotherapy, and large-scale clinical trials are still needed. It is a common evidence that CLCNEC harbor driver gene mutations such as EGFR mutation more commonly. The targeted drug has been proven to be clinically effective and can improve OS and achieve higher ORR. However, the available studies regarding CLCNEC treatment are mostly small samples and retrospective, showing discrepant results, contributing to low level of evidence. Hence further research needed to be done to design larger prospective studies to unveil the optimal treatment strategy for CLENEC.To date, it is still not investigated whether the treatment strategy aiming at LCNEC components ignoring the combination components will lead to acquired-resistant. The constituents of treatment may be selected in accordance with the reported efficacy of the relevant regimens for each component of combined LCNEC. Whether chemotherapy combined with targeted drugs and ICIs could achieve longer OS is a direction for future exploration, which needs a number of clinical trials.


Jiri Neuzil and colleagues review the processes and mechanisms that underlie horizontal mitochondrial transfer (HMT) and the metabolic consequences of HMT in cells. Mammalian genes were long thought to be constrained within somatic cells in most cell types. This concept was challenged recently when cellular organelles including mitochondria were shown to move between mammalian cells in culture via cytoplasmic bridges. Recent research in animals indicates transfer of mitochondria in cancer and during lung injury in vivo, with considerable functional consequences. Since these pioneering discoveries, many studies have confirmed horizontal mitochondrial transfer (HMT) in vivo, and its functional characteristics and consequences have been described. Additional support for this phenomenon has come from phylogenetic studies. Apparently, mitochondrial trafficking between cells occurs more frequently than previously thought and contributes to diverse processes including bioenergetic crosstalk and homeostasis, disease treatment and recovery, and development of resistance to cancer therapy. Here we highlight current knowledge of HMT between cells, focusing primarily on in vivo systems, and contend that this process is not only (patho)physiologically relevant, but also can be exploited for the design of novel therapeutic approaches. Mitochondria are essential organelles with multiple functions. As proteobacterial endosymbionts , mitochoA prominent feature of mtDNA is its heteroplasmy  mediated by tissue-specific non-random segregation . HeteropMitochondria have been increasingly linked to metabolic reprogramming and differentiation . MitochoAlthough the role of mitochondria in cell biology and pathophysiology has been studied and is relatively well established, novel properties of mitochondria and their regulation keep emerging. For example, it has been shown that not all eukaryotes contain mitochondria, with metabolic function being at least in part maintained by complementary systems . MitochoA prominent place among recent intriguing findings is the identification of horizontal mitochondrial transfer (HMT) with their DNA payload between mammalian cells in vivo in a tumor setting  and duriPrior to these studies, horizontal transfer of genes in eukaryotes had been considered rare , known oThis Review highlights recent evidence of HMT between cells in vitro and, in particular, in vivo. The different possible modes of HMT, cellular and molecular mechanisms underlying each type of HMT, and metabolic consequences of HMT-related events in physiological and pathological settings linked to pervasive plasticity and therapeutic potential will be discussed.Intercellular communication is essential for maintaining homeostasis in multicellular organisms. The modes of cell-to-cell communication are diverse, including entry of various signaling “entities” across the cell membrane , interceA landmark paper defined the so-called “highways for intercellular organelle transport” . This waTNTs have been reported to translocate various organelles, including endosomes , ER Kad, Golgi/EDonor cells are often MSCs . Other tIn vivo relevance of HMT has been established by several key publications. HMT from MSCs grafted into lungs of mice challenged with lipopolysaccharide (LPS) was documented using mitochondria-competent MSCs, which alleviated the injury . Using aMitochondrial dysfunction is associated with many types of human disease . Transfe0 cells devoid of respiratory function. Co-culture with MSCs or skin fibroblasts rescued ρ0 cells by import of functional mitochondria  function and thymidine kinase activity, with impaired de novo synthesis of pyrimidines , ECs use mitochondrial respiration to support stress resistance and biosynthesis . DespiteUnidirectional mitochondrial transfer was found in the direction of CMs upon co-culture of human MSCs with rat CMs , or fromRecently, it was shown that cardiac tissue releases “damaged” mitochondria via extracellular vesicles (ECVs) called exospheres are taken up by macrophages via their Mertk surface receptors and disposed of , contrib2+, and sending signals modulating neuronal survival  controls basic physiological functions, emotional changes, and mental health . Mitochosurvival . Vesiclesurvival . Contrarsurvival , and neusurvival . In the survival . Intercesurvival , and thisurvival .Mitochondrial motility not only impacts on tissues/cells in the CNS but also in the peripheral nervous tissue. A recent experiment demonstrated that exogenous mitochondria transplanted into injured rat spinal cord contribute to acute maintenance of bioenergetics as well as functional recovery after spinal cord injury . Mitocho. Mitochondria from astrocytes transfer to cerebrospinal fluid after subarachnoid hemorrhage, both in a rat model and humans  can be engulfed by MSCs and rapidly degraded. As a consequence, elevation of heme levels in the cytosol of recipient MSCs triggered upregulation of heme oxygenase-1, a stress-inducible protein endowed with cytoprotective properties that converts toxic heme into health-promoting compounds . Thus, hIn vitro studies found that intercellular transfer of mitochondria can be bidirectional. This is exemplified by exchange of mitochondria between renal tubular cells and mesenchymal multipotent stromal cells . BidirecPathological and non-pathological systems in which mitochondrial transfer has been documented are summarized in Intercellular mitochondrial transfer is important in multiple scenarios during physiology and pathophysiology. Mechanisms of HMT between cells are diverse as discussed in more detail below, including tunnelling nanotubes/cytoplasmic bridges, gap junctions, cell fusion, endocytosis of vesicles, or as free organelles . The varThe most studied mechanism of HMT is by means of F-actin–based cytoplasmic bridges referred to as TNTs . TNTs arTwo basic mechanisms of TNT formation exist: actin-driven protrusion of the cell membrane that fuses with another cell or its protrusion and “cell dislodgement,” where two initially attached cells part from each other, forming a TNT containing F-actin filaments . ExistenMitochondria associate with actin or tubulin fibers by means of Miro proteins, playing a role in mitochondrial transport . In vitrOccurrence of TNTs is a rather infrequent process taking place under a wide range of physiological conditions  and different pathological situations including tumor formation and metastasis . TNTs prStress signals generated during cellular mitochondrial damage, together with elevated levels of ROS, prompt donor cells to enhance their bioenergetics and initiate mitochondrial donation to injured recipient cells . FormatiDonor cells other than MSCs also transfer mitochondria via TNTs to recipient cells. Within the same cell type, healthy cells donate mitochondria to their injured counterparts. Pheochromocytoma (PC12) cells exposed to UV light were rescued when co-cultured with untreated PC12 cells. This was promoted by TNTs formed by the stressed cells, allowing for transfer of functional mitochondria and rescuing the cells from apoptosis . PorcineTNTs also form between lung epithelial cells over distances from 1 μm to more than 100 μm . In vitrGap junctions couple nearly all cells that line external and internal surfaces of the human body, being known for transferring small molecules between cells . During Interestingly, the role of Cx43 in the process of TNT formation was also shown in other models of HMT, for example in asthmatic inflammation, virus infection and leukemia , indicatCell fusion is a process of two individual cells fusing their plasma membranes, sharing organelles and cytosolic compounds while their nuclei remain intact . CytosolECVs are lipid-bound structures secreted into the extracellular space . They inDelivery of mitochondria by ECVs participates in immune regulation, modulating the function of macrophages and neutrophils and other cells, including alveolar epithelial cells, neurons, and ECs, and contributing to intercellular communication . The firECV-mediated HMT was found to occur between renal scattered tubular cells and tubular epithelial cells to alleviate renal stenosis and to recover mitochondrial respiration . MitochoAn interesting form of HMT between cells (or even organs) in response to stress involves release of damaged mitochondria from adipocytes in ECVs, with individual mitochondria originating from mitochondria-derived vesicles formed by budding from the mitochondrial network . The funA novel means of HMT has recently emerged involving migrasomes  that forHMT has been shown to play a critical role in cell and tissue regeneration, and in damage repair, or may contribute to healing processes in brain injury, ischemic heart disease, muscle sepsis, stroke, and lung disorders . VariousIn cancer, chemotherapy is mostly directed at cancer cells, driving them into apoptosis. Tumor cells importing mitochondria from stromal cells are better protected from apoptosis induced by chemotherapy or radiation therapy . HMT froAnother consequence of HMT particularly important for rapidly proliferating cancer cells relates to the ETC playing an essential role in anabolic cell proliferation . InvasivHMT is triggered by severely affected mitochondrial functions, such as mtDNA deletion or treatment with mitochondrial inhibitors . We showRegulation of mtDNA copy number in tumorigenesis , controlMitochondria are not only the primary powerhouse of cells, but also important regulators of life, death, proliferation, motility, stemness, and other functions . Whole mOur discovery that cancer cells lacking mtDNA acquire mitochondria from stromal cells to promote cancer progression  can be rHMT contributes to the rescue of mitochondrial function in recipient cells. It is a “double-edged sword” that provides both benefit and harm to cells and tissues, depending on the context. Its therapeutic implications are also twofold. HMT is detrimental in cancer where new mitochondria can rejuvenate damaged cancer cells and promote tumorigenicity, thus therapeutical benefit will be provided by inhibition of the process. In situations where new mitochondria enable normal tissue homeostasis, tissue stress resistance, or wound healing, therapeutic benefit will be provided by increased HMT. While pharmacological intervention targeting HMT is in an experimental stage, we outlined approaches with potential therapeutical relevance that imply mitochondrial transfer. The priority in this context is to identify molecular targets allowing selective modulation of HMT without compromising physiology of mitochondria and the cytoskeleton. An overview of possible therapeutic implications of mitochondrial transfer is in The primary goal of HMT-focused therapy in cancer is to curb tumorigenicity and resistance associated with mitochondrial fitness of cancer cells . Cancer Pharmacological targeting of HMT may be applied in hematologic malignancies since HMT contributes to treatment resistance. Inhibition of the adhesion molecule ICAM-1 and treatment with cytochalasin D, an inhibitor of actin polymerization that disrupts TNTs, prevents mitochondrial transfer from MSCs to leukemia cells, promoting chemotherapy-induced cell death . ApplicaPharmacological targeting of HMT has been pursued in solid tumors. Breast/lung cancer cells hijack mitochondria from tumor-resident immune cell via TNTs, dampening the anti-tumor immune response and reducing the effectiveness of immune checkpoint therapy. Pharmacological inhibition of TNT formation in syngeneic subcutaneous mouse models of lung and breast cancer by the farnesyl/geranyl-1 transferase inhibitor L-778123 (inhibits Ras/Rho GTPase activity required for TNT formation) enhanced the efficacy of immune checkpoint blockade, restored immune response, and limited tumor growth . HMT wasIn non-cancerous pathologies HMT is mostly beneficial. HMT improves the outcome of neurological injury and degenerative diseases affecting the brain, spinal cord, and visual system , cardiovThe therapeutic potential of mitotherapy was first explored in the cardiovascular system during ischemia/reperfusion injury. Respiration-competent mitochondria, isolated from healthy cardiac tissue, injected directly into the ischemic area of rabbit hearts during early reperfusion, enhanced myocardial functional recovery and cell viability . AutologMitotherapy was also extensively explored in the central and peripheral nervous system. Mitochondria derived from hamsters administered either via local intracerebral or systemic intraocular-arterial injection attenuated the area of brain infarction and neuronal death, and restored motor performance in a stroke model of middle cerebral artery occlusion . AdminisBesides mitotherapy, there are indirect approaches to stimulate HMT into damaged cells by delivery of efficient mitochondrial donors, such as MSCs that, once in close proximity, transfer mitochondria to recipient cells by ECVs or TNTs. Application of induced pluripotent stem cell-derived MSCs resulted in Miro1-dependent transfer of mitochondria, rescuing anthracycline-exposed CMs . AdminisThat HMT has a wide range of applications can be epitomized by two recent studies. Iron oxide nanoparticles enhanced formation of Cx43-containing gap junctions and increased the rate of HMT from administered MSCs in a model of pulmonary fibrosis ; and expSince the discovery of HMT in vitro  and in vHeterogeneity, mutations, and deletions in mtDNA have been implicated in a wide range of diseases, frequently involving neurodegenerative/neuromuscular pathologies . It is pFaster implementation of mitotherapy, in particular based on HMT, is hindered due to methodological limitations. Unequivocal evidence for acquisition of mitochondria in vivo was provided by stable homoplasmic polymorphisms in mtDNA , known tAlmost 20 yr after the discovery of mitochondrial transfer in vitro  and <10


Parkinson’s disease (PD) is a neurologic degenerative condition with complex neuropsychiatric manifestations which can be challenging to manage and greatly impact quality of life and prognosis.The description of this case aims to highlight the complex interaction between PD, drug-abuse and impulse control disorder (ICD).Clinical information was obtained through patient interviewing and medical records consulting. A literature review on the topic was conducted.We report the case of a 52-years-old male with PD diagnosed at the age of 45, presenting with rigidity of right limbs and freezing of gait. He had a history of multiple substance-abuse: hashish, heroin and cocaine, with cessation of all substances by the age of 40. The patient responded well to antiparkinsonian medication initially, but needed frequent adjustments and developed ICD secondary to dopamine agonists, presenting pathological gambling and hypersexuality. At 47 he restarted using cocaine stating that it diminished the motor symptoms. Motor symptoms worsened and became partially responsive to medication. Pharmacologic options were limited due to ICD. He developed dopamine dysregulation syndrome, abusing dopaminergic drugs and requesting multiple prescriptions. Deep brain stimulation surgery was proposed, but the patient was deemed unfit for the procedure after two separate psychiatric evaluations, mainly because of behaviour and social problems in relation to sustained cocaine abuse and personality disorder. Attempts to stop drug abuse were unsuccessful despite several interventions by addiction psychiatry.Co-occurrence of PD, substance-abuse and personality disorder poses as a therapeutic challenge conditioned by pharmacological iatrogenesis and behavioural disturbances, requiring a multidisciplinary and individualized approach.No significant relationships.


Original organics and soft tissues are known to persist in the fossil record. To date, these discoveries derive from a limited number of ancient environments, , and fossils from rarer environments remain largely unexplored. We studied Cretaceous–Paleogene fossils from a peculiar marine environment (glauconitic greensand) from Jean and Ric Edelman Fossil Park in Mantua Township, NJ. Twelve samples were demineralized in acid to remove the mineral component of bone. This treatment frequently yielded products that are visually consistent with bone cells, blood vessels, and bone matrix from modern animals. Fossil specimens that are dark in color exhibit excellent microscopic bone preservation and yielded a greater recovery of original soft tissues, whereas light-colored specimens exhibit poor microscopic preservation and yielded few to no soft tissues. Additionally, a well-preserved femur of a marine crocodilian was found to retain original bone protein by reactions with antibodies. Our results: (1) corroborate previous findings that original soft tissue and proteins can be recovered from fossils preserved in marine environments, and (2) expand the range of ancient environments documented to preserve original organics and soft tissues. This broadens the suite of fossils that may be fruitful to examine in future paleomolecular studies.Thoracosaurus was found to have retained endogenous collagen I by immunofluorescence and enzyme-linked immunosorbent assays. Our results thus not only corroborate previous findings that soft tissue and biomolecular recovery from fossils preserved in marine environments are possible but also expand the range of depositional environments documented to preserve endogenous biomolecules, thus broadening the suite of geologic strata that may be fruitful to examine in future paleomolecular studies.Endogenous biomolecules and soft tissues are known to persist in the fossil record. To date, these discoveries derive from a limited number of preservational environments, , and fossils from less common depositional environments have been largely unexplored. We conducted paleomolecular analyses of shallow marine vertebrate fossils from the Cretaceous–Paleogene Hornerstown Formation, an 80–90% glauconitic greensand from Jean and Ric Edelman Fossil Park in Mantua Township, NJ. Twelve samples were demineralized and found to yield products morphologically consistent with vertebrate osteocytes, blood vessels, and bone matrix. Specimens from these deposits that are dark in color exhibit excellent histological preservation and yielded a greater recovery of cells and soft tissues, whereas lighter-colored specimens exhibit poor histology and few to no cells/soft tissues. Additionally, a well-preserved femur of the marine crocodilian  Numerous molecular paleontological investigations have been conducted on geologically ancient fossils, , degree of consolidation (unconsolidated vs. consolidated), and grain size see . A few sk et al. , and then et al.  were repn et al.  and Lindn et al.  investigHerein, we examine marine fossils collected from the Jean and Ric Edelman Fossil Park (EFP) at Rowan University in Mantua Township, New Jersey. All specimens were recovered from the Late Cretaceous (Maastrichtian)–early Paleogene (Danian) Hornerstown Formation. All but two of the examined specimens derive from the same assemblage: the Main Fossiliferous Layer (MFL). The MFL is a rich, 10 cm thick, multitaxic bonebed that begins approximately 20 cm above the base of the Formation . As in tThoracosaurus for the preservation of the primary structural protein collagen I using molecular assays.We considered the Hornerstown Formation as a lithosome potentially favorable for the preservation of endogenous organics because glauconite is rich in iron, which has been suggested to aid in molecular preservation. Specifically, it has been hypothesized that dissolved iron in diagenetic pore fluids reacts with peroxides sourced from decaying lipids to form iron free radicals, which in turn can induce chemical chain reactions resulting in crosslinking of biomolecules, their decay products, metal cations in solution, and dissolved humics ,32,33. TThoracosaurus scute RU-EFP-00006-8, drawn from collections) were set aside immediately after discovery for molecular analyses by wrapping each in sterilized aluminum foil and placing them in autoclave-sterilized mason jars with silica gel desiccant beads. Collection was performed while wearing nitrile gloves to limit contamination, and specimens were stored in climate-controlled buildings, thus minimizing temperature and humidity fluxes after collection. Sediment that was adjacent to, but not in contact with, each fossil was collected for use as a negative control and stored as above. To avoid the possibility that glue residues could be mistaken for biological structures, no glues or stabilizing agents were used during either excavation or preparation of specimens. Eight specimens were recovered from the MFL and two were recovered from the upper Hornerstown Formation. Taxonomically, the specimens derive from the turtles Euclastes, Taphrosyphs, and two other unidentified turtles, the gavialoid crocodilian Thoracosaurus, and another unidentified crocodilian. Further details about each specimen are provided in Fossil specimens examined herein were collected from the Hornerstown Formation between 2011 and 2019; most were collected as part of a systematic grid excavation of the MFL . In the Thoracosaurus neocesariensis. The right femur (Alligator mississippiensis) served as a modern positive control for biomolecular assays . Both modern and fossil molecular analyses were conducted with solely cortical tissue.Specimen RU-EFP-00006 is a partially articulated skeleton of ht femur A was choht femur . AdditioThoracosaurus femur RU-EFP-00006-11) was demineralized at NCSU, seven samples were demineralized in a designated, sterilized, fossil-only chemical fume hood at Drexel University, and four were demineralized in a similarly dedicated, sterilized chemical fume hood at Rowan University. Negative controls, which included buffer-only solutions and sediments demineralized and/or co-extracted in the same reagents, were evaluated in tandem with the fossil for all assays. For immunoassays, specificity controls were also conducted (see below). Procedures for all controls and modern/fossil samples were performed in exactly the same manner unless otherwise noted. Three replicates were completed of each assay.All fossil analyses were performed in a permanently dedicated, fossil-only laboratory at North Carolina State University  that it is the most abundant protein in bone ,41,42,43® Heavy Duty 60 Minute epoxy . Thin sections were then ground to an appropriate thickness (~100 µm) and polished. The Histological Index (HI) of Hedges and Millard )~150 min . At thisFossil demineralization products reacted positively with polyclonal anti-chicken collagen I antibodies. Fluorescence was only observed in primary antibody-incubated tissue sections and was well above the negligible background fluorescence of secondary-only controls A–C. FluoAlligator bone demineralized with HCl exhibited relatively dimmer fluorescence than previous Alligator samples demineralized with EDTA and treated with the same primary antibodies , and studies of regional sequence stratigraphy  imply thTaphrosphys peripheral RU-EFP-02175) only yielded rare osteocytes, and crocodile humerus RU-EFP-00030-2 also only yielded rare osteocytes likely because it appears to be preserved in a state of partial degradation. Additionally, when present, the osteocytes recovered from light bones were typically poorly preserved,  compared to those from dark bones retaining well-preserved histology (HI = 4–5), which more frequently retain long, branching filopodia with multiple ramifications. The only other specimen to yield rare osteocytes (and no vessels or fibrous matrix) was turtle peripheral RU-EFP-02245. Although this specimen only exhibits a thin external rim of light bone, it is primarily composed of highly porous cancellous bone; its accordingly low volume of bone material may have reduced the chances of recovering soft tissues from this specimen, regardless of its level of preservation. All other specimens with a thin layer of light bone or composed entirely of dark bone yielded a consistently greater recovery of cellular and soft-tissue microstructures . This histologic alteration appears responsible for light bones yielding few cells and soft tissues upon demineralization . For exaructures . Based on our results, there appears to be no association (for these 12 specimens) between soft tissue preservation and either taxon, skeletal element, quality of macroscopic preservation, cortical thickness, or bone tissue type, . Of the limb bones sampled, only two yielded abundant cellular and soft tissue microstructures even though all are well-preserved at the gross-morphology level. At this locality, and based on current information, the best predictor of histologic and soft tissue preservation appears to be bone color: bone tissues that are dark are histologically well-preserved bones and generally yield far greater soft tissue recovery upon demineralization. A correlation between morphologic quality and molecular preservation has been suggested previously ,39,63,64Dimetrodon bone. As in our study, these authors were able to successfully demineralize their specimen in a solution containing HCl. The cause of such cases of slow demineralization in EDTA remains unknown. Powder XRD analyses identified RU-EFP-00006-11 as being primarily composed of fluorapatite (3+ ions or quartz with Si4+ ions) which cannot be chelated by EDTA is an unlikely explanation. It is possible that significant substitution of trivalent cations for divalent Ca2+ ions in bone apatite could hinder the demineralization process , but fuOsteocytes were the most abundant microstructures recovered from our EFP specimens. The common lack of recovery of microstructure morphologically consistent with blood vessels, at least in our crocodilian samples, may be due to the rarity of vessels in the original cortical/cancellous bone tissue. The cortex in modern crocodilians is not as vascular as that of non-avian dinosaurs ,70,71 orAlligator extracts exhibited less smearing and better banding than the fossil extracts (Taken together, our molecular assays support the conclusion that the soft tissues and collagen I recovered from this specimen are endogenous. Though a PAGE with silver-stain assay is not a specific test for collagen I or proteins, it can identify the presence and molecular weights of organic compounds in a sample, making it an informative screening assay for paleomolecular studies ,20,73. BThoracosaurus. Given the recognition of unique, albeit non-specific, organics in RU-EFP-00006-11 by silver-staining, we next performed ELISA and in situ immunofluorescence as independent assays to identify if the primary structural protein collagen I was present in both whole-bone extracts and demineralization products, respectively. These assays complement one another as ELISA is approximately an order of magnitude more sensitive than immunofluorescence ,77, wherAlligator tissue samples analyzed by in situ immunofluorescence exhibited fluorescence when exposed to polyclonal antibodies raised against chicken collagen I (Alligator, they were predicted to also bind to fossil crocodilian collagen I. The fluorescence signal exhibited by the fossil tissues was lower in intensity compared to the modern Alligator (Modern llagen I G,H. Togellagen I , these rlligator B,C, yet lligator A. Fluorelligator , again sThoracosaurus femur. PAGE with silver-staining exhibited evidence for organics in this fossil, and ELISA and in situ immunofluorescence results each independently support retention of collagen I in this specimen. Collectively, our results and those of previous authors [Our paleomolecular investigations of fossils preserved in the glauconitic, shallow-marine depositional environment of the Hornerstown Formation at EFP add a unique paleoenvironment to the growing list of those which have yielded biomolecular and soft tissue preservation within fossil bones. This depositional environment was rich in iron at the time of burial and remained rich in iron due to the glauconite-dominated composition of the sediments and influx of dissolved iron from recent groundwaters. We hypothesize that this abundant supply of iron may have facilitated soft tissue and biomolecular preservation in these specimens via the free radical-induced crosslinking reactions elucidated by Boatman et al. . Soft ti authors ,10,16,35 authors  and Hedg authors  that rel


Olfactory impairments contribute to the psychopathology of mental illnesses such as schizophrenia and depression. Recent neuroscience research has shed light on the previously underappreciated olfactory neural circuits involved in regulation of higher brain functions. Although environmental factors such as air pollutants and respiratory viral infections are known to contribute to the risk for psychiatric disorders, the role of nasal inflammation in neurobehavioral outcomes and disease pathophysiology remains poorly understood. Here, we will first provide an overview of published findings on the impact of nasal inflammation in the olfactory system. We will then summarize clinical studies on olfactory impairments in schizophrenia and depression, followed by preclinical evidence on the neurobehavioral outcomes produced by olfactory dysfunction. Lastly, we will discuss the potential impact of nasal inflammation on brain development and function, as well as how we can address the role of nasal inflammation in the pathophysiological mechanisms underlying psychiatric disorders. Considering the current outbreak of Coronavirus Disease 2019 (COVID-19), which often causes nasal inflammation and serious adverse effects for olfactory function that might result in long-lasting neuropsychiatric sequelae, this line of research is particularly critical to understanding of the potential significance of nasal inflammation in the pathophysiology of psychiatric disorders. Alterations in multiple sensory modalities, including auditory, visual, and olfactory processing, have been reported in patients with psychiatric disorders, such as schizophrenia and depression, and these deficits may underlie complex cognitive dysfunctions –9. WhileEvolutionarily, the olfactory system is a crucial sensory modality, essential for survival behaviors and behavioral adaptation upon detecting odor cues , 15. OdoAccumulating evidence suggests that olfactory impairments are involved in the pathology of Alzheimer’s disease and Parkinson’s disease , 24. In There is a large body of clinical evidence indicating that inflammatory processes are involved in the pathophysiology of schizophrenia and depression , 60. ComIn this article, we will first give an overview of published findings on how nasal inflammation impacts the olfactory system. We will also summarize clinical evidence on olfactory impairment in psychiatric disorders, with a particular focus on schizophrenia and depression. We will then provide an overview of preclinical studies on the neurobehavioral outcomes produced by olfactory dysfunction. Finally, we will discuss the potential impact of OE inflammation on brain development and function, as well as in disease-associated mechanisms, which may contribute to understanding the importance of OE inflammation in the pathophysiology of psychiatric diseases.The OE is located at the dorsal and posterior portion of the nasal cavity, variably extending inferiorly along the nasal septum and turbinates . HistoloOE inflammation has been extensively studied in chronic rhinosinusitis, which is a common heterogeneous inflammatory condition of unknown origin. Regardless of whether it results from an external trigger  or an underlying intrinsic immune dysregulation, sinonasal inflammation causes symptoms of nasal congestion, drainage, and, in many cases, a diminished sense of smell. Most likely, a reduction in airflow plays an important role in olfactory loss as there is decreased conduction of odorants to the olfactory cleft. However, there is also a significant sensorineural component to olfactory loss that is not completely understood. This is at least in part because chronic inflammation damages the olfactory neuroepithelium and inhibits its regeneration , 74.The cellular and molecular mechanisms underlying air pollutant-induced nasal inflammation have begun to be investigated, mainly with a focus on the effect of particulate matter (PM) . For insRespiratory viral infections, such as influenza virus and coronavirus, induce olfactory inflammation , 82. PreIt is conceivable that OE inflammation impacts central olfactory neural structures. Both chronic rhinosinusitis as well as neurodegenerative and psychiatric diseases are found to involve OB volume loss , 97–99. In order to investigate how nasal inflammation impacts OE function, a genetic mouse model of inducible olfactory inflammation (IOI) has been developed . In thisOlfactory impairments have gained growing interest in psychotic disorders, such as schizophrenia , 25, 48.Accumulating evidence does indicate that various olfactory deficits are associated with negative symptoms and impaired social and cognitive function in patients with schizophrenia and early psychosis , 56, 112Neuroimaging studies reveal structural and functional abnormalities in various brain regions involved in olfactory processing in schizophrenia , 46, 48.While the pathological implication of olfactory impairment for schizophrenia has been extensively studied, the specific role of nasal inflammation in the developmental course of olfactory dysfunction is underexamined. The OE is the peripheral region of the olfactory system in the nasal cavity, where OSNs are directly exposed to the environmental stimuli . SeveralRespiratory viral infections  induce olfactory inflammation , 82. Pre2) exposure is associated with an increased risk of developing schizophrenia ) in depressive patients [2.5 exposure is involved in altered cortical neural circuit networks in patients with depression [Respiratory viral infections and air pollutants are potential environmental risk factors not only for schizophrenia and psychosis, but also for depression. For instance, a population-based study showed that people with a previous influenza infection had an increased risk of developing depression . Similarpatients , 67. In pression .The pathological implication of nasal inflammation is also supported by evidence that chronic rhinosinusitis is associated with an increased risk of depression , 102. AlStudies have reported reduction of OB volume in patients with major depressive disorder, as well as negative correlation between OB volume and depression scores . OlfactoBehavioral changes caused by olfactory dysfunction are observed in multiple rodent models Table . Surgicacyclic nucleotide gated channel subunit alpha 2 (Cnga2), which is essential for regulating odorant signal transduction, resulted in impaired spatial memory and social behaviors, as well as anxiety-like behavior [Rag-1), which is expressed not only in the lymphoid cells but also in OSNs, caused disorganized glomeruli structure in the OB, impaired odor-sensing, and anxiety-like behavior [Behavioral outcomes have also been elicited by genetic inhibition of olfactory function. Genetic deletion of behavior –167. OSNbehavior –170. Genbehavior . Furtherbehavior , 73. DifIt should be noted that rodents largely depend on olfaction for sensing the external world—more than humans do—and that their performance in specific behavioral phenotypes such as social behaviors, heavily depends on olfaction. By examining the behavioral impact of manipulating specific olfactory-prefrontal neural circuits such as the OB-AON-mPFC and OB-Pir-OFC pathways, rodent models may help us to identify neural substrates involved in olfactory modulation of higher brain functions. In particular, it is of interest to examine the roles of olfactory-prefrontal circuits in the modulation of behavioral outcomes in positive valence systems, social processes, and cognitive systems: areas in which disturbances are associated with olfactory impairments in psychiatric disorders , 54, 56.In order to examine whether nasal inflammation-induced disturbance in the peripheral olfactory system indeed causes behavioral alterations of neuropsychiatric relevance, we have recently investigated the adverse effects of chronic and local OE inflammation on behavioral consequences using the aforementioned inducible olfactory inflammation (IOI) mouse model , 172. WhIn addition, rodent models of exposure to environmental risk factors for psychosis such as air pollutants and microbial infections displayed OE inflammation and OB volume loss –177. AdoThe question arises of how local OE inflammation contributes to neural dysfunction underlying behavioral phenotypes relevant to psychiatric disorders. There are several possibilities to be explored for the mechanistic routes of OE inflammation impacting the CNS: 1) OSN dysfunction induced by OE inflammation resulting in abnormalities in the structural or functional composition of the OB; 2) OE inflammation spreading to the CNS through the OB; and/or 3) direct translocation of virus and air pollutants to the olfactory system. These changes may contribute to disturbance of olfactory-prefrontal circuits, leading to neurobehavioral consequences relevant to psychiatric symptoms  [As described above, olfactory deficits are observed early in disease progression, including during the prodromal stages , 57, 58.-Kir2.1) –190 willIn the past decade, multiple lines of evidence from clinical studies and neuroscience research have shed light on the underappreciated olfactory pathway for regulation of higher brain function and its implications for the pathophysiology of psychiatric disorders such as schizophrenia and depression in a cross-disease manner. As growing evidence suggests that inflammatory processes play a role in disease pathophysiology, it is important to explore if and how OE inflammation induces molecular and neuronal alterations in the OE that provoke impairment in olfactory circuit-mediated brain systems, leading to neurobehavioral consequences relevant to these disease conditions.This area of research is particularly critical when we consider the current outbreak of COVID-19, which may increase the risk of psychiatric disorders via nasal inflammation. However, it should be noted that the psychological stress produced by social isolation and restriction may also be involved in the increased risk of psychiatric disorders in patients with COVID-19. Although this variable is difficult to address in clinical research, it is testable in preclinical studies. By using rodent models of social isolation and SARS-CoV-2 infection, we can explore how social isolation may have a convergent effect with SARS-CoV-2 infection on brain function, which may include disturbances involved in the psychopathology of psychiatric disorders. Psychiatric consequences of COVID-19 should also be longitudinally monitored, and future preclinical investigations are needed to characterize the pathological effect of SARS-CoV-2 infection on brain function.In summary, the findings discussed above suggest that nasal inflammation impairs the peripheral olfactory system and may affect olfactory-higher brain circuits, leading to neurobehavioral abnormalities. Further research into the molecular, cellular, and circuit mechanisms underlying the effects of nasal inflammation on brain function is crucial in addressing how OE inflammation contributes to the adverse effects of environmental factors such as air pollutants and viral infection on the central nervous system, potentially leading to neuropsychopathology relevant to psychiatric disorders.


Ocular drug delivery has been significantly advanced for not only pharmaceutical compounds, such as steroids, nonsteroidal anti-inflammatory drugs, immune modulators, antibiotics, and so forth, but also for the rapidly progressed gene therapy products. For conventional non-gene therapy drugs, appropriate surgical approaches and releasing systems are the main deliberation to achieve adequate treatment outcomes, whereas the scope of “drug delivery” for gene therapy drugs further expands to transgene construct optimization, vector selection, and vector engineering. The eye is the particularly well-suited organ as the gene therapy target, owing to multiple advantages. In this review, we will delve into three main aspects of ocular drug delivery for both conventional drugs and adeno-associated virus (AAV)-based gene therapy products: (1) the development of AAV vector systems for ocular gene therapy, (2) the innovative carriers of medication, and (3) administration routes progression. The anatomical and physiological barriers of the eye render this organ largely impervious to external factors, protecting against pathogen entry while simultaneously impeding drug permeation. The anterior and posterior segments of the eye both present their own unique challenges for drug delivery, as illustrated in TM, for the treatment of type 2 Leber congenital amaurosis (LCA) ,10796,10In 2021, Zhang et al. evaluated the therapeutic potential of subconjunctival tumor necrosis factor-alpha-treated bone marrow-derived mesenchymal stem cells in rat corneal alkali burns. This intervention increased corneal epithelium repair, as well as decreased inflammatory cell infiltration and fibrosis, compared to control. This study suggested that it may be mediated through the upregulation of prostaglandin-endoperoxide synthase 2 and TNF-inducible gene 6 protein, which may serve as potential treatment modality .A recent case report about the management of post-cataract surgery cystoid macular edema (CME) discussed the use of subconjunctival interferon alpha 2b for refractory disease . DespiteIn corneal diseases that involve the deeper stroma, topical and subconjunctival drug administration show decreased effectiveness, which is particularly true for infectious corneal diseases, such as fungal keratitis. Moreover, there are few antifungal drugs that can adequately penetrate the deeper layers of the cornea. To increase drug penetration, intrastromal injections, which can effectively deliver drugs to the site of pathology, have been utilized clinically for the past decade. The use of intrastromal amphotericin B, voriconazole, and natamycin have been reported as a safe, effective adjuvant therapy in the management of recalcitrant fungal keratitis ,114. The intrastromal administration of AAVs has also recently been used in a canine model to treat mucopolysaccharidosis type I, a lysosomal storage disorder in which patients can experience corneal clouding. Researchers used AAV8G9-expressing IUDA, an enzyme required for glycosaminoglycan degradation, to reverse corneal opacity within one week of intrastromal administration, which persisted for at least 25 weeks . FurtherIntracameral injections involved the administration of therapeutic agents to the anterior segment of the eye though the cornea  116]. T. T116]. The delivery of therapeutic agents to the eye by means of intravitreal injection has been widely used in clinics to treat ocular diseases. From 1997 to 2001, there were less than 5000 intravitreal injections performed each year worldwide . As of 2Subretinal drug administration is being investigated for gene therapy, particularly regarding the treatment of inherited retinal diseases. Although this technique directly exposes the retina to therapeutic agents, it is arguably the most invasive administration route as it requires vitrectomy prior to administration in an operating room, which put the patient at risk of complications  121]. . 121]. As discoveries are made in subretinal gene therapy delivery, there is an increasing need for the development of new techniques that safely achieve required drug concentrations in the posterior segment of the eye. Recently, there has been interest in using robotic assist devices for subretinal injections. A recent clinical trial compared the use of robot assist devices against vitreoretinal surgeons not using assistive devices (NCT03052881). The results showed that both groups were able to successfully complete the procedure, with the results and surgery times similar between both groups. Although the difference in results for each arm of the study was not statistically significant, this comparison confirmed that assistive devices may have utility in this procedure and could be utilized to overcome the limit of human capabilities in surgery . Suprachoroidal (SC) space injection technique involves the delivery of medication to a 30-micron thick area of tissue between the sclera and choroid using hollow microneedles . ImportaNotably, Regenxbio is utilizing suprachoroidal injections to deliver its gene therapy RGX-314, an AAV8 vector containing a transgene coding for an anti-VEGF fab, for the treatment of nAMD and diabetic retinopathy. There are concurrent clinical trials evaluating the safety and efficacy of RGX-314 when administered using IVT or subretinal injections as well. In addition to the numerous increased toxicities that can result from the systemic delivery of viral and non-viral vectors, there are robust anatomic barriers that prevents substances in systemic circulation from reaching the posterior segment of the eye. The blood–retinal barrier (BRB) is a part of the blood–ocular barrier (BOB) and functions analogously to the blood–brain barrier (BBB) preventing large, hydrophilic molecules from entering the eye from the blood. These barriers result in the inability of many drugs to be delivered in a way that provides therapeutic concentrations at the target site without reaching toxic levels systemically. For this reason, many drugs that can be delivered orally have been adapted to be delivered topically. Examples of this include antihistamines for allergic conjunctivitis and antiviral drugs in the treatment of viral infections, such as varicella zoster and herpes simplex. Compared to other routes of administration, there is less investigation to improve orally administered drugs. Recently there have been studies exploring orally administered drugs for a noninvasive means of medically managing central serous chorioretinopathy (CSCR). Of the many drugs investigated, the mineralocorticoid receptor antagonist eplerenone has shown the most potential ,126. SinRecently there has been investigation into the use of subcutaneously administered medication for the treatment of ocular disease . For insEffective ocular drug delivery has posed a challenge to ophthalmologists for decades. Despite the obstacles, the compartmentalization, accessibility, and immune privilege of the eye still make it an excellent candidate for gene therapy research. The increase in the development and availability of gene therapy products has prompted the study of viral and non-viral-based vectors administration and expanded the scope of drug delivery. Transgene construct optimization, vector selection, and vector engineering are now essential to further development and eventual approval of disease-specialized gene therapy products. Although both viral and non-viral vectors have advantages and disadvantages, current research trends point to adeno-associated viruses (AAV) as an area of great interest in ocular drug administration. AAVs are efficient at transducing photoreceptors (PRs) and retinal pigment epithelium (RPE) cells, and future studies should seek to increase capacity while reducing immunogenicity ,134. With advances in ocular vector technology, carrier system technology and ocular therapeutic administration routes will improve to maintain therapeutic concentration at the target site, reduce administration frequency, overcome various ocular barriers, and enhance drug bioavailability. The unique anatomy and natural barriers of the eye present challenges to such systems, but advancements in novel and non-novel delivery systems continue to show promising results in multiple clinical trials. Topical solutions have increased their effectiveness through the development of cyclodextrins, the addition of permeation enhancers, and delivery via suspensions or emulsions ,102,135.Furthermore, topical drugs typically have low bioavailability and are often used incorrectly by patients . IntraviDespite the challenges of ocular drug delivery, advancements in gene therapy for ocular diseases are occurring at a rapid pace. The combined efforts of academia, industry, and regulatory agencies are continually improving the state-of-the-art and safer, more efficacious drug delivery systems are being developed, which will continue to improve therapeutic outcomes.


Indeed, patients prescribed antipsychotic medications, regardless of diagnosis, have higher incidence of NAFLD than population norms. The mechanistic pharmacology of antipsychotic-associated NAFLD is beginning to emerge. In this review, we aim to discuss the pathophysiology of NAFLD including its risk factors, insulin resistance and systemic inflammation as well as its intersection with psychiatric illnesses.Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in the world and one of the leading indications for liver transplantation. It is one of the many manifestations of insulin resistance and metabolic syndrome as well as an independent risk factor for cardiovascular disease. There is growing evidence linking the incidence of NAFLD with psychiatric illnesses such as schizophrenia, bipolar disorder and depression mechanistically  Non-alcoholic fatty liver disease (NAFLD), sometimes referred to as metabolic dysfunction associated fatty liver disease (MAFLD), represents the metabolic syndrome of the liver. NAFLD and its progressive form, non-alcoholic steatohepatitis (NASH), is a multi-system progressive disease with associated increased risk of cardiovascular disease, diabetes, osteoporosis, chronic kidney disease and cancer . EmerginNAFLD has an approximate 25% global prevalence in the adult population and is a key factor driving increased morbidity and mortality in patients with metabolic syndrome, psychiatric disorders, as well as other conditions . The higIn the United States, the highest prevalence of NAFLD in adults has been reported in Hispanics, and the lowest prevalence in Afro-American populations . Few stuNAFLD is increasingly prevalent in children, specifically in those with obesity and genetic predisposition . NAFLD iPsychiatric patients have a shorter lifespan and higher all-cause mortality than non-psychiatric population norms; the significant reduction in life span in patients with mental illness is highly associated with increased cardiovascular disease risk and metabolic syndrome/insulin resistance . EmerginThe intersection between psychiatric illness in children and metabolic liver disease is an area that is understudied. NAFLD in children and adolescents is the most common cause of liver disease in this age group  and is hChildren presenting with mood disorders, behavioral disorders or developmental disorders are often treated with psychiatric medications. Psychiatric drugs are highly prescribed in pediatric populations (both on and off label) and are associated with increased incidence of adverse metabolic effects including obesity, diabetes and dyslipidemia . PsychotThe liver plays a crucial role in the regulation of many physiological systems including carbohydrate and lipid metabolism, drug metabolism, iron metabolism and immune function. NAFLD is a progressive disease that is characterized by hepatic insulin resistance and inflammation associated with fat accumulation in the liver . NAFLD, The simple steatosis characteristic of NAFLD is often reversible with lifestyle modifications; however, more advanced forms of NASH are not reversible. Advanced stages of NASH are thought to be triggered by multiple, synergistic mechanisms including insulin resistance, genetic and epigenetic factors, mitochondrial mutations and dysfunction, adipokines, the microbiome (gut-liver axis), and diet .Diagnosis of NAFLD/NASH often occurs in the later stages of disease, when non-surgical interventions that would ameliorate earlier disease are largely ineffective. This is due to a combination of factors including a lack of symptoms early in disease leading to an absence of clinical attention, the expense and invasiveness of effective diagnostic procedures, and the absence of circulating biomarkers . Liver bWhole liver imaging studies, both ultrasonography and magnetic resonance imaging (MRI) have been historically used as a proxy for liver biopsy. Ultrasonography, specifically transient elastography (TE), has emerged as a valuable tool for the diagnosis of NAFLD in the absence of liver biopsy. TE allows for the calculation of the controlled attenuation parameter (CAP), a determination of the “stiffness” of liver tissue, widely interpreted as a measure of hepatic fibrosis, and hepatosteatosis. The positive predictive value of CAP as determined by ultrasonography for NAFLD/NASH is 86% , indicatCirculating biomarkers represent an ideal, low-cost diagnostic screening tool for NAFLD/NASH; however, highly specific and sensitive blood tests remain elusive. Liver enzymes are within normal limits in up to 80% of patients with histologically confirmed NAFLD/NASH , and NAFMultiple indices utilizing widely available measures to calculate a composite score for the probability of NAFLD/NASH have been developed. The NAFLD liver fat score (NLFS) incorporates metabolic syndrome, type 2 diabetes status, fasting insulin level, and fasting aspartate aminotransferase/alanine aminotransferase ratio, and has an 86% sensitivity in detecting NAFLD . The hepprior to drug associated weight gain  are altered with AA treatment, preclinically . Thus, pDopamine (DA) is a neurotransmitter that plays important roles in learning, cognition and motivation/reward systems . AlteratAntipsychotic medications  are potent antagonists/inverse agonists of dopamine receptors  as most were designed to moderate the overproduction/overactivity of dopamine in patients with psychosis (the dopamine hypothesis of psychosis) . Publishvia a large family of 5HT receptors  is part of the leptin signaling pathway in the hypothalamus  impact the severity and prevalence of NAFLD . ObesityThe prevalence of obesity among adults with psychiatric disorders is approximately twice that of those without psychiatric disorders  and adolde novo lipogenesis as well as a reduction in insulin-inhibition of lipolysis in adipose tissue, with the net effect of increasing hepatic lipid content  is both causal and reciprocal, an example of immunometabolic disease . InflammMitochondria act to produce energy/ATP as well as generate reactive oxygen species (ROS) and play a prominent role in regulation of apoptosis . MitochoMany psychiatric disorders, including depression, schizo phrenia, autism spectrum disorder and neurodegenerative disorders are associated with chronic neuroinflammation, oxidative stress and mitochondrial dysfunction . MitochoConversely, AA medications downregulate inflammatory responses both clinically and preclinically, , 2020, aAssociations between dysregulated iron metabolism and certain psychiatric conditions have been described. This includes both serum iron deficiency  and ironvia association with both obesity and insulin resistance  receptor signaling  is an endogenous timing system that consists of a central circadian clock (CCC) located in the suprachiasmatic nucleus (SCN) as well as peripheral circadian clocks (PCC) located in various tissues including the liver . The cenignaling . Furtherignaling . Circadiignaling .In addition to metabolic processes, mood and mental health are also under circadian influence. Circadian disruption is associated with mood disorders including depression and bipolar disorder . AlteratDrug efficacy and toxicology are also under circadian control; it has been long known that timing matters in terms of drug dosing, with clinically relevant, time of day effects being observed across myriad drug classes, including psychotropic medications . MechaniPNPLA3, TM6SF2, INFL3, and GCKR, associated with NAFLD. Patatin-like phospholipase domain-containing protein 3 (PNPLA3) is one such gene that has not only been linked to greater risk of progressive steatohepatitis and fibrosis but also of hepatocellular carcinoma (TM6SF2 (transmembrane 6 superfamily member 2) gene has been shown to increase blood lipid levels and has been associated with prevalence of both NAFLD and NASH (GCKR locus (glucokinase regulatory gene) has been known to be involved in insulin sensitivity and has been linked to maturity-onset diabetes in young people (INFL3) gene have been reported to be associated with increased hepatic inflammation and fibrosis in lean individuals with NAFLD . Although the pathophysiology of LNAFLD is not fully understood, it is an emerging medical problem that can be challenging to diagnose . Patientin the absence of obesity is not known, largely due to its diagnosis often being incidental. A recent report indicated that perceived stress was a significant, independent risk factor for NAFLD prevalence in apparently healthy women and men, including non-obese cohorts  are both causes and results of disrupted homeostasis. NAFLD patients with and without psychiatric comorbidities have alterations in their gut microbiomes, often reciprocally linked to altered inflammatory responses and to metabolic syndrome . A direcThe mechanisms by which gut dysbiosis leads to or exacerbates NAFLD are not clear, and are likely multi-faceted. Because the gut microbiome plays a central role in digestion and drug metabolism, changes in its composition can have profound effects on the gut metabolome. The gut-liver axis features blood flow from the small intestine and the colon to the liver, where exposure to potentially inflammatory metabolites such as phenols, ethanol, acetaldehyde, ammonia, and secondary bile acids from the gut is very high . DysbiotBacillota to Bacteroidota  ratio relative to healthy control patients is common. An additional trend evident in NAFLD/NASH patients is an increase in Pseudomonadota (formerly Proteobacteria) species, particularly members of the Enterobacteriaceae  intervention. CRP is an easily detected marker of inflammation; however, its use for medical decision-making has been historically controversial . The benMultiple drug classes currently in Phase III clinical development for NAFLD/NASH target the diverse pathophysiology associated with metabolic liver disease including fibroblast growth factor analogs, PPAR transcription factors, bile acid receptors, SGLT2 inhibitors , GLP-1 rAG contributed to writing the manuscript and figure creation. RI and KT contributed to writing the manuscript. MM contributed to writing and editing the manuscript and figure creation. KH contributed to manuscript concept development, writing, figure creation, and editing. All authors contributed to the article and approved the submitted version.