We also provided an overview of evidence-based strategies that may help the physician to safely prescribe effective antimicrobial doses in critically ill patients with sepsis-associated multi-organ dysfunction who receive extracorporeal organ support.Sepsis is a leading cause of disability and mortality worldwide. The pathophysiology of sepsis relies on the maladaptive host response to pathogens that fosters unbalanced organ crosstalk and induces multi-organ dysfunction, whose severity was directly associated with mortality. In septic patients, etiologic interventions aiming to reduce the pathogen load via appropriate antimicrobial therapy and the effective control of the source infection were demonstrated to improve clinical outcomes. Nonetheless, extracorporeal organ support represents a complementary intervention that may play a role in mitigating life-threatening complications caused by sepsis-associated multi-organ dysfunction. In this setting, an increasing amount of research raised concerns about the risk of suboptimal antimicrobial exposure in critically ill patients with sepsis, which may be worsened by the concomitant delivery of extracorporeal organ support. Accordingly, several strategies have been implemented to overcome this issue. In this narrative review, we discussed the pharmacokinetic features of antimicrobials and mechanisms that may favor drug removal during renal replacement therapy, coupled plasma filtration and absorption, therapeutic plasma exchange, hemoperfusion, extracorporeal CO Sepsis is a heterogenous clinical syndrome characterized by host and pathogen factors  and reprMoreover, inadequate antimicrobial exposure may be fostered by the concomitant delivery of extracorporeal organ support (ECOS) ,9, whichIn this narrative review, we highlighted the PK alterations of antimicrobials induced by sepsis and ECOS. Moreover, we focused on specific antimicrobial properties that may favor drug removal via ECOS. Finally, we provided an overview of strategies that may help the clinician to overcome the issue of inadequate antimicrobial exposure during ECOS in critically ill patients with sepsis-associated MOD.Antimicrobial therapy is one of the most common pharmacologic interventions prescribed in the ICU ,19. In o−S—susceptible, standard dosing regimen: high likelihood of therapeutic success using a standard dosing regimen of the antimicrobial;−I—susceptible, increased exposure: high likelihood of therapeutic success if antimicrobial exposure is improved by increasing the dosing regimen in order to reach high drug concentration at the site of infection;−R—resistant: high likelihood of therapeutic failure even for increased exposure.The PK profile of an antimicrobial relies on the interaction between patient characteristics , concurrent interventions  and drug properties  is above the MIC breakpoint indicating antimicrobial resistance, some author suggested to target an antimicrobial exposure at the source of infection equal to 4 x pathogen MIC, unless the drug dose exceeds the threshold of toxicity . ➢Solubility is the major determinant of antimicrobial volume of distribution (Vd), which is the theoretical volume necessary to contain the total amount of the drug at the same concentration measured at the steady state in the plasma. The Vd drives the titration of the loading dose of antimicrobials [crobials . Specifically, hydrophilic antimicrobials  are characterized by small Vd (<2 L/kg), being mainly concentrated into the bloodstream. However, sepsis-associated endothelial dysfunction and capillary leak syndrome coupled with fluid overload due to large fluid resuscitation and oliguric acute kidney injury (AKI), may lead to extravascular fluid shift and, consequently, low bloodstream concentration of hydrophilic antimicrobials. This condition implies an increase in the loading dose in order to secure an effective exposure to these drugs. In contrast, lipophilic antimicrobials  are characterized by large Vd (>2 L/kg) and are not significantly influenced by fluid shift, being mainly concentrated in the adipose tissue. ➢Protein binding varies among antimicrobials  and extracorporeal membrane oxygenation (ECMO). Trans-membrane removal is regulated by concentration gradients , pressure gradients  or both  along the device [ECOS represents an additional PK compartment that may influence antimicrobial exposure by altering the distribution and clearance of these drugs. The delivery of ECOS implies an unavoidable administration of intravascular volume due to priming solution, which increases Vd and lowers the bloodstream concentration of hydrophilic drugs . Moreovee device ,11. TranThe majority of research on PK alteration of antimicrobials induced via ECOS is represented by small case series not accounting for the endogenous clearance  , thus imMoreover, most of the studies in this field are represented by pre-clinical investigations using mechanistic ex vivo one-compartment models, whose translation into the clinical scenario may be limited by several factors. First, ex vivo models do not account for the endogenous clearance of antimicrobials. Second, antimicrobials are dissolved in surrogate solutions of patient’s blood  that may alter the PK characteristics of the drug . Third, ex vivo models evaluate the effect of ECOS on a single antimicrobial dose, thus underestimating drug accumulation and device saturation for repeated antimicrobial administration, both mitigating the impact of ECOS on antimicrobial exposure in vivo. For these reasons, in our review, we preferentially reported the results of clinical studies over ex vivo models and mentioned the latter if we could not retrieve evidence in vivo.Sepsis is the major cause of AKI in the ICU . Specifi2) membranes compared with the AN69 . However, limited evidence exists on the clinical impact of this phenomenon, especially for newly developed membranes . Moreove AN69ST ). UF < 12 mL/mmHg/h) is negligible for molecular weight >1000 Da, while it is relevant with high-flux membranes  and may be even greater for medium (mean pore radius 5 nm) and high-cutoff  membranes.Membrane permeability to solutes is expressed by the Sieving coefficient (SC) for hemofiltration and the saturation coefficient (SA) for hemodialysis, which is about 30–40% less than SC. The SC refers to the ratio of solute concentration in the ultrafiltrate to solute concentration in the bloodstream, while the SA corresponds to the ratio of solute concentration in the dialysate to solute concentration in the bloodstream . AccordiHydrophilic drugs with small molecular weight (<500–1000 Da), low protein binding (<80%) and small Vd (<2 L/Kg) are theoretically susceptible to trans-membrane removal during HD ,30. In cThe effluent flow rate (intensity) refers to the volume of blood cleared from solute by the extracorporeal circuit per unit of time and body weight (mL/kg/h) ,11. The Recently, Backdach et al.  systematThe Kidney Disease Improving Global Outcome (KDIGO) guidelines  recommenTPE allows patient’s plasma removal and replacement with human donor plasma, colloids, crystalloids or a mixture thereof, with the aim to improve immune dysfunction and coagulation abnormalities . TPE is The CPFA combines plasma filtration and adsorption via styrene resin. Briefly, the volume of plasma purified via mediators is reinfused into the blood line, which passes across an hemofilter . CPFA was demonstrated to significantly lower the bloodstream concentration of colistin, whose amount was directly proportional to the volume of plasma filtered over time . MoreoveSeveral devices have been implemented in clinical practice with the aim to remove specific mediators in sepsis ,44,60. HThis device consists of a column made by polystyrene fibers and Polymyxin-B, which is a cationic antibiotic binding endotoxin through ionic and hydrophobic forces. Each session lasts for 120 min and a second cycle has been repeated 24 h afterwards in most of the trials in this field . ToraymyThis device contains a column made by highly porous polystyrene divinylbenzene copolymer covered with a biocompatible polyvinylpyrrolidone coating and is used for cytokine removal ,44,60. HThe Seraph 100 Microbind Affinity Blood Filter  is a sorbent made with polyethylene beads, whose internal surface has been modified to contain end-point attached heparin . Hemoper2 removal and oxygenation in the context of Acute Respiratory Distress Syndrome (ARDS); veno-arterial ECMO, to provide organ perfusion in the context of acute cardiac dysfunction  [ECCO2-R is applied for the management of patients with hypercapnic respiratory failure . ECMyopathy) . Althougyopathy) ,35. Furtyopathy) . Moreoveyopathy) , lipophiyopathy) ,35. Gomez et al.  reviewedp = 0.009). In contrast, positive clinical outcomes were associated with 50% fT>MIC and 100% fT>MIC ratios  [Appropriate dosing regimens are of paramount importance to achieve a therapeutic concentration of antimicrobials and allow microbiological eradication, contrast the emergence multidrug resistant pathogens  and prevUnit-level interventions: this strategy includes the administration of antimicrobials driven by the PD characteristics of the drug, leading to the administration of time-dependent antimicrobials . AltPK/PD-based antimicrobial dosing program: this strategy includes the use of software that performs a PK assessment based on patient-specific characteristics in conjunction with population pharmacokinetic models, via a Bayesian parametric approach and a Monte Carlo simulation . HoweverTherapeutic Drug Monitoring (TDM): this strategy includes the evaluation of antimicrobial exposure via the assessment of drug concentration at the site of infection  and implies dose adjustment according to the pathogen susceptibility to the drug (MIC), in order to improve the PK/PD target attainment. In most of the cases, plasma concentration has been used as a surrogate for antimicrobial exposure at the source of infection . TDM mayFor this reason, several strategies for antimicrobial dosing have been implemented in clinical practice :Unit-levCurrently, TDM has not been widely used in daily clinical practice and significant variation among hospitals was reported in terms of use, antimicrobial selection, sampling time points, assays, PK/PD targets and dose adjustment algorithms ,99. MoreIn critically ill septic patients who receive ECOS, antimicrobial exposure is highly-variable and may lead to poor target attainment with consequently worse clinical outcomes. In comparison with “standard” dosing regimens, several strategies have been proposed to improve antimicrobial exposure, although low evidence supports their use in daily clinical practice. Among them, the therapeutic drug monitoring appears as a promising tool to efficiently measure the antimicrobial PK and adapt antimicrobial dosing to pathogen susceptibility, in order to target an adequate exposure via a precision medicine and personalized approach. For this reason, further large-scale investigation is necessary to place a role for therapeutic drug monitoring in the management of critically ill septic patients receiving ECOS in daily clinical practice.


Compared to liver and lung metastases, brain metastases (BMs) from colorectal cancer (CRC) are rare and remain poorly investigated despite the anticipated rise in their incidence. CRC patients bearing BM have a dismal prognosis with a median survival of 3–6 months, significantly lower than that of patients with BM from other primary tumors, and of those with metastatic CRC manifesting extracranially. While liver and lung metastases from CRC have more codified treatment strategies, there is no consensus regarding the treatment of BM in CRC, and their management follows the approaches of BM from other solid tumors. Therapeutic strategies are driven by the number and localisation of the lesion, consisting in local treatments such as surgery, stereotactic radiosurgery, or whole-brain radiotherapy. Novel treatment modalities are slowly finding their way into this shy unconsented armatorium including immunotherapy, monoclonal antibodies, tyrosine kinase inhibitors, or a combination of those, among others.This article reviews the pioneering strategies aiming at understanding, diagnosing, and managing this disease, and discusses future directions, challenges, and potential innovations in each of these domains.• With the increasing survival in CRC, brain and other rare/late-onset metastases are rising.• Distal colon/rectal primary location, long-standing progressive lung metastases, and longer survival are risk factors for BM development in CRC.• Late diagnosis and lack of consensus treatment strategies make BM-CRC diagnosis very dismal.• Liquid biopsies using circulating tumor cells might offer excellent opportunities in the early diagnosis of BM-CRC and the search for therapeutic options.• Multi-modality treatment including surgical metastatic resection, postoperative SRS with/without WBRT, and chemotherapy is the best current treatment option.• Recent mid-sized clinical trials, case reports, and preclinical models show the potential of unconventional therapeutic approaches as monoclonal antibodies, targeted therapies, and immunotherapy. CRC is a major health concern worldwide, being the second and third most diagnosed cancer in women and men, respectively, and the fourth most common cancer-related cause of death .While most CRC metastasize in the liver and/or the lungs, brain metastases (BMs) in CRC are very uncommon, especially when occurring without simultaneous extracranial disease . ImproveIn this review, we firstly discuss the characteristics of CRC patients with BM, the risk factors for central nervous system (CNS) involvement, the characteristics of metastatic lesions, and prognostic factors. In the second part, we present the current pathophysiological hypotheses underlying the occurrence of BM and discuss the potential role of liquid biopsies in the early diagnosis of this disease. Finally, we investigate the molecular characteristics of the metastatic lesions and the potential targets for future pharmacological interventions.BMs are the most common intracranial neoplasm in adults and are 10 times more frequent than primary tumors of the CNS, occurring in 20–40% of all cancer patients . CRC patBMs are more commonly observed in patients with distal CRC compared to proximal ones, and primary tumors localized in the sigmoid and rectum account for 65–75% of the GI-metastatic lesions in the brain ,10–14. MPIK3CA . However, in their effort to identify biomarkers associated with metastasis, the authors identified molecular drivers for metastasis that appeared to greatly overlap with those of carcinoma initiation in mCRC, and were therefore not specific to metastasis [40••].Sottivera et al. suggested an alternative explanation in which tumors evolve in a “big-bang” fashion, rather than a linear one Fig.  38]. Th. Th38]. 40The genomic landscape of CRC has been extensively studied and has identified several pharmacological targets. However, that of the brain lesions in CRC patients is not fully explored.••]. Whole-genome sequencing analysis of BM from various tumor types showed genetic distinction from their respective primaries as well as from their lymphatic and extracranial counterparts . Genomic analysis revealed BM-associated genes that carry frequent BM-specific mutations including SCNF family members 7A, 5A, and 2A (a voltage-gated sodium channel), as well as tumor suppressor genes IKZF1 and PDZRN4, that are linked to metastasis in many cancers and associated with poor survival, especially when found in cerebral metastases [•].Recent work by Sun et al. confirmed that brain lesions in CRC patients exhibit a diverse mutational pattern compared to their primary origin. In a cohort of 19 CRC patients with BM, they found elevated mutational signatures of homologous recombination deficiency (HRD) and mismatch repair deficiency (MMRd) in the brain biopsies but not in the respective primary tumors nor in the adjacent normal colon •. Genomitastases •.The conclusions drawn from the different driving pathways of metastasis in CRC as well as the molecular divergence between primary CRC and their respective BM might offer the rationale for using liquid biopsies in the early detection of CRC-derived metastatic cells as well as for molecular profiling of these cells. These biopsies detect and profile the following: circulating tumor cells (CTCs), tumor-derived cell-free products including tumor-associated DNA (cft-DNA), -miRNA, and -exosomes. Among all these biomarkers, experimental studies suggest CTCs and cft-DNA to have a great potential in metastatic CRC management.The extremely rare CTCs can be detected using immunomagnetic capturing techniques in which the antibodies recognize the Epithelial Cell Adhesion Marker (EpCAM) . This haCTCs can also be detected by PCR-based identification of genes expressed in epithelial cells or those associated with carcinoma, looking for specific DNA mutations, epigenetic modifications, or mRNA profiling. The most frequent parameter for detecting CTCs in CRC settings using this technique involves mRNA profiling of CK20 .in vitro cultures containing cells derived from the peripheral blood , a homologous-recombinant deficiency that has been recently proposed as an ideal biomarker for NHEJ inhibitors like PARP inhibitors used in breast cancer , suggest immunotherapy targeting the PD-1/PD-L1 axis as a potential therapeutic option. Immunotherapy using checkpoint inhibitors has always been considered to have limited potential in controlling brain metastases, but recent studies involving the tumor-microenvironment in BM showed that the brain is an immunologically distinct compartment rather than an immune-isolated one [•]. However, only limited data are available concerning immune-checkpoint blockade inhibitor in BM-CRC, and the few clinical studies available in mCRC show comparable efficacy of these biologic drugs on BM and other extra-cranial metastases [The observations that a subgroup of mCRC patients had BM infiltrated by cytotoxic T lymphocytes , express47ated one . Indeed,ated one •. Howevetastases .One of the relatively recent approaches to increase BBB permeability to ensure better delivery of large-sized monoclonal antibodies into the CNS consists of transiently disrupting the BBB itself using hypertonic solutions. Mannitol for example draws water into the blood vessels from endothelial cells, causing them to shrink and allow the drugs through . MannitoAlthough poorly documented , many exOther studies suggested that the true incidence of BM is likely underestimated, especially in retrospective studies collecting data before the 2000s, because tumor registries emphasize coding of the primary tumor over subsequent metastases . MackenzAltogether, these data suggest that BM might be relatively early events in the evolution of metastatic CRC, with late clinical manifestation. Indeed, the symptoms indicating the involvement of rare metastatic sites in CRC might depend on the interactions between tumor cells and the remaining components of the tumor microenvironment including local specialized tissue, fibroblasts, blood/lymphatic vessels, and most importantly immune cells. This might explain how a microscopic lesion in the brain may be present at initial diagnosis and remain indolent for relatively long periods. Patients with similar scenarios may never develop clinically apparent disease in these sites. In such settings, one can imagine that improved therapy for the extracranial disease at its early stage would prolong the OS and may thus increase the incidence of clinically apparent BM.BM lesions from CRC are rare but are becoming more frequent with the increasing survival of mCRC patients. Compared to their primary tumors, BMs exhibit a diverse molecular pattern that could be potentially druggable. This emphasizes the need for molecular assessment techniques of the BM. New technologies such as CTCs or ctDNA technologies may have a huge impact on the stratification of CRC patients at risk of developing BM, as well as on the treatment options.In conclusion, increasing the awareness that BM can occur in CRC patients, even silently, and the surveillance of those at risk of developing this rare metastatic profile could potentially lead to earlier detection and treatment. Patients with BM should be included in clinical trials to better define effective treatments and ultimately improve the prognosis of these patients.


Whole white rice is a major staple food for human consumption, with its starch digestion rate and location in the gastrointestinal tract having a critical role for human health. Starch has a multi-scale structure, which undergoes order-disorder transitions during rice cooking, and this structure is a major determinant of its digestibility. The length distributions of amylose and amylopectin chains are important determinants of rice starch gelatinization properties. Starch chain-length and molecular-size distributions are important determinants of nucleation and crystal growth rates, as well as of intra- and intermolecular interactions during retrogradation. A number of first-order kinetics models have been developed to fit starch digestograms, producing new information on the structural basis for starch digestive characteristics of cooked whole rice. Different starch digestible fractions with distinct digestion patterns have been found for the digestion of rice starch in fully gelatinized and retrograded states, the digestion kinetics of which are largely determined by starch fine molecular structures. Current insights and future directions to better understand digestibility of starch in whole cooked rice are summarized, pointing to ways of developing whole rice into a healthier food by way of having slower starch digestibility. Whole rice is the main staple food for a significant fraction of the world’s population, especially in Asia and Africa. It supplies many nutrients, including starch, protein and lipids. Starch is the most abundant nutrient in rice, and supplies more than 40% of human daily energy world-wide. The rate and location of starch digestion in the human gastrointestinal tract is critical for human health. If starch is rapidly digested once entering the duodenum, it can cause a large fluctuation in the postprandial glycemic response, which is a risk factor for the development of many chronic diseases such as type 2 diabetes . On the Whole rice grains are almost always consumed by humans following dehulling, polishing and cooking, although a relatively small number of people consume unpolished rice (“brown rice”) in their diets. Development of whole rice or rice-based products with more slowly digestible starch and higher resistant starch content is important for the rice industry, as it would improve public health. However, cooked polished whole rice grains have undergone a high degree of starch gelatinization during cooking, and also there is the lack of a physical barrier to digestive enzymes because of what is removed or degraded by dehulling and polishing.During the cooking of rice, the starch undergoes order-disorder structural transitions due to the solvation of orthorhombic nanocrystals , which aStarch multi-scale structures, e.g., molecular fine structures (notably the chain-length distributions of both amylose and amylopectin), and, at a higher structural level, microcrystalline domains, are major controllers of starch physicochemical and digestion properties . As discThis review summarizes recent understandings on starch order-disorder structural transitions during conventional whole rice cooking, and the influence of starch fine molecular structures on these processes. Their influence on starch digestibility in cooked whole polished rice is further critically discussed. To the best of the authors’ knowledge, this is the first review to comprehensively discuss starch gelatinization, retrogradation and digestion in an integrated way for whole polished rice at the molecular level. An overview of these new insights, incorporating previous knowledge on starch structure-property relations, may aid the development of cooked whole polished rices with desirable starch digestion properties. This information indicates ways that more nutritionally beneficial cooked whole polished rice having slower starch digestibility could be developed, with potential improvements in public health.Starch has a multi-scale structure, ranging from nanometres to millimetres . Often, The first level is individual starch chain comprising glucose monomer units connected by (1→4)-α glycosidic linkages, with (1→6)-α branch points. Following enzymatic debranching of the starch sample to quantitatively break every (1→6)-α branch point, the molecular weight or number distribution of this level can be characterized by the following techniques. (a) Size-exclusion chromatography (a widely used technique in polymer characterization) with a mass-sensitive detector, e.g., a differential refractive index (DRI) detector, and a multiple-angle laser light scattering detector for weight-average molecular weight and radius of gyration. With appropriate columns, this technique can be used for any DP range A. (b) FlEach characterization method has advantages and disadvantages, as follows.SEC separates by molecular size, not by molecular weight. The column is a solid material with many channels and pores, and smaller molecules diffuse into the smaller pores as well as the larger, and thus elute more slowly than larger molecules. While SEC can characterize any DP range, it requires calibration with standards of known size to convert elution time (or elution volume) into a molecular size, if only a DRI detector is available, which is often the case. With the addition of a light-scattering detector, one has absolute size measurement, this size being the hydrodynamic radius, which is not exactly the same as the geometrical size (the radius of gyration) . It alsoFACE works by labelling the individual linear starch polymers (obtained after debranching) with a fluorophore, then separating them by mobility in an electric field; it uses a fluorescence detector. It has very high resolution, with baseline separation between individual DPs, but only works up to DP below ~180 : this coHPAEC   can be uRice can be classified into waxy (0–2%), very low (3–9%), low (10–19%), intermediate (20–25%) and high (>25%) amylose content; these classes can have distinct textural and nutritional properties .Amylopectin CLDs have distinct features, including a global maximum around DP 12 and a shoulder around DP 45, the former being chains confined to a single lamella and the latter being trans-lamellar chains. These amylopectin CLDs can be fitted by a model  that notRice amylose CLDs frequently show only a single broad peak , althoug4 (asymmetirc-flow field-flow fractionation) and by size-exclusion chromatography  and amylopectin (Rh~100 nm) molecules are typically observed for ordinary rice starches . Th. Thq powThe fifth level of rice starch structure comprises the starch granules, which can be characterized quantitatively by a variety of particle-size measuring devices for the appropriate size range, and qualitatively by scanning electron microscopy (SEM). Native rice starch has a polyhedral shape E, which The sixth level of rice starch structure is frequently referred to as the cellular or grain structure F. In theLevels 1 and 2 starch structures are normally referred to as amorphous structures, while higher levels of native starch structures (level 3 to 6) can be referred as crystalline structures, due to the presence of amylopectin double helices. Conventional cooking of whole dehusked  rice involves the cooking with certain amount of water until the disappearance of the white core in the grain, followed by cooling to various extents (depending on the culture and region) prior to human consumption. During this process, rice starch undergoes gelatinization and then retrogradation, involving starch structural order-disorder transitions, which have been shown to be critical for starch digestibility in cooked whole rice.As stated, during the cooking of whole rice, starch (mainly the amylopectin component) undergoes an order-to-disorder phase transition, which greatly disrupts starch semi-crystalline structures, the extent of which depends on the cooking method. Starch gelatinization involves disruption of the hydrogen bonding in the crystal, which can be followed by events such as starch-granule swelling and amylose leaching, as well as the disruption of amylopectin double helices . (1) At cltr chains  and Afp chains  . Lo. Locltr eratures  57,63].,63.cltr Tc − To) of rice starches  nucleation, (2) crystal growth and (3) maturation . The nucl growth . Crystall growth ,72.Rice starch fine molecular structures are the main driving factors determining the nucleation and crystal growth rate during retrogradation, when all higher levels of starch structures are destroyed during gelatinization. Amylose has a rapid retrogradation rate due to its high mobility, which can thus result in the development of the skeleton of a starch hydrogel network, within which amylopectin molecules retrograde with a much slower rate ,75,76,77Starch fine molecular structures can also determine interaction patterns  among starch molecules during retrogradation . DiffereIn vitro digestion models simulating human gastrointestinal tract are widely applied to study rice starch digestibility , as theyA sequential digestion pattern is defined as that when the digestion of a slowly digestible starch fraction (SDF) only starts when the digestion of essentially all rapidly digested fractions (RDF) are completed. Seeing more than one straight-line region in an LOS plot indicates more than one starch digestion step. For heterogenous food systems containing simultaneously digestible fractions, e.g., a partially gelatinized starch with both melted (RDF) and intact (SDF) double helices, a parallel first-order kinetics model (PK) should be applied  87]. An. An87]. The major patterns in the starch digestibility of cooked whole rice depend on whether the starch is in a raw, gelatinized or retrograded state. Raw starch is difficult to digest compared to gelatinized starch, due to the presence of crystalline and granular structures, as summarized in When completely gelatinized, all starch crystalline structures are melted, which can substantially increase the starch digestibility of cooked whole rice. Before the consumption of cooked rice, either short-term  or long-term (storage in a refrigerator overnight or for few days), retrogradation is common. Differences in starch digestibility after gelatinization are thus determined by factors relating to starch fine molecular structures and their tendency to retrograde: a higher extent of retrogradation will result in a slower starch digestion rate ,91,92.The transition from disordered to ordered starch structures during retrogradation has a critical role in determining starch digestibility in cooked whole rice. There are two simultaneous starch digestion fractions for fully gelatinized rice starches , with thThere is moderately good understanding of the effects of starch fine molecular structures on starch gelatinization, retrogradation and digestion properties in whole cooked rice, but many questions remain to be further investigated. For example, cooking conditions (including the time and storage conditions between cooking and consumption) are also important for starch digestibility in cooked whole rice . It is uFreshly cooked white rice is digested very rapidly unless protected by other food components. For example, adding red-grape polyphenols during cooking can increase the RS content in cooked whole white rice . More foMany new insights have been obtained on the importance of starch fine molecular structures in determining the starch gelatinization, retrogradation and digestibility of cooked whole rice. Starch has a complex multi-scale structure in whole rice grains, which undergoes order-disorder structural transition during rice cooking. Amylose chain-length distributions, as well as the length of amylopectin chains, are significant factors in determining rice starch gelatinization properties. Amylopectin and amylose with different CLDs and molecular size distributions are involved in determining the nucleation and crystal growth rates, as well as inter- and intramolecular interactions during retrogradation.A number of first-order kinetics models have been developed for fitting starch digestograms, which offer a powerful tool to understand the structural basis for starch digestion properties in cooked whole rice. Different numbers of starch digestible fractions with different digestion patterns have been found for the digestion of rice starch in the fully gelatinized and retrograded states, which are partly determined by starch fine molecular structure. The combined effects of starch fine molecular structures, other ingredients in whole rice  and cooking conditions on the starch digestibility of cooked whole rice should be a focus of research in the future. Considering the popularity of cooked whole rice as a staple food, the information summarized in the current review can help the food industry to develop whole rice into healthier food products with slower starch digestibility, as long as there is no significant diminution of palatability.


Since articular cartilage is lacking blood vessels and nerves, its capacity to heal is extremely limited. This means that ruptured cartilage affects the joint as a whole. A health issue known as osteoarthritis can develop as a result of injury and deterioration. Osteoarthritis development can be speeded up by the widespread deterioration of articular cartilage, which ranks third on the list of musculoskeletal disorders requiring rehabilitation, behind only low back pain and broken bones. The current treatments for cartilage repair are ineffective and rarely restore full function or tissue normalcy. A promising new technology in tissue engineering may help create functional cartilage tissue substitutes. Ensuring that the cell source is loaded with bioactive molecules that promote cellular differentiation and/or maturation is the general approach. This review summarizes recent advances in cartilage tissue engineering, and recent clinical trials have been conducted to provide a comprehensive overview of the most recent research developments and clinical applications in the framework of degenerated articular cartilage and osteoarthritis. Cartilage degeneration is turning out to be progressively problematic for physicians because of restricted self-recuperation abilities coming about because of the negligible development limit of chondrocytes, the sole cell components of cartilage, and an absence of veins, nerves, and lymphatics. The articular cartilage that covers synovial joints is the most commonly recorded cartilage deterioration. The fact that articular cartilage damage affects so many people is a major clinical concern. Hence, over time, it can add to the movement of osteoarthritis, which ranks third on the list of musculoskeletal disorders that necessitate rehabilitation, behind only low back pain and broken bones –3.Besides, the fairly high commonness of articular cartilage debasement and the proclivity for osteoarthritis are exacerbated by the world's maturing populace. In 2019, there were 320.7 million cases of osteoarthritis in adults aged 30 years and above globally, and by 2028, this number is expected to rise to 367.7 million .The three kinds of restorative procedures for treating articular cartilage corruption are as follows: medications to treat symptoms, restoration, and regeneration. Anti-inflammatory medications such as ibuprofen, acetaminophen, and ibuprofen are examples of indicative medicines. Restorative therapy incorporates microfracture, scraped spot, penetrating, osteochondral allograft, and mosaicplasty, and regeneration treatment incorporates autologous chondrocyte implantation and framework-initiated autologous chondrocyte implantation. Treatments for chondral and subchondral defects using restorative and regeneration techniques have been reported to be beneficial methods to restore natural articular cartilage, but they cannot completely stop the degeneration of articular cartilage, so tissue engineering approaches have been developed to address this issue. Articular cartilage tissue engineering has advanced significantly since its inception and has just been considered a potential opportunity for recovering natural articular cartilage –7. A comin vivo, and in vitro experiments, along with current clinical trials. Through the use of articular cartilage engineering, it has been intended to produce tissue that is structurally, biochemically, and mechanically similar to natural articular cartilage tissue through the use of articular cartilage engineering. This field of research has also generated a wide range of biomaterials, biofabrication, and assessment methods , 8. The 2 laser to imbed native articular cartilage extracellular matrix in trilayered zones. An in vivo model of decellularized GAG-depleted fiber shows better capacity to conduct the newly produced fibers in parallel direction, preventing unwanted irregular accumulation and thus enhancing cartilage-like tissue recovery [Scaffolds are designed to promote cellular differentiation and proliferation while also supplying chondrogenic bioactive substances, and several scaffolds have been constructed for varied goals in articular cartilage tissue creation , 10. Nürrecovery .An osteochondral defect in a rabbit model was studied using recombinant transglutaminase 4 in combination with mesenchymal stem cells derived from the synovial membrane and encapsulated in collagen, hyaluronan, and fibrinogen blend hybrids. By boosting integrin 1 expression and reorganizing actin, recombinant human transglutaminase 4 improves articular cartilage regeneration .Collagen sourced from the skin of a human being could be used as a framework for articular cartilage tissue creation. A dermal collagen sheet and adipose-derived mesenchymal stem cells were integrated with collagen substrates in an experimental setup developed by Dang et al. They found that dermal collagen had a big effect on the structure and development of chondrocytes in the lab .In vivo osteochondral damage: this model was tested first-hand both inside a laboratory setting and outside, and the results showed that self-assembling peptide scaffolds with chondrocytes were similarly efficient in patching up osteochondral damage [Additionally, Dufour and colleagues involved fibrin and chondrocytes that had been allowed to be treated with chondrogenic mixtures in their study. l damage .in vitro coculture system of mesenchymal stem cells and chondrons, using three different cultures of chondrons or chondrocytes with mesenchymal stromal cells. The coculture technique was found to be higher to single-cell cultures in terms of cartilage extracellular matrix synthesis [in vitro 3D scaffold for the encapsulation of bone marrow-derived mesenchymal stromal cells, and then human articular cartilage chondrocyte spheroids were added to the composite. It was found that the coculture system demonstrated promising regeneration of the cartilage, implying that mesenchymal stromal cells may play an important role in improving chondrocyte metabolic activity, which is normally lower in wounded areas. Chondrons are used in conjunction with other cells in the second type of the coculture model [in vivo against chondrocytes and chondrons alone to see if the coculture method was effective in treating osteochondral lesions in the knees of white rabbit models. While collagen type II, aggrecan, and GAG were made well by the coculture method, the results were the same as when chondrocytes were grown alone [Coculturing is another new advancement in cartilage tissue engineering techniques because cell signaling can help counterbalance articular cartilage's poor regenerative capabilities by retaining chondrocyte phenotype and boosting cartilage extracellular matrix regeneration. Owida et al. investigated an ynthesis . A thermre model . For thewn alone .Natural-based scaffolds, mainly collagen type I, are commonly used for cell-free articular cartilage repair. Szychlinska et al. evaluated collagen type I natural scaffolds in vivo using outbred rat models with femoropatellar groove cartilage lesions, and this scaffold displayed biocompatibility and efficient recruitment of host cells for articular cartilage regeneration. Collagen type I-based scaffolds have been studied before although under different experimental settings .in vitro and in vivo studies demonstrated that this scaffold allowed bone marrow mesenchymal stromal cells to migrate and distribute more effectively than random poly(lactide-coglycolide) scaffolds [In 2020, Wang and colleagues employed biological chondrocytes-based sheet technology to produce a natural-like extracellular matrix scaffold for osteochondral repair obtained from allogeneic bone marrow mesenchymal stromal cells. To do this, cell sheets were created, decellularization was performed using sodium dodecyl sulfate, and decellularized extracellular matrix scaffolds were obtained. An osteochondral defect model in a rabbit was found to be best served by treatment with 0.5% sodium dodecyl sulfate, which was found to re-establish both healthy periosteal bone tissue and avascular articular cartilage at the same time . In 2018in vitro trinetwork hydrogel comprising two biphasic double network hydrogels and a polymer, and the research showed that this hydrogel had outstanding resistance properties and could inhibit conflicting chondral injury in partial joint restoration [in vitro and in vivo [Milner et al. created a new scaffold that mimics the articular cartilage's mechanical characteristics. It was possible to fabricate and assess an toration . Other r in vivo .in vitro, the following in vivo models were used: human Wharton's jelly mesenchymal stem cell-derived exosomes were injected into Sprague Dawley rat models to investigate the regulation consequences upon the articular cartilage tissue, while human Wharton's jelly mesenchymal stem cell-derived exosomes were embedded in an acellular cartilage extracellular matrix scaffold implant in rabbit models to investigate the reparative effects. These tests demonstrated that human Wharton's jelly mesenchymal stem cell-derived exosomes had anti-inflammatory and osteochondral regeneration properties [For example, Jiang et al. investigated the use of human Wharton's jelly mesenchymal stem cell-derived exosomes together with a scaffold made from extracellular matrix and porcine acellular cartilage for the recovery of articular cartilage lesions. Following the positive cytocompatibility experiments operties .In vitro experiments showed that mesenchymal stem cells have more likely chondrogenic potential than in control samples, implying that they have promising expression potential for cartilage-like biomarkers [in vitro. The 3D-microenvironment composite promoted the employment of rabbit bone marrow mesenchymal stem cells from the damaged tissue two weeks after graft in vivo. A rabbit study using a 3D-microenvironment composite found that it was successful in regenerating healthy hyaline cartilage, as opposed to the control treatment, which mainly restored fibrous tissue instead [In 2022, Davachi et al. fabricated a hyaluronic acid/chitosan cartilage-like scaffold via horseradish peroxidase enzymatic crosslinking. omarkers . Huang e instead .in vivo. In contrast to the control group, the supplied adipose-derived mesenchymal stem cells demonstrated protective qualities toward chondrocytes, reducing cartilage degradation and resulting in a slower development of osteoarthritis [in vivo experiment (rabbit model) to assess the efficacy of adipose-derived mesenchymal stem cells injection for the treatment of temporomandibular joint osteoarthritis in vivo. After a month of follow-up, stem cells, particularly those implanted in hyaluronan, showed the best results in terms of articular cartilage regeneration; nevertheless, there were no statistically significant differences between the four groups when it came to tissue porosity and mineralization heterogeneity [Researchers are encouraged to use tools that will allow them to perform treatments that are as noninvasive as possible for articular cartilage recovery that will eventually replace invasive surgeries. It is common practice to deliver cells only to the site of the defect with the most basic injectables . In 2021rthritis . In theiogeneity .Qu et al. tested a similar formerly stated injectable, with the goal of delivering bone marrow-derived mesenchymal stromal cells via alkaline treatment using open-porous poly(lactide-coglycolide) microparticles; also, in a rat model with cartilage injury, it exhibited better cartilage defect recovery .Co et al. used injectable biomolecules in protective treatment with the purpose of using click chemistry to combat posttraumatic osteoarthritis. They devised a dual-acting method for this aim, which uses polyethylene glycol to first target apoptotic chondrocytes and then deliver chondrocytes that are actively metabolizing. The results employing autogenic cartilage implanted in a pos-traumatic osteoarthritis defect indicated favorable results in cartilage damage specifically . FurtherYuan et al. investigated the use of cell-free injectables in mice and rabbit models with cartilage defects. This was accomplished using a unique one-step ultrasonication crosslinking approach for the restoration of cartilage defected tissue that was both safe and effective . Schaeffvitro tests revealed suitable mechanical characteristics, whereas in rat experiments of osteoarthritis and osteochondral osteoarthritis revealed adequate cartilage tissue preservation, early degeneration of cartilage, and increased cartilage repair in the later stages of osteoarthritis [In 2021, Tang and his team made thermosensitive poly-polyethylene glycol-poly hydrogels. These hydrogels were used to make composite hydrogels that could deliver platelet lysate. In rthritis . In 2020rthritis .in vivo than the untreated group and hydrogel alone [In 2022, Zhou et al. fabricated catechol-modified chitosan 3D-microenvironment hydrogel for cartilage regeneration. In a rat model, the injected hydrogel within bone mesenchymal stem cells demonstrated a promising ability promoting proliferation and chondrogenic differentiation. According to the findings of gross assessment and histology, hydrogel loaded with bone mesenchymal stem cells repaired cartilage defects better el alone . Anotherel alone .The goal of cell sheet technology is to create an implantable sheet of cells that is densely packed with high-density cells coupled by a dense extracellular matrix collected without the use of biomolecules, catalyst, which is the most widely utilized technology for this purpose , 40.in vivo investigations revealed that, after 12 weeks, all groups witnessed a decrease in the number of cells, and therefore, only chondrocyte-based sheets were capable of filling the lesions with a conjunction of articular cartilage and fibrous tissue [Wongin et al. conducted one of the most recent studies on cell sheet technology, attempting to assess whether the formation of chondrocyte sheet-cancellous bone tissues is accomplished using a trichondrocyte sheet cultured on the top of cancellous bone. In rabbit models with cartilage injury, experiments were conducted for this purpose, with the latter revealing that chondrocyte sheets aid in the formation of hyaline-like cartilage and that chondrocyte sheet-cancellous bone tissues aid in osteochondral repair . Takizaws tissue . Cell shs tissue . In 2020s tissue .  Table The most recent and descriptive research on articular cartilage tissue engineering has been described previously. In spite of the fact that these studies have contributed to significant advancements in cartilage tissue recovery, turning their findings into clinical practice has been hampered by the restricted number of available clinical trials. The results of clinical investigations on cartilage tissue engineering techniques are presented as follows .Zhou et al. published a recent clinical trial that has shown that the infrapatellar fat pad, a common source of mesenchymal stem cells throughout knee arthroscopy, is safe and effective. Both knee arthroscopic therapy and knee arthroplasty therapy with patient-derived infrapatellar fat pad cell concentrates were offered to patients suffering from symptoms of knee osteochondral lesions. The results confirmed that infrapatellar fat pad cell concentrates had a significant effect on lowering hurt and enhancing cartilage recovery in these individuals .Hyaluronan-packed mesenchymal progenitor cells from a person's own fat were used in another clinical trial by Qiao et al. Thirty patients with osteoarthritis of the knee and medial femoral-tibia condylar abnormalities were randomized to one of three treatment regimens. Microfracture combined with hyaluronan and autologous human adipose-derived mesenchymal progenitor cells injection resulted in long-term clinical improvement . Kim et Other clinical trials looked into tissue engineering techniques that did not require surgical intervention. In 2020, Garza and colleagues performed a trial on 39 patients with symptomatic knee osteoarthritis injected autologous stromal vasculature portion achieved by minor rhinoplasty harvest into the joint. Two dosages of stromal vascular fraction were compared to placebo injections in this clinical trial, and the results demonstrated a 12-month follow-up found a dose-based reduction in pain, but no change in cartilaginous-like structure .The safety and efficacy of intra-articular injections of allogeneic human adipose-derived mesenchymal progenitor cells were investigated in a comparable clinical trial. Lu et al. studied 19 symptomatic intraregional knee osteoarthritis patients who received two injections of three different dosages of allogeneic human adipose-derived mesenchymal progenitor cells and found that despite improvement in health status, however, only those in the lowest quartile demonstrated slight articular cartilage regeneration . Yoon etCole et al. used an industrial cartilage allogeneic-graft as platform which are assistant cells released after microfracture in a recent prospective cohort research. This study comprised 48 patients with symptomatic localized cartilage abnormalities in the knees, and the results showed favorable clinical outcomes after enhanced microfracture at a 2-year follow-up . Wolf etFor patients with early osteoarthritis who are not finding relief from nonsurgical treatment, hand surgeons should consider using autologous fat grafting as a viable alternative. In their study , Herold in vitro and in maxillofacial patients with malar augmentation procedures, seeded adipose-derived stem cells appear to be an excellent biomaterial capable of driving bone regrowth and remodeling in the hydroxyapatite-collagen hybrid scaffold [Adipose-derived stem cells can be seeded on biocompatible scaffolds or biomaterials to produce bone regeneration grafts using bone tissue engineering methods . An implscaffold .The outcomes of recent cartilage tissue engineering clinical studies are presented in in vitro, in vivo, and clinical studies on articular cartilage sores prior to osteoarthritis progression seem pointless. In addition, a number of large-scale clinical preliminary and long-term follow-up studies, including the requirement for replication of in vitro, ex vivo, and clinical in vivo examinations, are needed. Long-term recovery is more important than short-term improvements in clinical symptoms and radiologic evaluations. In addition to the previously mentioned challenges, focusing on accessibility now presents new ones. Cell-based tissue design is extremely difficult because of the enormous number of studies and a wide range of tissue design parts and advancements. A lack of studies, a focus on collagen type I platforms, and information on the hidden tools of activity and advantages it has over cell-based tissue design and other existing intercessions are all problems with non-cell-based tissue design. Adaptability and clinical interpretation of these techniques are directly affected by other factors that influence their adaptability and microenvironment. Recreating the articular cartilage microenvironment is certain to show powerful cartilage recovery. Although there are some disadvantages, the design of articular cartilage tissue holds a lot of promise for the repair and prevention of cartilage degradation.Articular cartilage tissue design, a comparatively recent scientific field, has made significant progress in the last two decades, but there are still many obstacles to practical application. Translatability and reproducibility are absent from the design of articular cartilage tissue in the seat-to-bedside process, and this is reflected in the inability of translational examination to overcome this barrier. Endoplasmic reticulum or mitochondrial breakdown, apoptosis, or excessive production of reactive oxygen species are all possible outcomes of chondrocyte passing. An additional problem is that changes in articular cartilage caused by physiological maturation and changes in the extracellular matrix are often not clearly distinguished. Extracellular matrix-related cartilage irregularities may necessitate the use of multiplex tissue design techniques. When it comes to joints other than the knee, arthroscopy perceptions and articular cartilage desert outer extension are the only tools available. Since models with actual deformities are used regardless of the climate in which they are studied,


As such, it is necessary to develop novel nanomaterials with rational design to reveal the underlying mechanisms and to meet various needs in these different biomedical applications. Over the years, with the rapid development of material science and engineering, people can solve important biomedical problems by preparing nanomaterials with versatile functionalities, pushing the Frontiers of biomaterials forward in translational and clinical settings , chitosan (CS), and fucoidan (FD), named KCFMN, for accelerating full-thickness wound healing. Showed that the KCFMN patch displayed noticeable antibacterial properties and good cytocompatibility. In particular, the KCFMN patch significantly accelerated the wound healing development in a full-thickness wound in rats by improving the epithelial thickness and collagen deposition. Thus, this versatile KCFMN patch has great prospects as a dressing for full-thickness wound healing.For skin wound healing, it is usually difficult to be cured by conventional topical administration because it has been recognized that stratum corneum is the major obstacle for transdermal drug delivery. To address this issue, Wu et al. reviewed the recent Research progress of electrospun nanofibers to treat various oral diseases. Oral diseases have a relatively high prevalence rate that have been recognized as huge threat to public health. In recent years, electrospun nanofibers have shown great potential in biomedical fields especially for disease treatment, because they are an ideal platform for loading and delivering bioactive molecules due to their large specific surface area, as well as regulating cell behavior as they could easily mimic the extracellular matrix. They described the engineering strategies of electrospun nanofibers; introduced the biological functions that nanofiber scaffolds could provide; and indicated future development directions in terms of scaffold design, manufacture, engineering, and clinical applications. In another review, Shi et al. summarized recent development of nanomaterials for osteoarthritis (OA) therapy by targeting articular cartilage. OA causes enormous burden on human health and society as it is an obstinate, degradative, and complicated disease with various sequela. Compared with conventional systematic therapy that is less effective and may lead to multiple side effects, nanoparticles have been extensively exploited as novel medication to treat OA as they possess unique properties including high tissue penetration, biostability, and large specific surface area. Nano-drug delivery systems loaded with therapeutic drugs could target chondrocytes, synovium, or extracellular matrix and release the molecules sequentially. The nano therapeutical molecules could directly get to the targeted tissue, alleviating the inflammation and promoting healing. This article provides comprehensive overview of the nanomaterials targeting and treatment for OA, which could also be useful for other inflammatory diseases.For disease therapy, nanostructured biomaterials have offered unique advantages as well. Xia et al. prepared chitosan and hydroxyapatite nanowires (CS@HAP NWs) hybrid nanostructured scaffolds with suitable mechanical properties and porous structures. The 3D-hybrid scaffolds promote cell adhesion, migration and differentiation of human adipose-derived stem cells (hADSCs) inside the scaffolds. By rationally engineering HAP-based hybrid nanostructured scaffolds, this study provides a facile and effective approach for bone tissue engineering. In addition, titanium-based materials have been widely applied in bone-tissue engineering. However, there remains great challenge that osseointegration at the bone-implant interface is inefficient due to the inefficient neural network reconstruction. Zhao et al. used an electrochemical technique and a hydrothermal approach to construct a potassium titanate nanorod-decorated titanium oxide (K2Ti6O13-TiO2) nanotube array on the Ti implant surface. The osteogenic differentiation of mesenchymal stem cells was enhanced on the modified Ti due to the presence of nanotube array, while the neural differentiation of neural stem cells was accelerated due to the release of potassium ions from K2Ti6O13-TiO2 nanotube. The nanotube array proposed in this study is promising for promote neuralization on the surface of implants that is beneficial for bone repair.For tissue engineering, nanostructured biomaterials have shown their potent ability to enhance the regeneration of the tissue defect by actively regulate tissue forming-related cell behavior such as stem cell fate. To simulate the 3D structure of cancellous bone formation, In summary, the articles collected in this Research Topic demonstrate the development and application of biomaterials with designed nanostructures in regenerative medicine as well as disease therapy. We would like to thank the contributing authors and the reviewers for supporting this Research Topic. We believe, these articles will be helpful to researchers in both material science and biomedicine field.


Breast cancer is one of the most common cancers threatening women worldwide. A limited number of available treatment options, frequent recurrence, and drug resistance exacerbate the prognosis of breast cancer patients. Thus, there is an urgent need for methods to investigate novel treatment options, while taking into account the vast molecular heterogeneity of breast cancer. Recent advances in molecular profiling technologies, including genomics, epigenomics, transcriptomics, proteomics and metabolomics data, enable approaching breast cancer biology at multiple levels of omics interaction networks. Systems biology approaches, including computational inference of ‘big data’ and mechanistic modelling of specific pathways, are emerging to identify potential novel combinations of breast cancer subtype signatures and more diverse targeted therapies. Breast cancer is the most common malignancy threatening women's health worldwide . It affeWith the advent of precision oncology , the molRecent advances in molecular profiling technologies, including next-generation sequencing, transcriptomics and high-throughput mass spectrometry-based proteomics and metabolomics, have started to increase the number of potential targets for the development of personalised treatments , 15, 16.in vitro and in vivo models.Here, after introducing available omics data and databases from molecular profiling technologies analysing cancer samples, including those derived specifically from breast tumour samples, we will discuss how recent developments in data integration and mechanistic modelling can be used towards the development of more efficient personalised treatments. Two main types of multi-omics approaches can be distinguished: 1) data-driven statistical inference methods, in particular the latest deep learning techniques, to predict gene features that potentially affect patient characteristics and clinical responses; and 2) molecular target-focused mechanistic network modelling methods to identify novel therapeutic options. We will show that these two approaches can identify additional biomarkers, enrich our knowledge of the network underlying breast cancer mechanisms, be used for better patient molecular subtyping and for predicting drug response and post-treatment outcomes, and narrow down novel ‘driver’ pathways at the protein and metabolite level to be validated via BioRender.com.For each order of the central dogma, omics data layers and type are represented. Although copy number variations  and copy number alternations  are considered as mutations, they do not change the sequence and are stored and analysed as continuous data, in contrast to binary mutation data. Metabolite concentrations are mainly acquired by mass spectrometry (MS) and nuclear magnetic resonance (NMR) experiments. Clinical data attributed to patient samples commonly include age at diagnosis, ER/PR/HER2 status, and tumour grade and size. Created with Molecular profiling technologies include analyses of samples from cancer patients or from biological models of cancer at a global scale on multiple levels. In the order of the ‘central dogma’ of molecular biology, the major technologies target genetic mutations (genomics), epigenetic modifications (epigenomics), RNA expression (transcriptomics), protein abundance and post-translational modifications (proteomics) and metabolite concentrations (metabolomics) ,15,17 F. These tOmics data should be considered to study not only interactions in the current layer  but also interactive effects across layers . For example, mutation and copy number alone cannot determine mRNA expression, since DNA methylation modulates transcription. Although proteins are translated from mRNA, protein expression is also regulated by the silencing effects of miRNA including translational repression and mRNA degradation. In turn, protein products such as transcription factors affect mRNA expression throughout gene regulatory networks by binding to DNA sequences. However, integrating all omics data is challenging as these data types are unevenly deposited in publicly accessible data repositories, as shown for the cancer-specific data resources provided in As proteomics and metabolomics data are not as abundant as other data layers , currentRecent computational multi-omics data integration methods for cancer research have focused on utilising deep learning techniques , 33∗∗. DOne problem targeted by current deep learning approaches is to identify high-risk breast cancer patients using differentially expressed genes (DEGs) that could be experimentally validated, as illustrated by Denoising autoencoder for accurate CAncer Prognosis (DCAP)  and DeepAnother problem addressed by deep learning is to model drug responses and predict the long-term post-treatment outcomes. Two representations are BRCA Multiomics  and MultIn conclusion, deep learning methods for multi-omics integration have been experimented in a variety of applications to boost our understanding of breast cancer mechanisms, such as selecting expression signatures to characterise the risk of patients (mainly using AE architectures) and building causal relationships between expression profiles and clinical annotations (mainly using MLP architectures). The involvement of GAN also leads us to consider how we can enhance the feature selection procedure. Deep learning inference approaches can exceed other statistical methods in constructing nonlinear relationships, auto-learning and adjustable hidden architectures to fit the scenario of highly heterogeneous multi-omics data effortlessly. Ideally, it is hoped that the highly complex network structures in deep learning approaches will be able to learn the actual causal structure of biological networks from multi-omics data. However, this is currently not the case, as the “black box” problem remains a bottleneck, and hence future computational approaches will need to investigate how the abstract hidden units can be interpreted in the sense of molecular interactions.Mechanistic modelling, which uses biological hypotheses to build mathematical models and runs bioinformatics algorithms to predict systems behaviour and design experiments for validation, is another widely used approach to identify potential drug targets and drugs that will guide future clinical trials ,15. MechOne representative approach is proteogenomic analysis, combining next-generation sequencing and mass spectrometry to provide information on functional protein signalling in tumour samples . As protin silico analysed differentially expressed metabolic proteins using non-negative matrix factorisation clustering methods. By doing so, they constructed an immune landscape of phospho-retinoblastoma protein (Rb)-dependent kinase activity in TNBC, represented by a higher mammalian target of rapamycin (mTOR) kinase activity accompanied by increasing Rb phosphorylation . G. Gin viv[ex vivo  first id subtype . They aleriments .In conclusion, several recent pieces of evidence suggest that breast cancer can be considered as a metabolic disease as well as a genomic disease. Besides, as metabolic inhibitors often will not negatively affect normal cells , they arMulti-omics integration for breast cancer modelling has drawn considerable attention. This approach has been driven by developments in diverse disciplines – including molecular biology, biochemistry, bioinformatics and computer science – to discover novel mechanisms and ultimately contribute to clinical precision oncology. Despite current achievements in various cancer- and drug-specific data programs, integration algorithms and proteogenomic workflows, there are a variety of ongoing questions for future investigation. For instance, data are not available in equal amounts across all omics layers, where genomic, epigenomic and transcriptomic data are enriched, while proteomic and metabolic data are much scarcer. This requires the research community to reduce this gap to enable the construction of global patterns of information flow from genotype to phenotype.Two very different but complementary types of modelling approaches are contributing to our understanding of multi-omics data: 1) the statistical modelling at the heart of deep learning and computational inference, which focuses on the identification of predictive ‘features’ that identify, for example, breast cancer subtypes or predict treatment outcomes, and 2) mechanistic modelling, often based on systems of differential equations or network descriptions of cellular pathways, which serve to describe and simulate the dynamic function of biological systems at the molecular level. The deep neural networks used in statistical models for computational inference typically lack proper interpretability: the hidden units of these models represent high-level abstractions based on the combination of a variety of data . Their interpretation requires a mapping of this abstract information onto the actual molecular networks which are the centrepiece of mechanistic models . IdeallyIn practice, clinical applications such as a personalised drug recommendation system, would benefit from single-omics tests and a small number of biomarkers. Nevertheless, our understanding of breast cancer mechanisms is still in the phase of discovery, where a larger number of druggable targets, as well as a comprehensive understanding of their embedding in functional pathways across all omics levels are of critical importance. Therefore, we need multi-omics modelling to understand the complex molecular network landscape of breast cancer and maximise our chances to develop efficient applications for precision medicine.HM wrote the manuscript; RB, CF and JMS conceived the project and edited the manuscript. All authors have read and approved the final version.


Background: The healing of foot wounds in patients with diabetes mellitus is frequently complicated by critical limb threatening ischemia . In this situation, imminent arterial revascularization is imperative in order to avoid amputation. However, in many patients this is no longer possible . Besides conservative treatment or major amputation, many alternative methods supposed to decrease pain, promote wound healing, and avoid amputations are employed. We performed a narrative review in order to stress their efficiency and evidence. Methods: The literature research for the 2014 revision of the German evidenced-based S3-PAD-guidelines was extended to 2020. Results: If revascularization is impossible, there is not enough evidence for gene- and stem-cell therapy, hyperbaric oxygen, sympathectomy, spinal cord stimulation, prostanoids etc. to be able to recommend them. Risk factor management is recommended for all CLTI patients. With appropriate wound care and strict offloading, conservative treatment may be an effective alternative. Timely amputation can accelerate mobilization and improve the quality of life. Conclusions: Alternative treatments said to decrease the amputation rate by improving arterial perfusion and wound healing in case revascularization is impossible and lack both efficiency and evidence. Conservative therapy can yield acceptable results, but early amputation may be a beneficial alternative. Patients unfit for revascularization or major amputation should receive palliative wound care and pain therapy. New treatment strategies for no-option CLTI are urgently needed. The incidence of both diabetes mellitus as well as peripheral arterial disease of the lower limb arteries (PAD) is rising worldwide ,2. PAD oArterial revascularization is recommended in CLTI; there is adequate evidence ,7,8,9 onIn this situation, a host of alternative methods for the improvement of arterial perfusion, wound healing and pain therapy are employed, the proof of efficacy as well as the scientific evidence of which are lacking. The objective of this review is to investigate whether there are effective and guideline-compliant methods of treatment for diabetic patients with no-option CLTI, and whether they are more useful than conservative treatment or timely major amputation.The German Society for Angiology (DGA) performed an extensive literature search for the 2015 edition of its evidence-based PAD guidelines . For thePAD signalizes cardiac and cerebral complications as well as a reduced life expectancy. Risk factors include age, sex, cigarette smoking, arterial hypertension, hyperlipidemia, diabetes mellitus, obesity, lack of exercise, and previous events in other vascular territories. In 2015, more than 237 million people worldwide suffered from PAD . Only 1–The therapeutic goals for CLTI are pain relief, avoidance of infections, major amputations and care cases, healing of wounds, maintenance of walking function, self-determination and social integration, as well as an increase in the quality and duration of life.Reducing the progression of PAD and cardiovascular morbidity by lifestyle improvement, smoking cessation, or the administration of ASS and statins come too late for DFS patients with CLTI, while optimal control of blood pressure and diabetes are important in view of imminent operative procedures and wound healing.Arterial revascularization should be performed soon . Revascularization may be impossible if the patient does not offer any technical option for revascularization (“no-option”), comes “too late” to avoid major amputation, or is “too sick” to indulge it.“No option”: 20 years ago, 40% of CLTI patients  were con“Too late”: Tissue loss is too extensive , bacteri“Too sick”: The patient is not “fit for operation”, owing to serious comorbidities .Many methods are applied in CLTI patients when arterial reconstruction is no longer possible. This “real world non-evidence practice”  arises fThere is no proven benefit of vasoactive drugs such as naftidrofuryl, cilostazol or pentoxyphyllin on wound healing and amputation rate in CLTI ,7,8,9,21Fibrinolytic drugs are supposed to decrease plasma-fibrinogen, plasma viscosity, the aggregation of erythrocytes, and to improve collateralization. However, they do not reduce amputation rates or promote wound healing . In an uThe effects of HBOT on wound healing are most pronounced when blood flow to the foot is maintained. In CLTI, however, they are virtually undetectable . EarlierLSE  may reduce rest pain in CLTI but has no effect on ankle brachial index (ABI), mortality, or the amputation rate . In neurEvidence for SCS in CLTI in terms of avoiding major amputations is low. SCS does not decrease the amputation rate or mortality of DFS patients with CLTI . Others Much hope rests on regenerative (gene and stem cell) formation of new capillaries from progenitor cells, angioblasts or pre-existing vessels.Although the results of gene-based therapy were initially encouraging, they have so far been contradictory and questionable . A placeMononuclear bone marrow stem cells may promote the formation of collaterals in patients with no-option CLTI. Previous studies with intramuscularly administered bone marrow stem cells showed a significant decrease in resting pain and amputation rate as well as an improvement in the ABI and foot ulcer healing rate. None of these positive results in no-option CLTI remains significant if the analysis is limited to randomized, placebo-controlled studies or low-bias RCTs . The plaHELP aims at the formation and expansion of collaterals to prevent major amputation in no-option CLTI patients through shear stress and increased wall tension. The procedure comprises isolated arterial perfusion of the affected limb with a heart-lung machine at 200–300% of the normal blood pressure . AmputatIPC is a procedure that was first described some 90 years ago . It wasTES may promote angio- and vasculo-genesis. In an RCT with 22 patients with no-option CLTI , an imprAfter extensive minor amputations of no-option diabetic patients, major amputation could be avoided by skin replacement material stimulating the synthesis of extracellular matrix from fibroblasts and creating a ‘neodermis’ . The stuImmunomodulation with ozonated autologous blood or oils to increase vasculo-genesis in patients with no-option CLTI was repeatedly shown in small observational studies. Ozone therapy is considered irrational and life-threatening because such high doses of ozone significantly increase the risk of neoplasia . There iAttempts have been made to arterialize the deep veins of the lower leg and foot  in no-opThe model has been rediscovered as “percutaneous arterialization of the deep leg veins” or a combination of open bypass surgery on deep leg and foot veins with intraoperative destruction of the venous valves. In particular, open surgery showed leg preservation and wound healing between 25 and 100%, primary patency between 44 and 88%, and the elimination of resting pain between 12 and 100% . MidtermThe aims are to avoid pain, wound infections, hospitalization and amputation in patients unfit for revascularization or amputation, or for no-option patients.“Real-world” data show that CLTI patients without revascularization have an extremely low amputation-free survival . RecentlUnfortunately, almost no study  dealing with the prognosis of conservative therapy of CLTI differentiates between people with and without diabetes. People with diabetes mellitus have little or no pain despite ischemic foot lesions due to diabetic polyneuropathy. The adherence to pressure relief, restriction of walking distance etc. is generally low, in contrast to non-diabetic CLTI patients who voluntarily relieve their feet due to severe pain. This is why recurrent ulcers in DFS patients occur at about 30% within one year after entering remission . The morIn diabetic patients without polyneuropathy, long-term conservative treatment without escalation of the painkiller dose is not possible, which is why a major amputation should be considered sooner .No-option DFS patients often have to offload the foot  in the lThe influence of foot lesions or Charcot osteoarthropathy on QoL can be as negative as a major amputation . QoL canA special item is revascularization of CLTI patients on dialysis. The prognosis for wound healing and survival is poor, so early amputation in patients with extensive soft tissue damage  and seveA major limitation of our clinical review arises from the fact that our literature research was not strictly systematic as required by the PRISMA statement guidelines for systematic reviews and meta-analyses. We chose a pragmatic literature research sufficient for a clinically oriented narrative review, since we did not expect surprisingly new information from additional literature which mostly lacks high scientific evidence. Nevertheless, the algorithm used for our research was the basis for the German evidence-based clinical practice guideline on the diagnosis and treatment of PAD, which is an internationally respected guideline of high scientific quality.In DFS patients with CLTI, revascularization should be performed quickly in order to avoid major amputation (“time is leg”).In patients with no-option CLTI, the effectiveness for gene and stem cell therapy, hyperbaric oxygen, CT-guided sympathectomy, urokinase, prostanoids, intermittent pneumatic compression, transcutaneous electrostimulation, interactive wound dressings, and the arterialization of deep leg veins remain unproven.Conservative treatment for no-option CLTI includes the therapy of cardiovascular risk factors and concomitant diseases, appropriate wound treatment, pressure relief, avoidance of progressive soft tissue infection and timely palliative pain management. This approach may be more successful than previously assumed, especially in neuroischemic DFS patients.For most patients who come too late for revascularization or are too sick for it, only conservative treatment or major amputation remain as therapeutic options. In certain cases, some of the above-mentioned therapeutic alternatives may be helpful. If amputation is impossible due to concomitant diseases, palliative pain therapy should be the main focus.In no-option CLTI, timely amputation should be considered an opportunity, not an inevitable stroke of fate.New treatment strategies for no-option CLTI patients are urgently needed. There is need for future scientific research in order to overcome the lack of efficient therapeutic options for these patients whose risk of major amputation is high.


Global emergence of the COVID-19 pandemic in 2020 curtailed vaccine-preventable disease (VPD) surveillance activities, but little is known about which surveillance components were most affected. In May 2021, we surveyed 214 STOP  Program consultants to determine how VPD surveillance activities were affected by the COVID-19 pandemic throughout 2020, primarily in low- and middle-income countries, where program consultants are deployed. Our report highlights the responses from 154 (96%) of the 160 consultants deployed to the World Health Organization African Region, which comprises 75% (160/214) of all STOP Program consultants deployed globally in early 2021. Most survey respondents observed that VPD surveillance activities were somewhat or severely affected by the COVID-19 pandemic in 2020. Reprioritization of surveillance staff and changes in health-seeking behaviors were factors commonly perceived to decrease VPD surveillance activities. Our findings suggest the need for strategies to restore VPD surveillance to prepandemic levels.  Routine immunizations are among the most effective interventions to reduce illnesses, hospitalizations, and deaths from vaccine-preventable diseases (VPD)  may have hindered detection and timely notification of VPD cases  Program has supported the Global Polio Eradication Initiative (GPEI) and national ministries of health to strengthen routine immunization and surveillance programs to reduce global VPD morbidity and mortality  of all STOP consultants were deployed. The survey questions primarily focused on their perceptions and observations about how COVID-19 had affected surveillance for poliovirus, measles, rubella, and other VPDs  and asked STOP consultants to recall changes to their work in 2020 compared with 2019. The survey, developed in both English and French, included categorical responses and free-text fields and was sent to respondents by email with 2 weeks for completion.https://www.r-project.org) to conduct descriptive analyses to summarize the quantitative survey findings by calculating the proportion of responses to each question. We then reviewed qualitative information provided through the free-text responses to identify trends and themes that provided more context and descriptive information about the disruptions to VPD surveillance activities observed by the STOP consultants. We used R version 9.1.3  completed the survey . SeventyAmong respondents, 97% observed that the COVID-19 pandemic either somewhat  or severely  affected measles or rubella surveillance in 2020. Themes from free-text responses suggested movement restrictions implemented to mitigate the risk of COVID-19 transmission affected the ability of surveillance staff to conduct supervisory visits, active case searches, suspected case investigations, community-based surveillance, and capacity-building activities and impeded collection and transportation of blood samples. About two thirds of the African Region STOP respondents  suggested that COVID-19 mitigation efforts also potentially disrupted the detection, notification, and reporting of measles or rubella cases.Almost all of the African Region STOP consultants surveyed observed that AFP surveillance for poliovirus was either somewhat  or severely  affected by the COVID-19 pandemic during 2020 . Some reAfrican Region STOP consultants noted the number of active AFP surveillance activities they conducted decreased  or were not completed  in 2020 compared with 2019. Respondents also noted that lockdowns to mitigate the transmission of COVID-19 often reduced the public’s access to and use of local healthcare facilities and services, which may have allowed AFP cases to go undetected. Most respondents felt that COVID-19 either somewhat  or severely  affected surveillance of other VPDs, such as pertussis, yellow fever, and neonatal tetanus, in 2020. Specifically, 65% (100/154) of respondents suggested that active surveillance conducted for other VPDs decreased in 2020 compared with 2019; 16% (24/154) noted they did not conduct any active surveillance for these other VPDs in 2020. However, African Region STOP consultants did observe some improvements in measles or rubella surveillance in 2020, including the integration of VPD surveillance activities into COVID-19 response activities; using phone, WhatsApp, and similar technologies for communication when field access was limited; improving community-based surveillance; and implementing VPD surveillance refresher trainings for health facility staff. As the number of undervaccinated children increases because of disruptions in routine immunization services, understanding how VPD surveillance systems have fared during the COVID-19 pandemic becomes critical (STOP consultants spend most of their time at local or district levels, and results from this survey suggest that certain VPD surveillance activities such as detection, notification, and reporting were affected primarily at those levels; however, some effect was observed on regional and national activities in many WHO African Region countries because the COVID-19 response was prioritized. Respondents also noted that measles and rubella surveillance staff were often shifted to COVID-19–related activities. In countries where staffing and funding are limited, integrating VPD surveillance functions across systems, instead of relying on standalone systems, could be a mechanism to address resource limitations, even moreso as COVID-19 becomes endemic in countries.In addition, some respondents indicated that country lockdowns and movement restrictions contributed to delays in suspected case investigations and transportation of samples to reference laboratories. Although the Global Polio Eradication Initiative had published interim guidance on how to continue conducting polio surveillance with COVID-19 mitigation measures in place (Among limitations in our survey, consultant-respondents were asked to respond to questions based on their personal knowledge and experience, which is likely to have varied depending on location, length of time in assignment, and type of assignment, and should be considered a collection of observations or case series. These responses provide a valuable starting point to generate hypotheses for future public health investigations and research into impacts of VPD surveillance systems during the COVID-19 pandemic. Second, each STOP consultant surveyed was contracted through WHO to work in partnership with the Ministry of Health in their country of assignment. Thus, responses might not represent observations of the COVID-19 pandemic’s effect on VPD surveillance activities among private sector or non–Ministry of Health immunization and surveillance staff, or in countries without STOP consultants. Since 2020, the COVID-19 pandemic has disrupted or delayed many aspects of both aggregate and case-based VPD surveillance systems in Africa. A conscientious effort should be made to connect COVID-19 response activities to existing public health surveillance systems, especially where substantial investments have been made towards strengthening VPD contact tracing, active surveillance, and specimen collection and transportation. Efforts to integrate systems across diseases would promote and facilitate efficient restructuring, integration, and coordination of surveillance systems globally.


JCI examines how chromatin accessibility and structure may explain the mechanisms by which noncoding variants increase susceptibility to cardiac arrhythmias. We discuss the implications of these findings for cell type–specific gene regulation and highlight potential therapeutic strategies to engineer locus-specific epigenomic remodeling in vivo.How chromatin accessibility and structure endow highly specialized cells with their unique phenotypes is an area of intense investigation. In the mammalian heart, an exclusive subset of cardiac cells comprise the conduction system. Many molecular components of this system are well studied and genetic variation in some of the components induces abnormal cardiac conduction. However, genetic risk for cardiac arrhythmias in human populations also occurs in noncoding regions. A study by Bhattacharyya, Kollipara, et al. in this issue of the  Proper electrophysiological signaling through the cardiac conduction system is necessary for postnatal life. Thus, genetic variation that completely disrupts cardiac conduction in early life is only rarely observed. More common is a heritable predisposition to cardiac arrhythmias, often coincident with cardiomyopathy, wherein the genetic code establishes a cardiac substrate more vulnerable to improper conduction. This vulnerable substrate can manifest in ventricular or atrial myocytes, as a tissue-level phenomenon of the cardiac conduction system itself, or through the interactions of specialized cells of the heart with the vasculature, the immune system, and the myriad of environmental factors that trigger cardiac arrhythmias.JCI, Bhattacharyya, Kollipara, et al. examined SNPs in noncoding genomic regions that associate with risk for cardiac arrhythmias (Genetic variation associated with cardiac conduction system (CCS) diseases is only partially understood, with a proportion of this variation mapping in or near ion channels, transcription factors, or other proteins . GWAS rehythmias . The authythmias .More compact genomic regions reflect a chromatin landscape where genes are typically repressed, while more accessible chromatin is associated with active transcription. These regions can be distinguished across the genome using the assay for transposase accessible chromatin followed by short read sequencing (ATAC-Seq) . ATAC-SeMyh6 and Actb target loci, as well as binding of ONECUT1 to the promoters of 5 target genes, suggesting that these transcription factors may interact with regulatory elements in addition to the target genes themselves , a second in an intergenic region between Rhob and Hs1bp3 (AVN), and a third in an intron of Igf1r (VCS)   but haveSubpopulations of CCS cell types revealed from single-cell experiments could inform disease mechanisms, and coupled with epigenomic measurements like those in Bhattacharyya, Kollipara, et al., could reveal how gene expression is controlled in these specialized cells. Because CCS cells are difficult to visualize during cardiac procedures, putative markers could reveal specific subpopulations of the SAN, AVN, and VCS, perhaps using a recent conjugated antibody approach developed to mark CCS cell–surface markers . Such su


Pneumatosis intestinalis (PI) is characterised by submucosal and/or subserosal collections of free gas, forming cystic lesions within the gastrointestinal (GI) tract, most commonly seen in the small intestine but it can also involve large intestine or the stomach. PI is idiopathic in about 15% of cases but the majority is secondary to conditions such as autoimmune, infectious, inflammatory, pulmonary, drug and/or traumatic aetiologies. PI is a rare and usually benign complication of systemic sclerosis (SSc), and most patients are relatively asymptomatic. Its pathogenesis is likely to involve complex interplay of mechanical, biochemical, bacterial and/or drug factors.A 67-year-old man with SSc-myositis overlap syndrome for over nine years on long term Mycophenolate mofetil 500mg BD and Prednisolone 8mg OD presented acutely unwell with worsening abdominal pain, bloatedness, distension, intermittent bloody diarrhoea and vomiting for three weeks. He was afebrile but slightly hypotensive and tachycardic. His abdomen was distended with mild generalised tenderness but soft and regular bowel sounds were audible. There were no palpable organomegaly, guarding, rebound tenderness or other signs of peritonism.He had raised serum lactate at 3.1 and pre-renal acute kidney injury secondary to GI losses and reduced oral intake but his full blood count, liver blood tests, serum amylase, calcium profile, blood glucose, venous blood gas and C-reactive protein were all within normal range. His coeliac screen (IgA tTG) was normal. He tested positive for ANA Hep2 (speckled) but negative for ENA, anti-dsDNA and anti-centromere antibodies. His other SSc presentations include Raynaud’s phenomenon and diffuse scleroderma. His contrast-enhanced CT abdomen and pelvis on admission displayed extensive pneumatosis changes, moderately dilated small bowel loops and pneumoperitoneum. There are prominent atherosclerotic changes seen in aorta and its major branches with associated narrowing but there is no acute thrombotic occlusion seen in the main-stem superior or inferior mesenteric arteries or their major branches.The patient was managed conservatively with bowel rest, intravenous fluids and antibiotics, and was referred for palliative care as surgical exploration was deemed inappropriately risky given his underlying ischaemic heart disease and impaired cardiac reserve. He was discharged home following a short hospital stay with anticipatory medications and a short course of Rifaximin followed by monthly antibiotic cycling with Co-amoxiclav, Metronidazole and Ciprofloxacin. He made a surprisingly excellent recovery on the antibiotics and his repeat CT scans at 11 weeks showed complete resolution of the pneumatosis intestinalis.PI with or without pneumoperitoneum is a rare gastrointestinal complication of SSc characterised by numerous intramural air-filled cysts within the GI tract. In spite of its usually extensive involvement of the GI tract, this condition generally runs a benign course and is managed conservatively in most cases. The development of PI in SSc is multifactorial, including mechanical , biochemical (excessive hydrogen production via fermentation processes in gut), overgrowth of gas-producing bacteria and drugs such as corticosteroids that could possibly cause intestinal mucosa atrophy and breakdown.Symptoms of PI can include diarrhoea, constipation, abdominal pain, rectal bleeding and mucous discharge. CT scan has high sensitivity and is the best diagnostic modality for PI. The treatment of PI is based on the severity of symptoms. The underlying cause of PI should be appropriately addressed and managed in all cases. Patients with asymptomatic PI need no further treatment but regular clinical review and monitoring are advisable. Conservative management is preferable to surgical intervention after careful exclusion of acute surgical causes or complications such as bowel perforation, ischaemia or obstruction. For patients with mild symptoms who do not require hospitalisation, antibiotics and elemental diet are recommended. However, for acutely unwell patients with moderate to severe symptoms, hospitalisation is usually required for bowel rest or decompression, fluid and electrolyte replacements, elemental diet or parenteral nutrition, antibiotics, high concentration oxygen, hyperbaric oxygen therapy or octreotide infusion.Our patient was managed conservatively as he did not exhibit any clinical signs of peritonism or bowel ischaemia and surgical interventions were deemed too risky given his underlying cardiac status. He was treated with and has responded well to cycling oral antibiotics for small intestinal bacterial overgrowth which was thought to be contributory to his PI.This case report illustrates that PI could be a rare gastrointestinal complication and presentation of SSc-myositis overlap syndrome, therefore clinicians should be aware of this uncommon manifestation of SSc. Other more common differentials such as inflammatory bowel disease, infections or even an underlying malignancy must be thoroughly assessed for and excluded.Pneumoperitoneum in the context of SSc-associated PI is generally benign in nature, spontaneous i.e. non-surgical and it occurs as a result of spontaneous rupture of the air-filled cysts within the gastrointestinal walls, rather than due to true bowel perforation. PI with or without pneumoperitoneum in patients with SSc is usually asymptomatic and only discovered incidentally on imaging or screening endoscopy. However, patients can present with more acute symptoms such as generalised abdominal pain/tenderness, distension and/or vomiting. These clinical presentations and imaging findings may simulate acute surgical abdomen such as bowel perforation and/or ischaemia, leading to diagnostic dilemma and unnecessary or inappropriately risky surgical interventions. Therefore, a precise diagnosis of PI and correct interpretation of its clinical significance are crucial, since PI is generally managed conservatively with favourable response.Surgical treatment is generally not preferred because GI involvement in SSc is almost always extensive, and operative manipulation is likely to result in post-operative complications. However, emergency laparotomy should be considered in patients who exhibit signs of peritonism or bowel ischaemia and therefore timely involvement of surgeons and multidisciplinary team is essential.