Rib fractures occur in almost half of blunt chest wall trauma victims in Australia. They are associated with a high rate of pulmonary complications, and consequently, with increased discomfort, disability, morbidity, and mortality. This article summarises thoracic cage anatomy and physiology, and chest wall trauma pathophysiology. Institutional clinical strategies and clinical pathway “bundles of care” are usually available to reduce mortality and morbidity in patients with chest wall injury. This article analyses multimodal clinical pathways and intervention strategies that include surgical stabilisation of rib fractures (SSRF) in thoracic cage trauma patients with severe rib fractures, including flail chest and simple multiple rib fractures. The management of thoracic cage injury should include a multidisciplinary team approach with proper consideration of all potential avenues and treatment modalities (including SSRF) to obtain the best patient outcomes. There is good evidence for the positive prognostic role of SSRF as part of a “bundle of care” in the setting of severe rib fractures such as ventilator-dependent patients and patients with flail chest. However, the use of SSRF in flail chest treatment is uncommon worldwide, although early SSRF is standard practice at our hospital for patients presenting with multiple rib fractures, flail chest, and/or severe sternal fractures. Several studies report that SSRF in patients with multiple simple rib fractures lead to positive patient outcomes, but these studies are mostly retrospective studies or small case–control trials. Therefore, prospective studies and well-designed RCTs are needed to confirm the benefits of SSRF in patients with multiple simple rib fractures, as well as in elderly chest trauma patients where there is scant evidence for the clinical outcomes of SSRF intervention. When initial interventions for severe chest trauma are unsatisfactory, SSRF must be considered taking into account the patient’s individual circumstances, clinical background, and prognostic projections. The Greek physician Soranus first described the pathophysiology of rib fracture in the early first century, but only in the 1940s and 1950s was surgical treatment first advocated . HoweverIt is important to understand the anatomy and physiology of the thoracic cage (rib cage) and of its contents towards comprehending the pathophysiology of rib fractures. The thoracic cage consists of a musculoskeletal framework that is held together by 12 thoracic vertebrae . They foThe twelve ribs in the musculoskeletal chest wall function as a unit alongside the diaphragm to facilitate ventilation . During Thoracic trauma causes disruption to the chest wall, impacting respiration and/or circulation, leading to death or increased morbidity. Rib fractures can compromise respiratory function by direct pulmonary injury and/or by interfering with breathing mechanics. Direct trauma to the lungs or central circulatory system can cause immediate life-threatening conditions such as tension pneumothorax, cardiac tamponade, aortic injury, haemothorax, and tracheobronchial disruption . MoreoveRib fractures complicating trauma are common in Australia, occurring in 20% to 40% of blunt chest wall trauma patients . Rib fraIn elderly patients with osteoporosis or brittle bones, rib fractures are associated with relatively higher mortality and morbidity . PatientDespite evidence and benefits, a surgical approach is still not widely utilised in major metropolitan trauma centres in Australia. The aim of this paper is to review and evaluate the pathophysiology of rib fractures and the outcome-based role of SSRF as part of an institutional clinical plan/pathway.Extensive searches were conducted using PubMed, Google Scholar, and government reports. Word searches were performed with relevant combinations of words such as chest trauma, chest injury, flail chest, randomised control trial, observation study, retrospective study, cross-sectional study, rib fracture; surgical stabilisation of rib fracture, thoracic injury, video-assisted thoracoscopic surgery, and outcomes. From more than 70 references, we identified ~32 papers that addressed management pathways for acute traumatic rib fractures involving surgical stabilisation. References from publications resulting from these sources (~6 papers) were also investigated for relevant data or information suitable for our manuscript. Topically relevant general review articles were excluded. Original clinical research, systematic reviews, and meta-analyses demonstrating statistical significance were dissected further with reference to criteria and outcomes involving continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), chest injury activation protocol (ChIP), high flow nasal prongs (HFNP), hospital length of stay (HLOS), ICU length of stay (ILOS), intermittent positive pressure ventilation (IPPV), mechanical ventilator days (MVDs). This honing approach resulted in ~36 publications that informed the evidence behind our report.Ethical approval was not required by our institution for this submission. However, in several (latter) parts of this paper, we include observations and preliminary concepts/results from our use of SSRF in our trauma care practice at our hospital. Moreover, we include information about ongoing clinical studies linked to the information presented in this paper. Unfortunately, this paper does not have an adequate word count to fit into a submission under the “review” category. Therefore, this paper has been processed as a “brief report”.This submission did not use the preferred reporting items for systematic reviews and meta-analysis (PRISMA) as it was not relevant. However, it is evident that we utilised a systematic approach for this submission. Moreover, we are currently preparing a systematic PRISMA-guided systematic review covering evidence-based management for elderly patients with rib fractures. This manuscript, which we expect to be submitted in a few weeks’ time, may have an adequate word count to fit into the “review category” as a systematic review.Complications such as pneumonia and respiratory failure are common when blunt chest injuries are not treated promptly with adequate analgesics, physiotherapy, and respiratory support . These pDelayed and inadequate analgesia for chest trauma patients can lead to anorexia, insomnia, stress, and limited mobility . These pSeveral studies show standardised clinical pathways that streamline patients with rib fractures and improves clinical outcomes for chest trauma patients. Sahr et al. set up a “bundle of care”, which included early referral to trauma services . This paAs part of these pathways or bundles of care, SSRF should also be considered. Early SSRF (≤72 h) is now advocated in our hospital for patients meeting set criteria such as multiple rib fractures, flail chest, trauma patients requiring video-assisted thoracoscopic surgery (VATS), severe sternal fractures, and extubation failure. Unfortunately, the use of SSRF in flail chest treatment is still uncommon worldwide. One study showed only 0.7% of 3467 adults with post-trauma flail chest undergoing SSRF at level 1 and 2 trauma centres .In the absence of flail chest in patients with multiple rib fractures, several papers report the successful use of SSRF with positive clinical outcomes ,25,26,27Developing a flail chest from blunt trauma can be a life-threatening injury. A flail chest is characterised by paradoxical motion of the flailing chest wall segment that results from three or more successive rib fractures in two or more places. The considerable morbidity and high mortality rate associated with flail chest varies between 20% and 30% . The usuCurrent evidence suggests that conservative treatment alone may not guarantee a positive outcome . SSRF isA meta-analysis of pooled data from 11 studies showed SSRF to be beneficial in flail chest patients resulting in shorter mechanical ventilator days (MVDs), hospital length of stay (HLOS), ICU length of stay (ILOS), chest deformity, pneumonia incidence, septicaemia, need for tracheostomy, and mortality . A meta-A 2020 meta-analysis by Long et al. scanned 1917 articles and identified 7 eligible RCTs, with a total of 538 multiple rib fracture patients for their analysis . Out of Currently, SSRF for flail chest patients is recommended by the British National Institute for Health and Clinical Excellence (NICE) and the American Eastern Association for the Surgery of Trauma (EAST) to decrease MVDs, HLOS, ILOS, pneumonia incidence, and mortality .Management approaches encompassing SSRF are also being evaluated for simple rib fracture patients. The results of a multicentric RCT carried out in level 1 trauma centres in metropolitan Australia were recently published by Marasco et al. . AlthougIn a 2019 cohort study paper involving non-ventilator-dependent patients with multiple simple rib fractures, Lin, et al. showed that adding SSRF during VATS improves patient outcomes such as better pain control, and decreased ILOS and HLOS . In a 20We analysed current thoracic trauma management algorithms (“bundles of care”) and evidence-based rib fracture therapy interventions (including SSRF), which focus on pain control, injury seriousness, and the anatomical extent of involvement. There is good evidence for the prognostic role of SSRF as part of a “bundle of care” in the setting of severe rib fractures such as ventilator-dependent patients and patients with flail chest. At our hospital, early SSRF (within 3 days) is recommended for patients with multiple rib fractures, flail chest, severe sternal fractures, extubation failure, and trauma patients requiring VATS.We showed that blunt chest wall trauma and rib fractures are common in the elderly, with its associated mortality and morbidity far higher in the elderly when compared to that in younger patients . CurrentAlthough good quality evidence exists for the utility of SSRF in patients with severe rib fractures and/or flail chest, we also reveal that SSRF use in flail chest treatment is minimal (0.7%) worldwide in these clinical settings . AlthougAlthough blunt chest wall trauma and rib fractures are common in the elderly, and their associated mortality and morbidity are far higher, evidence for the clinical outcomes of SSRF in elderly rib fracture patients is sparse  or non-existent. This underlines the necessity for conducting RCTs and prospective studies towards establishing evidence-based guidelines to manage this frail group of patients.Although we presented the first ever retrospective study on outcomes of SSRF in multi-trauma patients with contaminated wound fields and positive sputum culture, our monocentric study had a small sample size.The clinical impact of thoracic trauma depends on the severity of the trauma, the anatomical regions involved, and the age of patients.When initial interventions are unsatisfactory, VATs and SSRF must be considered considering the patient’s unique individual/holistic circumstances, clinical background, and prognostic expectations.Trauma centres and other healthcare providers should have updated evidence-based information about available management modalities. The best outcomes for individual patients are accomplished by combining various treatment approaches and individualising them according to the patient’s holistic situation and clinical condition.As part of rib fracture management pathways or “bundles of care”, early SSRF must be considered.Prospective studies and well-designed RCTs are required to confirm the benefits of SSRF in multiple simple rib fractures and in elderly patients with any sort of rib fracture(s).At our hospital, early SSRF is standard procedure for patients with multiple rib fractures, flail chest, severe sternal fractures, extubation failure, and trauma patients requiring VATS.In 2019, we presented the encouraging results of a small retrospective study on SSRF outcomes in multi-trauma patients with contaminated wound fields and positive sputum culture.The standard management of thoracic injury includes a multidisciplinary team approach with proper consideration of all potential avenues and treatment modalities (including SSRF) to give the best possible clinical outcome to the patient. Trauma centres and other healthcare providers should have updated evidence-based information about available management modalities. Multiple randomised control trials (RCTs) and meta-analyses show SSRF to be beneficial in flail chest patients resulting in reduced mortality and morbidity including shorter MVDs, HLOS, and ILOS; and a lower incidence of infections, pneumonia, sepsis, and other complications. Prospective studies and well-designed RCTs are badly needed to confirm the benefits of SSRF in multiple simple rib fractures and in elderly patients with any sort of rib fracture. Such quality studies with good sample sizes are also essential to evaluate the outcome of SSRF in patients diagnosed with pneumonia or contaminated surgical fields.


Autogenic training (AT) is a well-established self-induced relaxation technique based on autosuggestion. From the past two decades, an increasing number of AT studies strongly suggests the practical usefulness of psychophysiological relaxation in the area of medicine. Despite this interest, to date, limited critical clinical reflection on the application and effects of AT in mental disorders exists. The present paper reviews psychophysiological, psychopathological, and clinical aspects of AT in persons with mental disorders with emphasis on implications for future research and practice. Based on a formal literature search, 29 reported studies  were identified that examined the effects and impact of AT on mental disorders. The main psychophysiological effects of AT include autonomic cardiorespiratory changes paralleled by central nervous system activity modifications and psychological outputs. Studies demonstrate consistent efficacy of AT in reducing anxiety and medium range positive effects for mild-to-moderate depression. The impact on bipolar disorders, psychotic disorders, and acute stress disorder remains unexplored. As an add-on intervention psychotherapy technique with beneficial outcome on psychophysiological functioning, AT represents a promising avenue towards expanding research findings of brain–body links beyond the current limits of the prevention and clinical management of number of mental disorders. The burden of mental disorders continues to grow with a profound impact on the wellbeing of people around the world. While effective treatments and social support are available in many countries, access to them is limited. Autogenic training (AT) is a well-established self-relaxation technique based on autosuggestion related to passive concentration of bodily perceptions of heaviness and warmth accompanying a slow breath, which elicits a psychophysiological relaxation response . AutogenAutogenic therapeutic approaches are methods based on the homeostatic self-regulatory brain mechanisms to support and facilitate existing natural self-healing mechanisms, and thus help to regulate and readjust a variety of functional disorders  ,4. AutogFrom the past two decades, an increasing number of AT studies strongly suggests the practical usefulness of psychophysiological relaxation in the area of medicine. The beneficial effects of AT have been observed in many somatic disorders, including but not limited to migraine, chronic pain, essential arterial hypertension, preeclampsia, coronary heart disease, bronchial asthma, unspecified type of somatoform pain disorder, Raynaud’s disease, and functional sleep disorders ,3,9,10. The present paper reviews psychophysiological, psychopathological, and clinical aspects of AT in persons with mental disorders. This review focuses on advanced understanding of the effects of AT in mental disorders with emphasis on implications for future research and practice. The practical aspects are preceded by a theoretical overview of autonomic dysfunction in mental disorders and psychophysiology of AT. Finally, the review highlights some promising new strategies for future targeted research to advance science, promote efficacious clinical practice, and thereby ultimately optimize care for persons with mental disorders.Based on the search, appraisal, synthesis, and analysis (SALSA) framework , the preBased on this formal literature search, 29 reported studies  were identified that examined effects and impact of AT on mental disorders .The etiology of mental disorders is multifaceted and complex. The biopsychosocial model considers the interaction of biological, psychological, and social factors that may be contributing to the development of mental illnesses; there are suggestions for dynamic three-dimensional gene-by-environment-by-time interactions . UnderlyAutonomic dysfunction has been observed in a range of mental disorders, including schizophrenia, bipolar disorder, depressive disorders, anxiety disorders, obsessive–compulsive disorder, posttraumatic stress disorder, and substance dependence ,45,46,47Alvares and colleagues  meta-anaThe AT self-induced relaxation technique is based on autosuggestion. The autosuggestion is a psychophysiological form of psychotherapy that individuals carry out on themselves using passive concentration and certain combinations of mental and physical stimuli ,7. AutogHeaviness, warmth, breathing, personal formulae (modified Schultz technique);Heaviness, warmth, coolness, calmness, and peaceful relaxation (Luthe’s technique);Heaviness and warmth (Schultz and Luthe’s technique);Heaviness (Budzynski’s technique—taped);Heaviness, warmth, breathing patterns, neck and shoulders, mental picture of body alignment (Schultz technique);Heaviness and warmth (Luthe’s technique).The AT procedures may vary, utilizing, e.g., modified AT phrases, tape recorded AT + music = taped AT phrases, synthesized with music (Luthe’s technique), along with 6 SE :HeavineIn the United Kingdom, clients are taught six simple mental formulae designed to induce a calm state of mind and body, five additional emotional expression exercises, and individually tailored personal formulae for supporting positive change . Each seIn 10–20% of patients, a more intensive method called autogenic neutralization may be necessary; autogenic modification, autogenic feedback training, and autogenic behavior therapy  are neweThe main psychophysiological effects of brain–body interaction relaxation techniques include autonomic cardiorespiratory changes paralleled by central nervous system (CNS) activity modifications and psychological outputs.The psychophysiological changes during AT are closely associated with the induced voluntary control of slow breathing. The respiratory sinus arrhythmia is characterized by an increase in heart rate with inspiration and decrease during expiration . As a reElectroencephalogram (EEG) studies show a global increase in low-frequency alpha power  and a local decrease in theta power (a marker of an advanced meditative state) . Park anA systematic review  demonstrSystematic reviews and meta-analyses have demonstrated consistent and significant efficacy of AT in reducing anxiety ,15,19,21The AT can Induce a meditative state and elicit the relaxation response diametrically opposed to changes elicited by stress . During According to Wells’ self-regulatory executive function model of generalized anxiety disorder, specific emphasis is placed on metacognitive beliefs and appraisals in the maintenance of worry . EffectsThe intentional anxiety exercise can reduce reported distress associated with anxious thoughts by creating a detached mindfulness with defusion . A detacPeople experiencing significant anxiety often suffer from anxiety-related hypervigilance for bodily sensations. Therefore, anxiety treatments aim to help interrupt cyclical and problematic modes of self-focused processing. Of particular importance is to train an ability to let go of heightened body sensitivity, e.g., through a realization that worrying is neither necessary nor likely to be helpful .A recent study has demonstrated that Schultz’s AT and other relaxation techniques were effective in lowering the COVID-19 anxiety levels of young university students . The finn = 85, SMD= −1.37; 95% CI −2.07 to −0.67) and a reduction effect on the depression score by 0.29 point  [In a meta-analysis of clinical outcome studies, medium range positive effects of AT were found for anxiety disorders, mild-to-moderate depression/dysthymia, and functional sleep disorders . A meta-o −0.07) .p < 0.001; geriatric depression scale p < 0.001) [Relaxation techniques (including the AT) were more effective at reducing self-rated depressive symptoms than waitlist or no or minimal treatment  . However< 0.001) . Bowden < 0.001)  have dem< 0.001) .A recent study examined the attention efficiency as determined by the perceptual speed index measured using the attention and perceptiveness test in people with depression . The resFinally, emotional disorders are common among adolescents. A recent study  has demoTo date, to our knowledge, there is no evidence published examining effects of AT on bipolar disorders.Shibata and Motoda  demonstrBoth posttraumatic stress disorder (PTSD) and acute stress disorder are marked by increased stress and anxiety following exposure to a traumatic or stressful event. Autogenic training significantly decreased cardiac sympathetic nervous activity and significantly increased cardiac parasympathetic nervous activity along with a significant decrease in the total points of impact of event scale—revised questionnaire in fire service workers with PTSD . In a raJojic and Leposavic demonstrated a significant decrease in values of arterial blood pressure, pulse rate, concentration of cholesterol and cortisol following AT intervention as the sole therapy in adolescents  and in mA systematic review of the literature was carried out to examine the effect of stress management techniques, specifically of progressive muscle relaxation (PMR), AT, and guided imagery (GI), on stress levels of individuals with addictive behaviors . The finInsomnia, dyssomnia, and other sleep-related problems are commonly associated with depressive disorders, anxiety disorders, or psychological distress. Several studies have consistently demonstrated that AT may improve sleep patterns and increase sleep quality in persons with various health conditions, including functional sleep disorders ,3,17. ThSexual dysfunction is a common problem among both men and women due to many physical and/or psychological causes. Stanton and colleagues  investigAnxiety-, mood-, and stress-disorders are important challenges worldwide. Identifying novel treatments for mental disorders is urgently needed and is important for tackling their cardiovascular, metabolic, and other somatic sequelae. Given the dramatically increased number of persons affected by mental disorders, it is becoming even more critical to countries worldwide and their future to successfully address challenges associated with mental illnesses and their complications. While the present findings  have impThe adaptation of AT to each pathology, whether it is carried out in a guided or autonomous, virtual or face-to-face manner, are aspects that may be relevant for the conclusions. After careful reading reports of the reviewed studies, the complete relevant information regarding AT was available in 7 out of 29 papers. Majority of the studies exploring the effects of AT were pragmatic—designed to evaluate the effectiveness of AT in real-life routine practice conditions rather than under optimal situations. Although the detailed description of AT procedures, including the manner of AT is often missing in the published papers, pragmatic studies usually produce results that can be generalized and applied in routine practice settings.Recent results of the effects of AT on autonomic nervous system imbalance in mental disorders have been very promising. Yet, methodological variations may influence estimates of sympathovagal control and thus limit the external validity of the results. To examine the overall and specific impact of mental and physical health disorders and their treatment on autonomic function, more accurate autonomic function testing is needed. Specifically, for ANS monitoring, HRV should include respiratory parameters. Future studies should examine resting and dynamic ANS balance and ANS imbalances even in asymptomatic patients with mental disorders in order to individually tailor protective cardiovascular treatments early in illness progression.Previous studies have demonstrated an independent bidirectional link between depression and cardiovascular comorbidity ,62. Of pCurrently, the practice of AT is also recommended to people who live in fear or in anxiety, and to those who are afraid of illness or need to improve the quality of relationships with others .The majority of participants values AT highly and considers it helpful in maintaining psychological health . TherefoFuture research should aim at using the AT as an intervention to also improve autonomic function, and thus control  the progression of cardiometabolic complications. If this approach were successful, it would translate into fewer subjects requiring somatic treatments and fewer people progressing to cardiometabolic complications, which is an enormous benefit to individuals and society.Future studies should also be designed and conducted to test the hypothesis that reduced vagal tone may be an endophenotype for the development of psychotic symptoms in individuals with schizophrenia  and a maAutogenic training is a widely available self-relaxation procedure with beneficial outcomes on psychophysiological functioning. A strong co-occurrence of the mental illness and cardiometabolic complications highlights the need to diagnose and treat these frequent comorbid conditions early. Autogenic training as an add-on intervention psychotherapy technique represents a promising avenue towards expanding and translating future research findings of brain–body links beyond the current limits of the prevention and clinical management of number of mental disorders. Further clinical research studies in well-characterized patient populations are needed to improve and guide our current understanding of the pathophysiology of mental disorders and to allow identification of novel potential biomarkers and prognostic factors of disease progression based on responses to autogenic therapy interventions. This will also be essential for the identification of patients who may benefit best from an intervention. It is expected that the knowledge to be gained from future studies will inform interventions for mental disorders treatment and help ensure incorporation of findings into psychiatric care pathways and provision of funding to take the intervention directly into clinical practice.


The study aims to investigate the impact of social, economic and political globalization on the renewable energy-economic growth nexus in a panel of six Asian emerging economies over the period 1975–2020. The results of the CS-ARDL approach show that renewable energy consumption contributes significantly to long run economic growth. Economic and political globalization firmly hold back economic growth, while social globalization directly promotes economic growth. The nonlinear effects of political, social, and economic globalization on economic growth clearly demonstrate the validity of the inverted U-shaped relationship between political globalization, economic globalization, and economic growth, and the U-shaped relationship between social globalization and economic growth. The study also found that economic, social and political globalization moderated the impact of renewable energy on boosting economic growth. Based on the renewable energy consumption model, it is revealed that economic growth significantly promotes long run renewable energy consumption. Economic, social, and political globalization have significantly boosted long run renewable energy consumption. However, the nonlinear effect model reflects a U-shaped relationship between globalization indicators and renewable energy consumption. The interaction of political, economic, and social globalization with economic growth has also witnessed an increase in renewable energy consumption, which supports the scale effect hypothesis. The causality test concludes that there is a two-way causal relationship between renewable energy consumption and economic growth, thus supporting the feedback hypothesis. The policy implications for Asian emerging economies are discussed based on the empirical analysis of this study. In recent years, policy circles and academia have paid great attention to issues related to economic growth and renewable energy consumption. Numerous theoretical and empirical studies have been feverishly scrutinizing the interplay between economic growth and various aspects of energy consumption, including the mechanisms by which renewable energy consumption can sustain economic growth in the long run –3. The oGlobalization is said to facilitate technology transfer, thereby affecting renewable and non-renewable energy use and economic growth –31. MoreThis study contributes to the existing literature on globalization, renewable energy consumption, and economic growth in selected Asian emerging economies by precisely addressing three key questions. Different from the traditional methods used in previous panel studies, this study adopts the CS-ARDL method, which is robust to cross-sectional dependence (CD), heterogeneity and endogeneity, to explore the impact of globalization indicators  on renewable energy consumption and economic growth. Second, in contrast to previous empirical studies on the subject, this study examines the moderating effects of economic growth and globalization indicators on renewable energy consumption, and the moderating role of renewable energy consumption and globalization indicators on economic growth. Finally, this study explores the non-linear effects of social, political, and economic globalization on renewable energy consumption and economic growth as an extension of the empirical literature.The literature review in this section focuses on the role of globalization in the link between renewable energy consumption and economic growth. The literature is organized into three core sections: the link between renewable energy consumption and economic growth; the association between globalization and economic growth; and the link between globalization and renewable energy consumption. As noted in each subcategory, findings on these topics are mixed.A large literature reveals the link between renewable energy consumption and economic growth, reporting inconclusive empirical and theoretical evidence. However, research also shows a weak relationship between renewable energy consumption and economic growth –44. Othe illustraEvidence for the direction of causality between renewable energy consumption and economic growth is also mixed for individual countries.  use a VEGlobalization includes economic, political and social dimensions and is not limited to trade openness. As this phenomenon of globalization affects the development of a country is still a controversial topic because its impact varies according to the dimensions and relative resources of the country . The rolConversely, globalization can undermine growth in countries with weak institutions and political instability , 76. FewTrade liberalization is good for economic growth, which is concluded after reviewing the historical evidence on the link between globalization and economic growth , however investigIn conclusion, views vary on the link between renewable energy consumption and economic growth; the association between globalization and economic growth; and the relationship between globalization and renewable energy consumption. However, no studies have considered globalization as a channel influencing the link between renewable energy consumption and economic growth. For the most part, these relationships are explored independently in each model; thus, further research on the role of globalization in creating a win-win situation for specific emerging Asian economies is urgently needed.This study reveals the impact of disaggregated globalization  on renewable energy consumption and economic growth in emerging Asian economies. To detect this relationship, two main empirical models were developed.Following –95, the The above function can be expressed in log-linear form as:Few studies have emphasized that the impact of globalization on economic growth is not always linear but nonlinear –98. The Uncovering the moderating role of decentralized globalization in the link between renewable energy consumption and economic growth, Eq  is furthα0, α1, α2,….. αj reflect parameters to be estimated and μi,t is the random error term in the economic growth model.Where Following –101, theRenewable energy consumption model in the log linear form can be specified as:Eq  can be aUncovering the moderating role of decentralized globalization in the link between economic growth and renewable energy consumption, Eq  is furthβ0, β1,β2,….. βj reflect parameters to be estimated and εi,t is the random error term in the renewable energy consumption model.Where The As interdependence increases, panels may have significant cross-sectional dependence (CSD), so more stringent tests are needed to examine for cross-sectional dependence across countries. Thus, the current study explicitly examines cross-sectional correlation tests to address issues with panel data estimation and to ensure that empirical estimates are unbiased, consistent, and valid. Primarily Pesaran CSD, Pesaran scaled LM, bias-corrected scaled LM and Breush-Pegan LM test introduced by –108, expFirst-generation panel stationary tests, Augmented Dickey Fuller; Phillip Perron; Lin and Chu; Levin; Hadri; Breitung; Im, Pesaran, and Shin failed to account for cross-sectional dependencies in longitudinal datasets. Thus, to reduce this concern, the current study used second-generation panel unit root tests, namely the cross-sectional Im, Pesaran and Shin (CIPS) test developed by , and thezit−1 signify the lag level of each cross section and the mean value of the first-order difference operator, respectively. Eq (Substituting the lag term (t-1) in Eq  yields tvely. Eq  below reλi  the test statistic of CADF, so replacing λi  with CADF, the following Eq  and I(1), so we turned to cointegration analysis, using the  test to 0: ∅i = 1 for all i, where, i = 1,2,…..n. However, the alternative hypothesis can be exposed as 0: ∅i = 1 for all i, against the alternative hypothesis as The null hypothesis of the Durbin Hausman panel statistic (DHp) can be expressed as HThe next step after cointegration analysis is to estimate the long-term relationships among the proposed variables in the model. This study uses the CS-ARDL approach proposed by , which hThe CS-ARDL equation can be expressed as:The cross-sectional average can be expressed asloped by  is also The Granger causality test of  can be uFirst, cross-sectional dependencies in panel datasets can be detected to obtain robust estimation results. Pesaran Scaled LM, Pesaran CSD, Bias-corrected scaled LM, and BreuschPagan LM tests yielded strong evidence of cross-sectional dependence in the panel datasets for the six emerging Asian countries highlighted in The slope heterogeneity results in The variable descriptive statistics highlighted in Correlation coefficients and variance inflation factors (VIF) for each variable in Next, the  cointegrFocusing on decomposed globalization, it can be seen from the direct effect model that both political globalization and economic globalization have hindered the economic growth of emerging economies in Asia. For every 1 percentage point increase in political globalization and economic globalization, the economic growth rate can be significantly reduced by 0.218 percentage points and 0.533 percentage points respectively. Hence, economic globalization, including the flow of goods, services, and financial assets, has hindered economic growth in specific emerging Asian economies. This may be because it stimulates expertise in economic sectors with strong comparative barriers to technological innovation, learning by doing, and possible productivity growth that have mostly disappeared in emerging Asian economies , 121. InThe non-linear impact of political, economic and social globalization on economic growth shows that political and economic globalization significantly promotes economic growth, while social globalization significantly reduces economic growth. However, the square of political and economic globalization significantly reduces economic growth, while the square of social globalization significantly boosts economic growth in emerging Asian economies. This result clearly proves the validity of the inverted U-shaped relationship between political globalization, economic globalization and economic growth, and the legitimacy of the U-shaped relationship between social globalization and economic growth. This means that economic growth in the short run is boosted by political and economic globalization and held back by social globalization. However, in the long run, economic growth will only increase due to social globalization and decrease due to political and economic globalization. Furthermore, the moderating role of renewable energy in the link between globalization indicators and economic growth suggests that renewable energy consumption interacts with economic, social, and political globalization to promote economic growth in emerging Asian economies.To check the robustness of the long-term results of the economic growth model through the CS-ARDL test, the AMG estimator is used. The results also point out that decentralized globalization  has significantly boosted renewable energy consumption in emerging Asian economies. These globalization practices thus play an important role in renewable energy consumption in emerging Asian economies. For every 1 percentage point increase in economic, social and political globalization, renewable energy consumption will increase significantly by 0.488 percentage points, 0.383 percentage points and 0.373 percentage points, respectively. This result is consistent with . The resHowever, the nonlinear effect model reflects that the main term of economic, social and political globalization has a significant negative impact on renewable energy consumption, while its square term has a significant incremental impact on renewable energy consumption. This result suggests a U-shaped relationship between globalization indicators and renewable energy consumption. Thus, renewable energy decreases at the beginning of globalization, but renewable energy consumption increases after globalization reaches a certain threshold. The interaction of political, economic, and social globalization with economic growth has also witnessed an increase in renewable energy consumption, which supports the scale effect hypothesis.The AMG estimator is used to check the robustness of the long-term results of renewable energy models through CS-ARDL tests. Next, the Dumitrescu-Hurlin causality approach was used to detect causality among our variables of interest for specific emerging Asian economies, and the results are highlighted in Using the CS-ARDL approach, this study examines the impact of globalization indicators on the link between renewable energy consumption and economic growth in six emerging Asian economies over the period 1975 to 2020. The research analysis draws several findings. First, the results of the economic growth model show that renewable energy consumption has a significant contribution to economic growth. The conclusions further point out that economic and political globalization firmly hold back economic growth, while social globalization directly promotes economic growth in selected Asian emerging economies. The non-linear impact of political, economic and social globalization on economic growth shows that political and economic globalization significantly promotes economic growth, while social globalization significantly reduces economic growth. However, the square of political and economic globalization significantly reduces economic growth, while the square of social globalization significantly boosts economic growth in emerging Asian economies. This result clearly proves the validity of the inverted U-shaped relationship between political globalization, economic globalization and economic growth, and the legitimacy of the U-shaped relationship between social globalization and economic growth. The study also found that economic, social and political globalization moderated the impact of renewable energy on boosting economic growth.Second, for the renewable energy consumption model, it is revealed that economic growth significantly promotes renewable energy consumption. The results also point out that decentralized globalization  has significantly boosted renewable energy consumption in emerging Asian economies. However, the nonlinear effect model reflects that the main term of economic, social and political globalization has a significant negative impact on renewable energy consumption, while its square term has a significant incremental impact on renewable energy consumption. This result suggests a U-shaped relationship between globalization indicators and renewable energy consumption. The interaction of political, economic, and social globalization with economic growth has also witnessed an increase in renewable energy consumption, which supports the scale effect hypothesis. The causality test concludes that there is a two-way causal relationship between renewable energy consumption and economic growth, thus supporting the feedback hypothesis.The findings provide important policy implications for Asian emerging economies. Existing evidence in this study suggests that economic and political globalization promotes short-term economic growth but hurts long-term economic growth. However, social globalization inhibits economic growth in the short run and promotes economic growth in the long run. Although globalization brings short-term economic benefits, it is crucial for policymakers to implement favorable policies to limit the adverse effects of economic globalization on long-term economic growth. Economic globalization drives long-term economic growth in emerging Asian economies, which is critical for policymakers to formulate corporate policies that encourage a deeper understanding of economic sectors with dynamic comparative advantages in terms of output growth. Furthermore, given the technological impact of globalization, ensuring the transfer of technological innovation to less technologically innovative productive sectors is imperative to foster long-term economic growth. Finally, economic globalization in light of income inequality and unemployment may hinder long-term economic growth. Policymakers have an obligation to use necessary social interventions as a tool to provide a "safety net" for those harmed by economic globalization. Building on existing politically and economically extractive institutions remains crucial for globalization to foster long-term economic growth in emerging Asia. Renewable energy consumption interacts with economic, social, and political globalization to boost economic growth in emerging Asian economies. This means that productivity and commodity flow in the economic globalization based on advanced and friendly technology, will not only promote economic growth, but also bring about sustainable development of the environment.The nonlinear effect model of renewable energy consumption reflects a U-shaped relationship between globalization indicators and renewable energy consumption. Thus, globalization indicators only worsen renewable energy efficiency in the short run, while improving renewable energy efficiency in the long run. Thus, from a policy perspective, it has been recommended that policymakers in the Asian emerging economies should not misjudge the effects of globalization in renewable energy demand models while formulating and implementing environmental conservation policies.For future research directions, the role of renewable energy consumption in the link between fragmented globalization and environmental sustainability should be explored for Asian emerging economies. In addition, an N-shaped EKC assumption between globalization indicators and renewable energy consumption should be established for the specific panel to predict future environmental protection measures.


Understanding drivers of water quality in local watersheds is the first step for implementing targeted restoration practices. Nutrient inventories can inform water quality management decisions by identifying shifts in nitrogen (N) and phosphorus (P) balances over space and time while also keeping track of the likely urban and agricultural point and nonpoint sources of pollution. The Chesapeake Bay Program’s Chesapeake Assessment Scenario Tool (CAST) provides N and P balance data for counties throughout the Chesapeake Bay watershed, and these data were leveraged to create a detailed nutrient inventory for all the counties in the watershed from 1985–2019. This study focuses on three primary watershed nutrient balance components—agricultural surplus, atmospheric deposition, and point source loads—which are thought to be the leading anthropogenic drivers of nutrient loading trends across the watershed. All inputs, outputs, and derived metrics (n=53) like agricultural surplus and nutrient use efficiency, were subjected to short- and long-term trend analyses to discern how sources of pollution to surface water have changed over time. Across the watershed from 1985–2019, downward trends in atmospheric deposition were ubiquitous. Though there are varying effects, long-term declines in agricultural surplus were observed, likely because nutrients are being managed more efficiently. Multiple counties’ point source loads declined, primarily associated with upgrades at major cities that discharge treated wastewater directly to tidal waters. Despite all of these positive developments, recent increases in agricultural surpluses from 2009–2019 highlight that water quality gains may soon be reversed in many agricultural areas of the basin. Besides tracking progress and jurisdictional influence on pollution sources, the nutrient inventory can be used for retrospective water quality analysis to highlight drivers of past improvement/degradation of water quality trends and for decision makers to develop and track their near- and long-term watershed restoration strategies. Simple The statistical/process-based model SPAtially Referenced Regressions On Watershed (SPARROW) results, simultaneously calibrated for 1992, 2002, and 2012, suggested that reduction in point source loads explained >80% of the riverine water-quality improvement with the small remainder tied to improvements in nonpoint source loads  and wherThe more deterministic Chesapeake Bay Program’s Watershed Model (version 5.3) indicated that point source loads were indeed important for modeled improvements in water quality, but declines in nonpoint source loads from agricultural and forested areas actually explained slightly more improvement from 1985–2009 . It was Similarly, varying attributions of drivers to observed long-term trends in phosphorus (P) loads to the Chesapeake Bay have also been reported. Recent SPARROW modeling work suggest that declines in P load, where observed, was essentially driven by decreased point source loads with essentially no change in non-point source loads . Besides maps illustrating the magnitude of various variables for the years 1985 and 2019, all input, output, and derived metrics were subjected to long and short-term trend analysis to succinctly illustrate trajectories of likely point and non-point sources of pollution across the Chesapeake Bay —see Land use acreage , population, septic, point source loading, atmospheric deposition, crop removal with pasture removal, crop removal without pasture removal, crop fixation, agricultural fertilizer, urban fertilizer, biosolids, legacy P in soils, and livestock/poultry manure data were downloaded using the 1) Loads, 2) Atmospheric Deposition, and 3) Nutrients Available Reports feature on the Chesapeake Bay Program’s CAST website . Nutrient allocations to specific land uses in CAST are used to allow flexibility in estimating loads from various land uses and tracking the effects of various best management practices (BMPs) . However, the sheer volume of information inhibits general and succinct communication of changes in N and P cycling of a county and/or subbasin to a wider audience, thus limiting its interpretability and impact , however, declines in agricultural N were highest in New York and Maryland. For P surplus, declines were greatest in Maryland and Delaware (x emissions (−1 since 1985 with other states close behind (3-N) loads in predominantly forested and mixed land use basins  in agricultural production far exceeded that of N , resultiThe declines in agricultural N and P surpluses have likely already decreased or will eventually decrease agricultural nonpoint source loads to surface water, which is the largest source of nutrient pollution to the Chesapeake Bay. Future work could elucidate the role of changing agricultural surpluses on observed water quality trends. However, a simple comparison of declines in agricultural surpluses with the large relative declines (~10%–40%) in N and P export in many agricultural catchments provides compelling evidence for the role of improved use and management of N and P in agriculture in restoring water quality in the Chesapeake Bay . LackingThe coincidence of large declines in nutrient export in predominantly agricultural catchments with decreases in agricultural surplus certainly needs to be further explored as nutrient management plans, if properly implemented, can be the most cost-efficient of BMPs to implement, providing direct incentives and benefits to both farmers and restoration efforts . LikewisIn contrast to the widespread declines in atmospheric N deposition and agricultural surplus, a much smaller fraction of counties in the Chesapeake Bay watershed demonstrated declines in point source loads ; though x emissions, increase agricultural nutrient use efficiency, and investments to upgrade municipal and industrial wastewater treatment plants  likely made or have the potential to make positive impacts on water quality trends (While future work can more directly link observed nutrient water quality loading trends to these nutrient input inventories, our results highlight that agricultural nonpoint sources of pollution and atmospheric deposition across the watershed have indeed declined and lend clear evidence to the likely important contribution of decreasing nonpoint source pollution to water quality improvement across much of the Chesapeake Bay watershed . Larger y trends . This day trends , future Progress in decreasing nutrient pollution is not guaranteed. Continued urbanization, growing population, and continued evolution of agricultural practices are major challenges that will make it increasingly difficult to manage the various sources of nutrient pollution, especially under conditions of a changing climate (Efforts to further increase nutrient use efficiency and decrease agricultural surpluses will be key for attaining water quality goals under these changing conditions. Some available empirical evidence suggests that the instream response of N loads to shifts in nutrient balances ranges from 1–15 years , thus maOverall, the county-level nutrient inventories developed for the Chesapeake Bay watershed provide compelling evidence of spatiotemporal changes in nutrient inputs, balances, and point source loads that coincide with sometimes large relative changes in nutrient loads. Long-term declines in atmospheric deposition were observed throughout the Chesapeake Bay watershed, whereas major declines in point source loads largely occurred in tidal portions of the watershed. Unexpectedly, long-term improvements in nutrient use efficiency with corresponding declines in agricultural surplus were observed. The declines in agricultural surplus were substantial Bay-wide, and potentially explain a large fraction of observed improvements in long-term N and P loading trends in the watershed. Further research efforts should consider explicitly exploring the long and short- term impacts of declining agricultural surpluses on nutrient loads. Regardless, the report of improved agricultural nutrient management and its further promotion will help limit a major non-point source of pollution to waterways. Moving beyond identifying major drivers of water quality change in the Chesapeake Bay, users of this inventory can reference the >100 short and long-term trends of other fluxes and derived metrics that may be more locally relevant for them in achieving their local water quality goals (e.g., urban fertilizer, s1s2


Despite significant advances in anti-infective treatment and organ function support technology in recent years, the mortality rate of sepsis remains high. In addition to the high costs of sepsis treatment, the increasing consumption of medical resources also aggravates economic pressure and social burden. Extracellular vesicles (EVs) are membrane vesicles released from different types of activated or apoptotic cells to mediate intercellular communication, which can be detected in both human and animal body fluids. A growing body of researches suggest that EVs play an important role in the pathogenesis of sepsis. In this review, we summarize the predominant roles of EVs in various pathological processes during sepsis and its related organ dysfunction. Sepsis is a syndrome of systemic inflammatory response caused by the invasion of pathogenic microorganisms such as bacteria into the organism. Every year, 50 million people suffer from sepsis and 11 million die as a result EVs are a kind of membranous small vesicles released by cells to the extracellular matrix, with a particle size distribution range from 30 nm to 1 μm, which play a key role in intercellular communication and body regulation through signaling molecules such as proteins and lipids on the membrane, as well as neurotransmitters, enzymes, hormones and nucleic acids wrapped in the membrane There is a positive correlation between the number of EVs and the severity of sepsis when sepsis is present or when bacteria irritate the body It is important for nucleic acid transport to use EVs, which protect nucleic acids from degradation by nucleases and keep them stable. In sepsis, EVs carry a variety of nucleic acids, including mRNA, microRNA, long noncoding RNA (lncRNA), and circRNA. In patients with sepsis, EVs express higher amounts of mRNA involved in antioxidant defense and oxidative stress EVs originating from diverse cellular sources have been substantiated to exert significant roles in various biological processes. In the course of sepsis pathogenesis, pathogens  or their toxins induce systemic infection Gram-positive and Gram-negative bacteria, as the most prevalent infectious agents in sepsis, can produce EVs carrying bacterial endotoxins and transmitting bacterial proteins Table . In addition to activating innate immune responses, EVs in sepsis also induce Th1/Th2 cell differentiation, enhance T lymphocyte proliferation and migration during the course of sepsis, and activate adaptive immune responses During sepsis, host-derived EVs are predominantly produced by immune cells, such as platelets and innate immune cells However, there is a scarcity of research on the role of EVs in the immunosuppressive mechanisms of sepsis. Unveiling their functional mechanisms will provide insights for immune-based therapeutic approaches for sepsis.A close relationship exists between sepsis and cardiovascular dysfunction. Arterial hypotension is the most common feature of cardiovascular dysfunction in septic patients, primarily due to factors such as reduced blood volume, decreased vascular tone, and myocardial suppression In vitro experiments have demonstrated that OMVs from a uropathogenic Escherichia coli strain induce irregular calcium oscillations with reduced frequency in cardiomyocytes. Following intraperitoneal injection of sterile OMVs, OMVs can be detected within the heart. Troponin T levels in the blood significantly increase, while echocardiography reveals increased heart wall thickness and heart rate EVs may play a critical role in cardiovascular dysfunction during sepsis. During the progression of sepsis, the assembly of the TXNIP-NLRP3 complex in monocytes can be embedded into CD63+ exosomes, transported from circulating monocytes to local macrophages, and promote the cleavage of inactive IL-1β and IL-18 in macrophages, exacerbating cardiovascular inflammation and myocardial dysfunction Most sepsis patients exhibit coagulation dysfunction, which varies in severity. The most severe coagulation disorder in sepsis is disseminated intravascular coagulation (DIC), characterized by systemic thrombus formation and bleeding in vivo, induce systemic vasodilation, and reduce mean arterial pressure in septic infectious shock Increased circulating EVs derived from endothelial cells, platelets, red blood cells, and white blood cells are associated with coagulation activation, tissue factor release, inflammation, and ROS production, leading to small intravascular thrombi and endothelial damage Sepsis frequently leads to pulmonary inflammation, further progressing to acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) In sepsis-induced ALI and ARDS, both bronchoalveolar lavage fluid (BALF) and circulating EVs exhibit upregulation in quantity The viral infection caused by SARS-CoV-2 can lead to symptoms similar to those of sepsis caused by bacterial infections. In septic patients, renal dysfunction is a common and severe complication. Elevated serum urea (or blood urea nitrogen) and creatinine are common in sepsis-associated renal dysfunction, and even mild increases in creatinine concentration are associated with poorer prognosis in critically ill patients Table . The increased number of platelet-derived EVs is negatively correlated with AKI biomarkers blood urea nitrogen and creatinine concentrations EVs from various cellular sources may have regulatory effects on sepsis-mediated acute kidney injury, possibly related to the multiple non-coding RNAs carried by the EVs The impact of sepsis on the brain primarily manifests as acute and long-term neurological dysfunction, including sepsis-associated encephalopathy and cognitive impairment In the cecal ligation and puncture (CLP) rat model, blood-brain barrier damage and increased reactive oxygen species (ROS) levels promote ferroptosis, during which the expression of serum exosomal NEAT1 is upregulated, potentially regulating miR-9-5p/TFRC and GOT1 axis through a competing endogenous RNA mechanism to promote neuronal ferroptosis in rats, thus exacerbating sepsis-associated encephalopathy Although there are no overt structural abnormalities in the liver and biliary system in septic patients, alterations in liver function remain common. Liver dysfunction is mainly characterized by elevated bilirubin or transaminase levels While EVs derived from bacteria and immune cells may precipitate various complications in sepsis, those originating from mesenchymal stem cells (MSCs) have been found to play a pivotal role in different experimental models of acute tissue injury during the process of sepsis, which are largely attributed to the paracrine actions of MSC-EVs. These exosomes can either interact with receptors on the surface of target cells or fuse with them, releasing their contents into the cell and subsequently altering the function of the recipient cell . Similarly, the administration of MSC-derived EVs to patients with acute lung injury caused by sepsis in clinical settings has shown comparable protective effects. Intravenous injection of MSC-derived EVs can increase the rate of alveolar fluid clearance, reduce pulmonary protein permeability, enhance antibacterial activity In cardiovascular system, MSC-derived EVs have been identified that may contribute to this regulatory effect, including carrying PTEN-induced putative kinase 1, which ameliorates mitochondrial dysfunction in cardiomyocytes 154Figure . Sepsis manifests as a pleiotropic process in which exosomes carry a multitude of proinflammatory molecules, activate cellular signaling, and cause multiple organ malfunctions. Based on the contents of EVs, EVs might play specific roles in the organ damages and other complications induced by sepsis. Furthermore, we have detailed the mechanisms by which EVs exert their influence in this process. At the same time, it has also been pointed out that EVs derived from mesenchymal stem cells may play a positive effect in different organ of patients with sepsis, that is, they can significantly inhibit acute organ injury caused by sepsis. Studying its regulatory mechanism in sepsis can provide a theoretical basis for future diagnosis, treatment strategies, and vaccine prevention.In this review, we mainly introduced the roles of EVs in the pathogenesis of sepsis including cardiovascular function, coagulation dysfunction, acute lung injury, acute kidney injury, neurological dysfunction and liver injury


Epithelial-mesenchymal transition (EMT) is crucial to metastasis by increasing cancer cell migration and invasion. At the cellular level, EMT-related morphological and functional changes are well established. At the molecular level, critical signaling pathways able to drive EMT have been described. Yet, the translation of EMT into efficient diagnostic methods and anti-metastatic therapies is still missing. This highlights a gap in our understanding of the precise mechanisms governing EMT. Here, we discuss evidence suggesting that overcoming this limitation requires the integration of multiple omics, a hitherto neglected strategy in the EMT field. More specifically, this work summarizes results that were independently obtained through epigenomics/transcriptomics while comprehensively reviewing the achievements of proteomics in cancer research. Additionally, we prospect gains to be obtained by applying spatio-temporal multiomics in the investigation of EMT-driven metastasis. Along with the development of more sensitive technologies, the integration of currently available omics, and a look at dynamic alterations that regulate EMT at the subcellular level will lead to a deeper understanding of this process. Further, considering the significance of EMT to cancer progression, this integrative strategy may enable the development of new and improved biomarkers and therapeutics capable of increasing the survival and quality of life of cancer patients. Epithelial-mesenchymal transition (EMT) is recognized as a critical turning point for epithelial cells to acquire a mesenchymal phenotype with new biological functionalities. EMT is a process that happens to epithelial cells with appropriate external stimuli, where downregulation of epithelial traits and upregulation of mesenchymal characteristics allow these cells to escape mechanical and biochemical constraints while facilitating cell detachment and movement ,2,3. ThiDuring cancer progression, particularly for carcinomas, EMT-related alterations enhance the migratory and invasive potential of malignant cells, critically contributing to the early stages of metastasis. In recent years, an enormous number of epigenomics, transcriptomics, and proteomics studies have helped to characterize the regulatory mechanisms and consequences of EMT on cancer ,6,7,8. HHere, the current understanding achieved by independently using different omics to depict the EMT is reviewed. Large efforts have been made to portray the changes associated with the epithelial and mesenchymal phenotypes of carcinoma cells. Still, limitations imposed by available methods and experimental design have delayed and compromised the precise characterization of EMT drivers and the impact of their crosstalk during cancer progression. Therefore, implementing an approach focused on spatio-temporal multiomics may be the next step still required for the translation of EMT-related knowledge into clinics. This strategy may allow the development of efficient methods to detect, prevent, and treat disease progression, thus, improving the outcome of cancer patients.EMT is a complex event that involves multiple levels of molecular regulation that dynamically change throughout the process. Several positive and negative molecular regulators have been associated with this phenotypic alteration while several others are yet to be elucidated. Considering the multiple biological processes associated with the EMT, characterizing its regulatory mechanisms served as the basis for several in vitro and in vivo studies and the development of useful techniques for the diagnosis and treatment of different diseases ,10,11.EMT begins with the activity of EMT-inducers in the tissue environment, such as Epithelial growth factor (EGF), Fibroblast growth factor (FGF) and Transforming growth factor-beta (TGF-β) ,15,16,17As EMT may incur drastic disturbances to the tissue structure, this phenotypic transition is tightly regulated under physiological conditions to control the extent and duration of EMT ,24. NegaAs EMT and MET are critical for homeostasis, deregulated alterations in the mechanisms that control these processes unequivocally contribute to disease development and progression. Indeed, modifications driving EMT and MET in cancer are not easily controlled, being amplified by the dynamic modification of the tumor microenvironment and the crosstalk between cancer cells and non-cancer cells. Such deregulated changes critically correlate with cancer metastasis and resistance to therapy, which both are major causes of death for cancer patients. Therefore, characterizing the phenotypic alterations and the precise plethora of molecular mechanisms that collectively control EMT/MET in malignant cells may help to overcome existing limitations in the diagnosis and treatment of cancer patients.Although triggered by common inducers and characterized by similar molecular and cellular changes, EMT occurs in three contextually different situations. According to the outcomes, these are classified as type I EMT—embryogenesis, type II EMT—wound healing or fibrosis, and type III EMT—cancer progression and metastasis . As metaInterestingly, cancer cells undergoing EMT may show heterogeneous degrees of epithelial and mesenchymal characteristics, including intermediate states known as ‘partial’ (p)EMT ,36,39 F. This isNoteworthy, although many of the EMT outcomes are well described, further analyses of regulatory mechanisms are yet to be detailed. This need is associated with the complexity of this process and may be attributed to the large scale of molecular adaptations happening at different stages of EMT that are regulated by the crosstalk between multiple signaling pathways. Crucial molecular pathways and traditional transcription factors responsible for driving the molecular reprogramming that is associated with the EMT have been reasonably characterized so far, but understanding their crosstalk during EMT is still a complex task. An alternative to obtaining an unbiased portrait of changes during EMT is the simultaneous use of methods such as RNA and protein microarrays, RNA-sequencing (RNA-seq) and mass spectrometry (MS). Still, these technologies were rarely combined in EMT studies. Therefore, in the following sections, we review EMT-related changes established by studies at either DNA, RNA, or protein level, before discussing the integration of multiple platforms. As such, the limitations of the individual methods are minimized and compensated to better integrate them into mechanistic studies and clinical applications.In order to evaluate the gene expression profile of cancer cells undergoing EMT, it is important to successfully recapitulate this process under experimental conditions. Different models have been used to study EMT-related alterations and their impact on cancer progression. In vitro studies, as those discussed here, frequently rely on the treatment of cancer cells with known EMT inducers. Alternatively, the exogenously introduced overexpression of such molecules can also be used to investigate downstream consequences on cell transcriptomes. Moreover, while EMT is known to drive therapeutic resistance, recent studies have demonstrated that drug treatment can also induce EMT in cancer cells ,46. NoteETS and JUNB) were reported to start and end shortly (2 h) after cell stimulation secretomeGreening , Couch  and cell motility  [YBX1-exosomes effectively transferred Rac1 to 2F-2B endothelial cells, inducing 2F-2B cell migration in vitro [Focused on specific alterations that impact non-canonical routes of secretion, Tauro and collaborators (2013) compared the proteome of exosomes secreted by epithelial MDCK cells and mesenchymal 21D1 clones to establish the contribution of these EVs to EMT . SeveralMT state ,90. Comp., Rac1) ,90. Addiin vitro ,90. ThesAlthough limited by available techniques, in vitro studies have performed a deep evaluation of the proteome of cancer cells undergoing EMT and their secretome. It is clear so far that different EMT inducers and regulators can trigger similar mechanisms, thus driving cells to a common outcome. However, further analyses are still needed to better characterize the precise extent of the crosstalk and overlap between these mechanisms. Improvements in existing methodologies will allow not only the identification of poorly expressed relevant proteins, but also determine post-translational modifications that may be critical for their stability, localization, and activity. Still, from the understanding obtained from cell culture-based studies, many EMT effectors have been revealed. As discussed here, high-resolution methods have begun to be used to interrogate changes at the sub-cellular level. Similarly, as seen for enriched fractions from cell lysates, much information has also been described by exploring the localization of proteins in EVs ,94,95,96Although in vitro models are useful for exploring specific mechanisms that drive or block the EMT process, they usually lack natural intratumor and intertumor heterogeneity otherwise observed in real cancers. In addition, representing the interaction between cancer cells and non-cancer cells within the tumor microenvironment is a complex task. Therefore, characterizing the proteome of only one cell type may also mislead the interpretation of its real significance. In this context, the best approach to understanding the contribution of the EMT to the progression of real tumors may demand a careful analysis of the proteome of tumor samples. Still, as confounding factors might be more difficult to isolate in this scenario than in vitro, additional considerations should be kept in mind, such as the existence of distinctive molecular subtypes and clinicopathological characteristics for the patients included in the study.Considering that most proteomic techniques are very expensive and time-consuming, studies aiming to evaluate the proteome of human cancers would hardly be designed to exclusively evaluate EMT-related effectors or biomarkers. Otherwise, such proteins may eventually emerge among the set of differentially expressed molecules, particularly considering their well-established relevance in cancer invasion and metastasis, as discussed before. For instance, Moreira et al. (2004) have observed this pattern of differentially expressed proteins when comparing the proteome of bladder specimens derived from normal tissues and transitional cell carcinomas (TCCs) . Sixty pThe focus on proteins with a known significance to EMT might however mask the detection of new biomarkers contributing to EMT-related effects. Because EMT is frequently associated with cancer progression, an alternative is to group the samples according to the TNM stage, thus considering tumor size, impacts on nearby lymph nodes and metastatic occurrence. Celis and collaborators used this experimental design and reported that the downregulation of keratin-13, alpha-Fatty acid binding protein (α-FABP), Glutathione S-transferase (GST)-µ, and D-3-phosphoglycerate dehydrogenase (PDGH) was correlated with increasing grade in TCCs ,100. In As discussed before for in vitro studies, the presence of highly expressed proteins can mask the presence of less abundant molecules able to play critical roles in the biological process evaluated. Although sub-proteomes of human tumors have not been frequently evaluated, some examples highlight their relevance. The analysis of the cytosolic fraction of BCs, for example, associated higher levels of Ferritin light chain (FTL) with reduced metastasis-free survival ,105. IntAltogether, these studies confirm that many EMT-related proteins identified in vitro show potential use as biomarkers for different types of cancer, being associated with cancer recurrence, lymph node metastasis, and distant metastasis. Moreover, while important EMT-related alterations have been characterized in vitro, many proteins are regulated by the interactions between cancer cells and stromal cells. This observation reinforces the importance of integrative studies analyzing the proteome of immortalized cancer cells and human cancer samples. Still, because analyzing proteins from tumor samples demands highly invasive approaches to obtain biopsies and resected samples, this may be a problem when monitoring cancer patients before/after treatment. In the next section, studies focused on overcoming this limitation by investigating and establishing biomarkers in biological fluids are discussed.The analysis of tumor samples, particularly their proteomes, requires invasive procedures to obtain enough tissue to detect low-abundance proteins. Otherwise, the evaluation of biomarkers in biological fluids such as blood, saliva, and urine requires less invasive methodologies that enable a closer and easier follow-up of the patients. Moreover, analysis of patient-derived data obtained over time  may help to more accurately characterize the dynamic networks that regulate such a fluid process as the EMT.Aiming to establish biomarkers for bladder cancers, research led by Celis  and OsteWhereas the detection of cancer proteins in biological fluids shows clear benefits, it also incurs a methodological issue associated with the presence of highly expressed proteins that may mask less abundant molecules. To improve the detection of relevant molecules, particularly from serum and plasma samples, the depletion of excessively abundant proteins is recommended. In BC patients, proteomic analysis of albumin-depleted serum samples demonstrated the association between LN metastasis and several proteins related to the cytoskeleton and ECM structure or remodeling, including collagen α4I, Serpin C1, Fibrinogen gamma chain (FGG), and Tenascin XB (TNXB) . MoreoveSeveral cancer types lack specific diagnostic or prognostic biomarkers. Even for cancers better characterized , only a small number of biomarkers exist, and their use is restricted by reduced sensitivity and specificity. Moreover, many different conditions with clinical relevance cannot be determined by current biomarkers, including the progression toward resistance to anti-cancer therapies and the development of locoregional and distant recurrence. As observed by the studies discussed here, EMT-related proteins could be used as cancer biomarkers, particularly if considering their typical association with cancer progression and metastasis. Still, the reduced number of publications evaluating cohorts specifically grouped according to EMT-associated outcomes limits the generalization of the conclusions obtained. For instance, additional proteome-based studies including patients who progressed to LN metastasis or distant metastasis, may confirm the reliability of EMT-related proteins for this purpose. Investigations focused on recurrence and resistance to therapy have also been overlooked, and cancer types with lower incidence have been often ignored in this kind of evaluation. In addition to an experimental design focused on EMT-associated modifications, improved technologies may allow the characterization of cancer protein profiles, as has been currently performed for the characterization of cancer transcriptomes.In the next section, new perspectives to integrate multiomics data from real tumors are discussed to highlight how these approaches can further increase our understanding of EMT. Also, we prospect a better comprehension of the proteome of EVs and CTCs led by emerging methods with superior sensitivity. In addition to EVs and CTCs, improved methods may enable characterizing the proteome of cancer cells and non-cancer cells in the tumor microenvironment from a spatio-temporal point of view.In contrast to studying the changes at the DNA/RNA level, current proteomic methods cannot satisfactorily cover the entire diversity of proteins within cancer cells or the tumor mass. Additionally, evaluating the protein profile of multiple samples is highly expensive and time-consuming. These and other reasons led to a better understanding of how modifications in the epigenome and transcriptome impact biological processes while depicting global changes in protein levels was left behind. But to what extent should we rely on a single omics when translating EMT-related findings to the clinic? Although several studies individually demonstrated global alterations either in the epigenome, the transcriptome, or the proteome of cells undergoing EMT, the direct comparison of these results is still an issue. Besides analyzing different cancer types, in vitro studies frequently induce EMT by exploring only one EMT inducer at a time. In addition to differences across studies, this strategy limits the investigation of possible crosstalk between multiple signaling pathways. Therefore, multiomics may provide a more reliable source for the comparison of the many regulatory mechanisms impacting cancer cells at multiple levels during EMT—particularly when analyzing cancer patient samples that are inherently affected by several EMT regulators.In fact, seminal studies published throughout the last decade have already begun to adopt multiomics as an approach to analyze alterations in cancer samples that simultaneously impact DNA, RNA, and protein levels. Although most of these studies investigated different cancer types, some similarities are worth mentioning. Among them is the common divergence between transcriptome- or proteome-derived data, such as that reported in colorectal , breast Although the integration of multiple omics helps to overcome limitations otherwise imposed by the individual use of each approach, spatial alterations are often masked in bulk analysis, and detecting temporal modifications remains unfeasible—especially considering a clinical context. As mentioned before, the increasing association of deconvolution strategies and transcriptomic-focused methods with single-cell resolution has been instrumental in depicting the contribution of different tumor compartments regarding EMT-related alterations. Tissue microdissection also partially helps to overcome this limitation to individually investigate molecular signatures associated with either tumor epithelium or stroma. For instance, in microdissected prostate cancers, a gradual decline in phosphorylated (p-) Mitogen-activated protein kinase (ERK) levels and concurrent increase in p-AKT levels have been associated with cancer progression . SimilarFurther, a combined approach can also help to characterize alterations in rare samples that are not located within the cancer mass but have been shed by the tumor and may be scattered throughout the body, such as CTCs. For instance, in a study simulating CTCs by spiking immortalized cancer cells into blood samples, 4000 proteins were identified by one-dimensional high-resolution porous layer open tube-liquid chromatography (LC)-MS in samples spiked with 100–200 MCF7 breast cancer cells . ImpressAs for CTCs, few studies have comprehensively investigated the protein profile of EVs isolated from cancer patient biofluids. Nevertheless, initial studies in circulating EVs have already demonstrated an association between HCC progression and increased Galectin-3-binding protein (LG3BP) levels . In CRC,Altogether, the results discussed here demonstrate the possibility of evaluating the proteogenome of small samples, but future studies are still needed before implementing such analyses in clinical routine. While in vitro experiments benefit from “unlimited” starting material, human samples are finite, restricting the number of tests and especially compromising the detection of rare proteins. In addition to increasing the sensitivity of proteomics and their integration with epigenomics/transcriptomics, current studies highlight the importance of improving methods for the isolation of scarce samples, such as EVs and CTCs that are naturally obtained at small concentrations. Overcoming these limitations may lead to novel mechanisms and biomarkers to be used for the diagnosis and treatment of cancer patients .Although targeted therapies against some of the major EMT-inducers have been vastly used to treat cancer patients , others have repeatedly failed in clinical trials  ,145. ConMoreover, whereas important signaling pathways able to induce EMT-related cancer progression have been described, the existing methods used for the diagnosis and monitoring of cancer patients have rarely taken advantage of such well-defined knowledge. More specifically, the poorly efficient methods currently used in clinics still fail to efficiently distinguish healthy subjects and different cancer stages because of intrinsic conceptual limitations that overlook the impact of EMT inducers and regulators. Underlying such issues is the common adoption of biomarkers that are not involved in the core molecular program that ultimately promotes cancer progression. Accordingly, these methods are typically associated with reduced sensitivity and specificity. Thus, overcoming these limitations to improve patient diagnosis and monitoring will require the establishment of sensitive methods with a focus on detecting and tracking alterations in biomarkers with real impact on cancer progression, especially EMT drivers ,148,149.Furthermore, it is worth noting that the clinical samples analyzed in many studies (as those discussed here) are usually collected before treatment or, at best, once following the administration of anti-cancer therapies. Such a strategy may mask several alterations with critical relevance for the progression of the disease that cannot be detected when patient samples are collected and analyzed too long before or after treatment. This may be particularly important if considering low-abundance biomarkers that are unique to a small fraction of cells (or EVs) with elevated metastatic potential. Thus, a closer monitoring of cancer patients and the analysis of multiple samples collected over time might lead to the identification of alterations in molecules associated with response to treatment, therefore, helping to guide patient care. As omic-based methods may not be appropriate in this context, they may be used in conjunction with other methods of cheaper and quicker execution . Moreover, as sampling fragments of the tumor may not be suitable for repeated analyses, using biological fluids would be advantageous as they require less invasive techniques to be collected, thus preserving the quality of life of cancer patients.Whereas the past decades have been a stage for many studies focused on characterizing EMT drivers and regulators, efficient diagnostics and therapies based on these molecules are still missing. This highlights a major problem in precisely characterizing the mechanisms that promote cancer progression and our failure to use well-established mechanisms to benefit cancer patients. Thus, an innovative strategy to overcome such limitations is urgently needed.EMT is an intricate process that involves the crosstalk between multiple signaling pathways ,154,155.Furthermore, besides combining multiple omic techniques, improvements in current in vitro and in vivo methods will increase our understanding of the real complexity of EMT-related alterations. At the same time, the integration of pre-clinical studies with improved real-world data will lead to better options in the fight against cancer metastasis and recurrence. In the context of diagnostics and treatment, this will enable obtaining more precise and useful information about EMT-related changes to monitor disease progression in (nearly) real-time to ultimately improve patient outcomes.


Humans are strategically more prosocial when their actions are being watched by others than when they act alone. Using a psychopharmacogenetic approach, we investigated the endocrinological and computational mechanisms of such audience-driven prosociality. One hundred and ninety-two male participants received either a single dose of testosterone (150 mg) or a placebo and performed a prosocial and self-benefitting reinforcement learning task. Crucially, the task was performed either in private or when being watched. Rival theories suggest that the hormone might either diminish or strengthen audience-dependent prosociality. We show that exogenous testosterone fully eliminated strategic, i.e., feigned, prosociality and thus decreased submission to audience expectations. We next performed reinforcement-learning drift-diffusion computational modeling to elucidate which latent aspects of decision-making testosterone acted on. The modeling revealed that testosterone compared to placebo did not deteriorate reinforcement learning per se. Rather, when being watched, the hormone altered the degree to which the learned information on choice value translated to action selection. Taken together, our study provides novel evidence of testosterone’s effects on implicit reward processing, through which it counteracts conformity and deceptive reputation strategies. Humans behave more prosocially when their actions are watched by others . This phResearch in the past decade has demonstrated that testosterone is implicated in a wide spectrum of socially dominant behaviors , 9. ExogContrasting with this view, the hypothesis that testosterone drives status-seeking via reputation building rather than dominance , 16 woulThe present paper is the first that aimed to distinguish between these two alternatives of boosting one’s social status that testosterone may act on. One option is that, in line with the social dominance hypothesis , the horThrough what neurobiological pathways could testosterone modulate such complex social behaviors? Previously, exogenous testosterone was found to increase dopamine levels in the rat ventral striatum , suggestlearning rate parameters) and converted to actions (choice consistency parameter), the new combination of reinforcement learning and diffusion decision modeling also enabled us to explore the temporal dynamics of these latent processes . This provided a more comprehensive account of the latent processes involved in prosocial decision-making than previous separate RL and DDM approaches , 24. BesMale participants underwent a double-blind, between-subject, placebo-controlled, testosterone administration and then performed a reinforcement learning task Fig. . To compBased on previous audience-effect research –6, we prOur main hypothesis was that the effects of being watched on other- vs. self-benefitting behavior will be modulated by testosterone administration. Given that testosterone reduces submission signals and stress responses to the social evaluation, allowing for dominant status-seeking –13, we hPrevious research has suggested that testosterone possibly modulates social behavior through both androgenic and dopaminergic pathways and that testosterone effects on status-seeking behavior are moderated by CAG repeat polymorphism of the androgen receptor , and DATM = 24.89, SD = 4.08). The sample size was determined based on previous testosterone administration studies ; participants in the placebo group received an equivalent amount of placebo gel. The only difference between the testosterone and placebo gel was that the placebo gel did not contain testosterone. Participants rubbed the gel onto their upper arms and shoulders using disposable latex gloves. Gel administration was followed by a 2-h waiting period, during which participants remained in the laboratory premises, completed personality and demographic questionnaires, and were offered leisure-time reading materials. The testosterone dose and timing of the experiment were based on the previously established pharmacokinetic study of testosterone gel preparations in healthy young males , p < 0.001), and at the same time significantly predicted behavioral prosociality . On the contrary, in the testosterone group, observation, compared to privacy, decreased the consistency of choices made for the other (vs. self) . Altogether, these results suggest that testosterone eliminates audience-dependent prosocial behavior by affecting choice consistency.In the second step, we examined whether the parameters that showed a three-way interaction effect of our experimental manipulation predict behavioral prosociality (the difference between correct choices made for others and self). Out of the five parameters , only choice consistency showed the requisite three-way interaction of our experimental manipulations (p = 0.026). In a follow-up analysis aimed at decoding this interaction, the continuous measure of dominance was replaced by a categorical variable with levels of high and low dominance, based on the median split of dominance scores (Med = 3.949). Decomposition of the four-way interaction revealed that testosterone reduced the number of correct choices made for others during observation specifically among men with high trait dominance  and this effect was weaker and non-significant among those with low dominance . Trait dominance did not significantly interact with the RLDDM parameters .In further support of the social dominance hypothesis, trait dominance interacted with testosterone’s effects on correct choice .CAG-repeat and DAT1 polymorphisms did not interact with the effects of testosterone on correct choice or RLDDM parameters  measured using a self-report questionnaire , 36 inteself-enhancement value orientation with testosterone’s effect on the number of correct choices  and interaction of conservation value orientation and testosterone’s effects on choice consistency . The treatment contrast analysis of the interaction effect with self-enhancement showed that when testosterone participants were watched, a higher score in self-enhancement value was negatively associated with correct prosocial choices . In the placebo group, we did not observe such an association  and this difference between testosterone and placebo group was significant .This revealed an interaction of B = 1.29, CI = , p = 0.019). However, after testosterone administration, the link between conservation value and prosocial choice consistency was abolished , but this difference between testosterone and placebo group did not reach significance . No other interaction between value orientations and testosterone effect on choice behavior or RLDDM parameters was detected .The treatment contrast analysis of the interaction effect with conservation value showed that when placebo participants were watched, the prosocial choice consistency was positively associated with conservation value . In all conditions, both the posterior positive and negative learning rates were smaller with respect to the optimal ones , we tested and characterized testosterone’s role in audience-dependent prosocial behavior. The results show that testosterone diminishes the typical audience effect present in the placebo condition. Computational modeling pinpoints this effect to a reduction in the extent to which the performance of prosocial (vs. selfish) choices is consistent with learned reward values. Moreover, the effects are more pronounced in participants with higher trait dominance. Taken together, these findings are in line with the social dominance hypothesis and are thus consistent with the notion that testosterone decreases submission to audience expectations, rather than promoting the strategic display of socially pleasing behavior , 46.2 receptors [A growing body of evidence suggests that testosterone exerts its behavioral effects through the modulation of reward-related processes , 20. Howeceptors , which peceptors . This efAlternatively, it could be speculated that the elimination of the audience effect by testosterone stems from the hormone’s ability to reduce fear in social situations. Indeed, earlier research shows that exogenous testosterone diminishes the physiological stress response to the presence of an observer  and has Self-enhancement value, as measured here [The present data also shows that testosterone administration substantially alters the relation between the audience effect and self-reported value orientations. red here , is charred here . We showred here . Thus, tred here , 46. We Variability in dominance, conservation, and cultural differences in social status attaintment, can also account for the results of another recent study, which was conducted among Chinese students and showed that testosterone enhanced audience effects . Indeed,Our results are, furthermore, in line with studies showing that testosterone decreases deception –57. FurtThere are also some limitations inherent to the methodology of our study. Due to the sex differences in testosterone metabolism and unknown pharmacokinetics following the topical administration of testosterone in women , the stuIn conclusion, we conducted a multifaceted examination of the computational, endocrinological, and genetic mechanisms underlying audience effect and showed that testosterone reduced strategic prosocial learning through impairment of choice consistency. These findings provide evidence that in the Western student sample, testosterone abolishes audience effects, and therefore does not foster the seeking of social leadership by reputational politics. The present study is the first to specify testosterone’s role in reward processing by revealing that testosterone impacts status-seeking through modulation of how the learned reward values are expressed in behavior.Supplemental Material