The understanding that hyper-excitability and hyper-synchronism in epilepsy are indissociably bound by a cause-consequence relation has only recently been challenged. Thus, therapeutic strategies for seizure suppression have often aimed at inhibiting excitatory circuits and/or activating inhibitory ones. However, new approaches that aim to desynchronize networks or compromise abnormal coupling between adjacent neural circuitry have been proven effective, even at the cost of enhancing local neuronal activation. Although most of these novel perspectives targeting circuitry desynchronization and network coupling have been implemented by non-pharmacological devices, we argue that there may be endogenous neurochemical systems that act primarily in the desynchronization component of network behavior rather than dampening excitability of individual neurons. This review explores the endocannabinoid system as one such possible pharmacological landmark for mimicking a form of “on-demand” desynchronization analogous to those proposed by deep brain stimulation in the treatment of epilepsy. This essay discusses the evidence supporting the role of the endocannabinoid system in modulating the synchronization and/or coupling of distinct local neural circuitry; which presents obvious implications on the physiological setting of proper sensory-motor integration. Accordingly, the process of ictogenesis involves pathological circuit coupling that could be avoided, or at least have its spread throughout the containment of other areas, if such endogenous mechanisms of control could be activated or potentiated by pharmacological intervention. In addition, we will discuss evidence that supports not only a weaker role played on neuronal excitability but the potential of the endocannabinoid system strengthening its modulatory effect, only when circuitry coupling surpasses a level of activation. Epilepsy is a severe brain disorder intimately associated with excessive neural excitability and synchrony whose treatment is still limited to a few pharmacological and non-pharmacological approaches  for the treatment of epilepsy has been suggested for centuries (The use of the herb enturies . Howeverenturies . Howeverenturies .1 and CB2 (the molecular targets of THC), the endogenous ligands (endocannabinoids) arachidonoyl ethanolamide  and 2-arachidonoylglycerol (2-AG), and the enzymes responsible for their metabolism. Endocannabinoids are proposed to function as a retrograde neurotransmission system, being produced from lipid membranes in postsynaptic neurons. Their actions are terminated after they are removed from the synaptic cleft by a membrane transporter and hydrolyzed in the intracellular medium . The pharmacological studies with phytocannabinoids and synthetic cannabinoids finally led to the identification of their mechanisms of action and to the description of a new signaling mechanism in the brain, the endocannabinoid system . The endr medium . The mair medium .1 receptor agonists may even induce or aggravate epileptic seizures, depending on the dose  would occur. In line with this hypothesis, synthetic compounds that inhibit the enzymes responsible for degrading anandamide and 2-AG yields favorable results in experimental models of seizure and epilepsy. Concerning anandamide hydrolysis, the selective FAAH inhibitor AM374 inhibits kainic acid-induced seizure and neurotoxicity . Moreoveabinoids .Therefore, the endocannabinoid receptors and molecules deal with the brain hyperexcitability, one crucial aspect of epilepsy, by modulating the synaptic transmission in a neural activity-dependent manner. Nevertheless, recent studies have demonstrated that the cannabinoid system also modifies the neural synchrony, in some cases with a marginal effect on overall excitability, which is intimately associated with complex brain functions  and neurological disorders as schizophrenia, Alzheimer’s disease, and epilepsy .y = f(x) between oscillations if they are synchronized. Given the timescale of neural events of interest (in the order of milliseconds), electrographic recordings such as scalp electroencephalogram (EEG) in humans or intracranial local field potentials (LFP) in experimental animals are the main choice for objectively assessing neurodynamical synchronism underlying brain function and disease. Myriad approaches have been used to perform such investigation of EEG and LFP signals, ranging from assessment of occurrence and temporal coincidence of meaningful electrographic signatures by visual inspection to advanced computerized mathematical analyses such as cross-correlation, coherence, partial directed coherence, Granger causality, mutual information, phase lock value, and cross-frequency phase-amplitude coupling  to patients with epilepsy acutely suppressed gamma frequency (35–100 Hz) phase-locking  are screened according to their effects on synchronization levels of brain signals. For instance, different modalities of Deep Brain Stimulation (DBS) have been found, among other effects, to suppress aberrant oscillations while inducing beneficial rhythms . In fact-locking . Using e-locking .Of particular interest here, some ES approaches have been tailored to specifically tackle synchronization as a means to treat epilepsy in further corroboration of the notion of anticonvulsant effects of desynchronization. A non-standard form of low-frequency stimulation (four pulses per second in average) with randomized intervals between pulses, termed non-periodic stimulation (NPS) and devised by our group, has been shown to effectively suppress acute seizures induced by PTZ  and in cFrom this set of findings, one can conclude that assessing complex epileptic phenomena in the network level alongside its emerging properties such as synchronization  may reprFluctuations in the electrical field potential (LFP) are permanently present at the cerebral extracellular medium, reflecting the alternating pockets of higher/lower recruitment probability of localized population of neurons . The pacIn vitro and in vivo animal investigations additionally demonstrated that CB1-agonist disturbs gamma rhythm in limbic system areas  and impair auditory processing (sensory gating), acting mainly in GABAergic synapses (The LFP brain oscillations range from very slow (<0.01 Hz) to ultrafast frequencies (200–600 Hz), and distinct band rhythms become prominent when cerebral structures engage in specific tasks . Perceptsynapses . NonetheCompared with faster frequencies, slow oscillatory rhythms are associated with a more extensive brain volume alteration, longer time-window discharging probability and, the integration of a significant higher number of neurons . Of partDespite the rhythm disordering in healthy subjects, the CB activation may be beneficial to neural networks prone to develop hypersynchronous state. The synchrony reduction caused by CBR1 could balance the abnormal coupling among microcircuits present in epileptic brains, decreasing the pathological oscillatory attractor-effect, and, consequently, the occurrence of the seizures. Important to note, the endocannabinoid system offers an “on-demand” approach, with a major effect in excessively active neural ensembles [higher coupling probability ], which Although pertaining to the same neurochemical system, targeting directly CB1 receptors or the anabolic/catabolic pathways of endocannabinoid metabolism are fundamentally very different approaches. The most noticeable particularity of this specific neurochemical system, as shown in previous sections of this review, is its ability to promote homeostatic modulation of synaptic activity by targeting the presynaptic neuron, through a feedback mechanism. And, such backward modulation is mostly triggered by “abnormal” or excessive postsynaptic activation, that, consequently, promotes increased endocannabinoid release aimed at presynaptic receptors . It shou+) are fast-spiking, create time-delimited pockets of oscillations – sometimes referred to as the hippocampal “clocks,” but are also involved in very strong lateral inhibition modulation of similar feedforward/feedback microcircuit motifs within the hippocampus. Altogether, PV+ seems to promote an efficient mechanism of pattern separation with these circuit motifs that are consistent with engram formation and discrimination associated with different memory traces , and, as suggested by this review, the potentiation of the endocannabinoid system could render the same effect as an independent pharmacological treatment.Therefore, some of the same mechanisms associated with the behavioral manifestations after the recreational use of The NPS – DBS and the endocannabinoid pharmacological therapeutic approaches are obviously quite different treatment strategies for epilepsy, with no evidence in the literature of reciprocal modulation. Nevertheless, as proposed by this review, both strategies may share the common goal of focusing on desynchronizing network activity without necessarily affecting excitation/inhibition balance . It is qMore research and experimental data are needed in order to determine if DBS therapy (time-fixed pulses or NPS) predominantly has its effect by modulating or recruiting the endocannabinoid system; which is, at this time, speculative and solely based on the possible coincidental mechanisms of both therapeutical approaches. Aside from this potential caveat, a hypothetical rationale is that particular DBS patterns  could recruit the on-demand release of endogenous CBR1 ligands triggered by the increase in abnormal neural activity/connectivity. Thus, the DBS would directly modulate the brain’s dynamic functional connectogram by recruiting a built-in on-demand “circuit-breaker system” , consequently disrupting neural network abnormal synchronization. According to this proposal, the DBS and cannabinoid system would have a bidirectional collaborative effect on seizure suppression, substantially enhancing the common outcomes.DM, FM, and MM conceived the presented idea and supervised the project. DM, VC, FM, and MM wrote the manuscript. AO provided critical feedback and helped shape the manuscript. All authors reviewed, edited, and approved the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Vesicoureteral reflux, the retrograde flow of urine from the bladder into the upper urinary tract, is one of the most common urologic diagnoses in the pediatric population. Once detected, therapeutic options for urinary reflux are diverse, ranging from observation with or without continuous low-dose prophylactic antibiotics to a variety of operative interventions. While a standardized algorithm is lacking, it is generally accepted that management be tailored to individual patients based on various factors including age, likelihood of spontaneous resolution, risk of subsequent urinary tract infections with renal parenchymal injury, and parental preference. Anti-reflux surgery may be necessary in children with persistent reflux, renal scarring or recurrent pyelonephritis after optimization of bladder and bowel habits. Open, laparoscopic/robot-assisted and endoscopic approaches are all successful in correcting reflux and have been shown to reduce the incidence of febrile urinary tract infections. Vesicoureteral reflux (VUR) is one of the most common urologic diagnoses affecting children, with an estimated prevalence of 0.4-1.8% in the general pediatric population, 10-20% of those with antenatal hydronephrosis, and up to 40% of children with a history of febrile urinary tract infection (UTI) . Moreovehow to best surgically manage primary VUR is dependent on a multitude of factors, including the influence of training and personal experience of the surgeon, and the impact of published literature. Biases exist in data reporting and selective data use, as well as potential economic benefits to the surgeon using one approach over another. Ideally, after careful consideration of the various pros and cons of each approach, shared decision-making between the family and the surgeon will lead to the most appropriate intervention for a given patient.Successful surgical correction of VUR in children can be achieved via open, laparoscopic or robot-assisted laparoscopic or endoscopic approaches and fortunately for pediatric urologists and surgeons, all are potentially successful and have their merits. The decision Open ureteral reimplantation (OUR), robot-assisted laparoscopic extravesical reimplantation (RALUR), and endoscopic injection (EI) have all proven effective at correcting VUR and preventing febrile urinary tract infections , 8. Defiprimary definition of success and thus more important in the long term than radiographic findings. The clinical definition of success also underscores the importance of screening for and treatment of bladder-bowel dysfunction (BBD) prior to any anti-reflux procedure, as dysfunctional elimination influences not only surgical success but the risk of febrile UTI  procedure . Double Proponents of the endoscopic approach tout benefits including the ambulatory nature and decreased patient morbidity, while opponents note both higher initial radiographic failure and recurrence rates compared to ureteral reimplantation. Success rates of up to 94% have been reported by our group with the Double HIT methods , 33, 34.Our experience using Dx/HA over nearly twenty years has been quite good with outcomes similar to that reported for OUR and RALUR. In a series of 229 children undergoing EI with Dx/HA, 14 patients (6.3%) experienced a postoperative febrile UTI during mean clinical follow-up of 34.7 months . In a lo®)  . PPC has®) . In a co®) . These f®) . StudiesShared decision making, the collaborative process of clinicians and patients  making medical decisions together, takes into consideration not only risks and benefits of a given intervention, but also the preferences, goals, and concerns of the family before arriving at a decision . Perhapsall primary reflux, representing a shift towards a more selective approach. Not surprisingly, national trends in the surgical management of primary reflux in children have revealed significant declines in OUR and EI since the publication of the revised AAP UTI guidelines  revised the practice parameters regarding diagnosis and management of initial febrile UTIs in infants and young children aged 2 to 24 months; guidelines now recommend that children with initial febrile UTI undergo a renal-bladder ultrasound, but forego VCUG unless indicated by sonographic findings  . The revidelines . HoweverOver the past decade, there has been a shift towards a more selective approach to surgical management of primary urinary reflux, aimed at identifying children most likely to experience the untoward effects of recurrent pyelonephritis who would therefore benefit from surgical repair. While open ureteroneocystostomy, robot-assisted laparoscopic reimplantation, and endoscopic injection have differing ranges of reported radiographic success, it is important to note their rates of clinical success are similar. If the ultimate goal is prevention of febrile urinary tract infections, we must also acknowledge a shift in what is considered the “gold standard” in operative management of VUR. Based on our experience and that reported by others, we include our surgical treatment algorithm , emphasi


Drosophila, insulin resistance is induced by signaling factors released by bactericidal macrophages as a reflection of their metabolic polarization toward aerobic glycolysis. Such metabolic adaptation enables them to combat the invading pathogens efficiently but also makes them highly nutritionally demanding. Therefore, systemic metabolism has to be adjusted upon macrophage activation to provide them with nutrients and thus support the immune function. That anticipates the involvement of macrophage-derived systemic factors mediating the inter-organ signaling between macrophages and central energy-storing organs. Although it is crucial to coordinate the macrophage cellular metabolism with systemic metabolic changes during the acute phase of bacterial infection, the action of macrophage-derived factors may become maladaptive if chronic or in case of infection by an intracellular pathogen. We hypothesize that insulin resistance evoked by macrophage-derived signaling factors represents an adaptive mechanism for the mobilization of sources and their preferential delivery toward the activated immune system. We consider here the validity of the presented model for mammals and human medicine. The adoption of aerobic glycolysis by bactericidal macrophages as well as the induction of insulin resistance by macrophage-derived factors are conserved between insects and mammals. Chronic insulin resistance is at the base of many human metabolically conditioned diseases such as non-alcoholic steatohepatitis, atherosclerosis, diabetes, and cachexia. Therefore, revealing the original biological relevance of cytokine-induced insulin resistance may help to develop a suitable strategy for treating these frequent diseases.Insulin resistance and cachexia represent severe metabolic syndromes accompanying a variety of human pathological states, from life-threatening cancer and sepsis to chronic inflammatory states, such as obesity and autoimmune disorders. Although the origin of these metabolic syndromes has not been fully comprehended yet, a growing body of evidence indicates their possible interconnection with the acute and chronic activation of an innate immune response. Current progress in insect immuno-metabolic research reveals that the induction of insulin resistance might represent an adaptive mechanism during the acute phase of bacterial infection. In  Both cachexia and insulin resistance are in the spotlight of immuno-metabolic research and represent the most important comorbidities that often accompany acute and chronic inflammatory states and complicate their treatment . CachexiThe origin of insulin resistance and cachexia relies on the activity of immune cell-derived signaling factors and is thus a result of excessive activation of the immune system . HoweverDrosophila, such as metabolic misbalance and development, as well as immune response   . NRF2 tr2 (NRF2) . Therefo2 (NRF2) .Under conditions in which macrophages are exposed to excessive lipids for a time-restricted period, such as aerobic exercise, intermittent fasting, and caloric restriction, induction of mild mitochondrial stress may be beneficial for the organism. This phenomenon, called mitohormesls, alleviates systemic insulin signaling, which has a positive impact on lifespan . NeverthActivation of macrophages by excessive lipids may explain several metabolic syndromes such as adipose tissue inflammation, non-alcoholic liver steatosis, atherosclerosis, diabetes, and cachexia. This hypothesis is in concordance with clinical observations and experiments carried out on mice, in which the amelioration of macrophage polarization by anti-inflammatory agents and drugs affecting lipid metabolism leads to significant improvement of these syndromes in obese individuals .sensu stricto refers to lactic acid fermentation of glucose, here we perceive it as a complex phagocyte metabolic program including, in addition, increased pentose phosphate pathway, lipid synthesis, and the mevalonate pathway, as well as a rewired flow of the Krebs cycle  that show structural homology to either mammalian insulin or relaxin. Analogous to mammals, Drosophila insulin signaling also reflects the current metabolic status of the individual. DILPs 2, 3, and 5 are thus released by specialized neurosecretory cells in the Drosophila CNS to regulate reproduction, growth and lifespan. While most DILPs activate a single Drosophila insulin receptor, DILP8 binds to its own LGR3 receptor. The situation in humans is even more complicated because, in addition to insulin, we can recognize two insulin-like growth factors, relaxin, as well as several insulin-like peptides. Insulin signaling activity is affected by many convergent signaling pathways and factors, such as hormones of a lipophilic nature, as well as insulin-binding proteins and IGFs , the enzyme responsible for HIF1α degradation. PHD requires several metabolic products as essential cofactors for its enzymatic activity. From the most prominent, we should mention oxygen, Febs cycle . Althougbs cycle . These ltabolism . It shoutabolism .in vitro investigation of nutrient uptake and trafficking fully elucidated the complexity of HIF1a-mediated metabolic changes and the utilization of these nutrients by bactericidal macrophages , insulin/IGF antagonist Imaginal morphogenesis protein late 2 (ImpL2), and cytokine Unpaired3 (Upd3)] ] .It is almost 100 years since the discovery that cancer cells preferentially employ glucose fermentation as an oxygen-independent source of ATP even when sufficiently supplied with oxygen . This meUsing modern metabolomics techniques, it has been found that the lower yield of ATP is compensated by the increased glycolytic rate and that this metabolic setting represents an advantage in the production of essential precursors promoting cell growth, division, and active participation in many biological processes . As a reInterestingly, the pro-cachectic effect of tumors is interconnected with the adoption of HIFlα -dependent aerobic glycolysis . It has Leishmania  is known to be released from experimentally induced cancer cells in adult flies. ImpL2 affects the metabolism of adipose tissue via insulin resistance and induces the mobilization of nutrients subsequently exploited by the tumor for its own growth . Interestingly, this enzyme is produced by plasmatocytes as well, with an 8 h delay after adenosine. Lack of adgf-A function leads to wasting of glycogen stores and slow-down of development .Drosophila cancer model (Also, the ImpL2 production by plasmatocytes must be time-restricted. Chronically increased ImpL2 production by plasmatocytes leads to developmental malformations, reduced body size of the individual, and excessive melanization of immune cells . Moreoveer model .Drosophila plasmatocytes, analogous signaling in mammals remains controversial. However, all of these factors have their signaling counterparts in mammals. While the Upd3 functional homolog has been identified as IL6, studied mostly for its signaling and metabolic effects in immune response, the ImpL2 mammalian putative functional homolog IGFBP7, known for its ability to attenuate insulin signaling, has not yet been explored in the context of infection. Therefore, we speculate about the evolutionary conservation of the role of these SIFs in the following paragraphs.Although eAdo, ImpL2, and Upd3 meet the criteria of a selfish immune factor released by the Experimental studies performed on insects demonstrate that plasmatocytes release signaling factors to affect systemic metabolism and thus ensure a sufficient supply of resources. Here, we would like to consider the possibility that such a mechanism is also valid for mammals . The conA plethora of cytokines and chemokines are released from activated immune cells upon the adoption of a bactericidal polarization state. These are generally known as “pro-inflammatory cytokines” due to their potential to guide other myeloid cells toward inflammatory polarization. Here, we suggest their role in the regulation of systemic metabolism via the induction of insulin resistance upon bacterial infection.From several experimental and clinical studies, it is clear that macrophage production of pro-inflammatory cytokines is associated with HIF1α transcriptional activity and subsequent metabolic rearrangement toward aerobic glycolysis . HoweverThere is a compelling list of publications describing the release of pro-inflammatory cytokines from cancer and hypoxic tissues . RecentlConsistent with this hypothesis, hypoxic tissues also release a number of cytokines with pro-cachectic properties. Surprisingly, the elicitation of hypoxic response employs several immune-related signaling pathways such as JNK, NF-κB, and Hif1α . Their aAccording to the proposed theory, the central mechanism that changes the systemic metabolism from anabolism to catabolism is the induction of insulin resistance. In adipose tissue, the lack of insulin signaling serves as a signal for potentiation of lipolysis and subsequent fatty acid mobilization . TherefoAn opposite effect of insulin resistance can be observed in muscles, where a lack of insulin signal leads to a significant reduction of its metabolic rate and induction of autophagy . AutophaDrosophila ImpL2, may be a potential candidate (Besides the systemic impact on insulin resistance, we should also take into account the paracrine effects of cytokines in the liver. The liver is the central metabolic organ that coordinates the systemic metabolic changes upon infection . In addiandidate .Streptococcus pneumoniae (It has been shown that IGFBP7 expression increases fourfold in the culture of human THP-1 macrophages in response to their exposure to eumoniae . In addieumoniae . Althougeumoniae . Althougeumoniae .This review brings the new perspective that systemic insulin resistance represents an essential mechanism for overcoming the acute phase of bacterial infection. Insulin resistance is induced by immune cell-derived cytokines, which are produced as a reflection of their elevated metabolic demands resulting from the adoption of aerobic glycolysis. These cytokines induce both the mobilization of sources from the storage organs and their suppressed consumption by non-immune tissues. Titers of nutrients thus elevate in circulation to be utilized by the activated immune system. While such metabolic adaptation is fundamental for resistance to extracellular pathogens, it may become maladaptive upon infection by intracellular bacteria exploiting phagocyte cellular stores for its own benefits. Although cytokine-induced insulin resistance is beneficial during acute phase response, its chronic activation may progress into the wasting of nutrients and cachexia , which aInduction of insulin resistance in hepatocytes is central for the progress of obesity and obesity-associated diseases, such as non-alcoholic steatohepatitis, atherosclerosis, and diabetes. According to the presented hypothesis, liver and systemic insulin resistance are induced by chronically adopted aerobic glycolysis in activated liver macrophages. Reversal of macrophage metabolic switch may thus represent a powerful therapeutic strategy.AB, GK, and TD discussed the topic, conceptualized, wrote, and revised the manuscript. GK created the figures. AB and GK captured the microscopy images. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Mycobacterium tuberculosis (TB) were once thought to be harmless environmental saprophytics and only dangerous to individuals with defective lung structure or the immunosuppressed. However, NTM are now commonly infecting seemingly immune competent children and adults at increasing rates through pulmonary infection. This is of concern as the pathology of NTM is difficult to treat. Indeed, NTM have become extremely antibiotic resistant, and now have been found to be internationally dispersed through person-to-person contact. The reasons behind this NTM increase are only beginning to be elucidated. Solutions to the problem are needed given NTM disease is more common in the tropics. Importantly, 40% of the world's population live in the tropics and due to climate change, the Tropics are expanding which will increase NTM infection regions. This review catalogs the global and economic disease burden, at risk populations, treatment options, host-bacterial interaction, immune dynamics, recent developments and research priorities for NTM disease.The incidence and number of deaths from non-tuberculous mycobacterial (NTM) disease have been steadily increasing globally. These lesser known “cousins” of  Mycobacterium (which include Mycobacterium tuberculosis (TB) and Mycobacterium leprae), there are over 170 identified NTM species with new species discoveries increasing yearly (Non-tuberculous mycobacteria (NTM) are ubiquitous, free living, environmental saprophytic organisms known to occupy water systems, soil, and vegetation. Belonging to the genus M. tuberculosis as the causative agent of tuberculosis in 1882), decades passed before human NTM infection was identified (Mycobacterium avium complex (MAC) which now includes MAC subspecies silvaticum, subspecies hominissuis, and subspecies paratuberculosis, Mycobacterium intracellulare, Mycobacterium arosiense, Mycobacterium chimera, Mycobacterium columbiense, Mycobacterium marseillense, Mycobacterium timonense, Mycobacterium bouchedurhonense, and Mycobacterium ituriense  which were recently grouped as a separate clade named Mycobacteriodes abscessus based on phylogenetic characteristics  to aseptic meningitis. Infection of the lung is the most common clinical manifestation. Termed pulmonary NTM disease (PNTM), this manifestation has an evolving and complex pathology. Many questions remain including the mode of transmission, the period of incubation and the true disease burden. Three forms of PNTM are described based on distinct pathology. The three forms comprise fibro-cavitary disease, nodular bronchiectasis disease, and hypersensitivity pneumonitis. Given the generally low virulence of these organisms together with their slow growth rate, onset of disease symptoms is often insidious. Incubation periods can vary from months to years making diagnosis difficult and tracing the source of infection virtually impossible. A rise in the number of globally documented NTM infections has led to NTM being recognized as emerging threat causing significant morbidity and mortality in both immune competent and immune compromised populations . MAC andNTMs are considered opportunistic pathogens to humans. Exposure to these organisms in day-to-day life is common through shower aerosols but infection and clinical disease occur in only some individuals . Over thThe increase in research into the epidemiology, diagnostics, and treatment of this once obscure disease stems from the increasing numbers of cases being identified from populations with previously unknown and currently unidentified risk factors . AdvanceA fourth disease cohort include elderly white post-menopausal females who present classically with NTM infection of the middle or lingular lobe of the lung. Described as “Lady Windermere syndrome” these patients often have a distinct physical phenotype of slender build, pectus excavatum or scoliosis and mitral valve prolapse, though notably they have no known immune dysfunction , 19, 28.M. tuberculosis in the US and Canada with an increase of 8.4% annually being documented between 1997 and 2003 , Australia since the commencement of the tuberculosis (TB) control programme in the 1960s and is currently a notifiable disease , 60. ThePNTM treatment requires prolonged 12–18 months) multi-drug therapy . Disease months mAdjuvant therapies have been tested with little success. Preliminary trials of adjunctive IFNγ therapy were abandoned due to lack of response –74 althoNTM are not classic species-specific pathogens, rather they are environmental saprophytic organisms that make use of the new living opportunity presented when human habitation and bacterial habitation overlap. Unknowns include: (i) the percentage of a given population who are exposed; (ii) how infection occurs and by what source; (iii) what host and bacterial factors determine clearance; (iv) how NTM establishes itself as a colonizer without causing tissue invasion and; (v) why NTM are symptomatic in only some individuals. All that is currently known is that specific groups of individuals are at risk, some with known immune dysfunction, and others with specific medical characteristics.The immune responses seen in human NTM infection has shown similarities to TB. However, no consistent phenotype of immune protection or immune susceptibility has been described. Immune compromise caused by genetic mutations (MSMD) and acquired defects due to infections like HIV usually lead to disseminated infection while iatrogenic causes , and defects in lung structural and functional integrity  and pulmonary alveolar proteinosis, are known predispositions to pulmonary NTM disease , 22, 82.These predispositions tell a story of both local/systemic and innate/adaptive immunity being required to combat infection. Innate defense mechanisms such as effective respiratory epithelial ciliary function are likely required to keep colonizing NTM bacterial counts under control. When airway mucociliary clearance is impaired and/or when virulent strains of bacteria can locally invade tissue, cellular defense mechanisms are activated. The immune cascade then follows: (i) macrophage activation and local recruitment of innate cells including neutrophils, iNKTs and NK cells to control early infection and; (ii) migration to of APCs to lymph nodes for antigen presentation and activation of antigen specific T cells. A review by Tomioka  describeM. avium infection exist though currently, it is difficult to initiate infection, maintain infection, and measure immune responses in MABS mouse models  stimulated with mycobacterial antigens produced higher levels of IL-10 but lower levels of IFNγ, IL-12, and TNF. Other studies have shown similar results for IFNγ and IL-10 but not for the other cytokines , which activates myeloid cells, or phytohaemaglutinin (PHA), which stimulates cellular immunity. A comparison of MAC infected patients with no evidence of compromised immunity and ytokines –94. A stytokines . Longituytokines . A studyytokines . A more ytokines . These fytokines , 95. Intytokines . A recenytokines . A hi-diytokines . AdditioPreliminary evidence showed that T cell defects may play a role in MAC infection . T cellsStudies on human cells have varied in the specimen used , the stimulants used  and patient groups  as shown in + T cell deficiency have also been implicated in NTM susceptibility  are of high clinical value. Likewise, the identification of patients likely to recover and patients likely to develop serious life-threatening infection would be of enormous benefit to clinicians to guide the therapeutic decision-making process. Information from mouse models of MAC infection are available and less so for MABS. Human information is limited to small studies of generally <10 patients . InformaRecent findings of increased NTM pathophysiology are cause for global concern. Firstly, the recent emergence of person-to-person transmission of highly antibiotic resistant MABS across continents is highly alarming . These fResearch priorities recommended in the US and UK include rapid diagnostic tools fast identification of infecting species  and simpNTM infection presents a growing global health problem, complicated by ubiquitous exposure to the organisms, incomplete understanding of the immune susceptibility to disease, increasing numbers of immune compromised patients, cumbersome diagnostic tests (with no prognostic tests) and costly, multi drug treatment regimens that often fail to cure. However, we must keep in mind that different disease mechanisms may be operating between different risk groups and preclinical models.NTM disease is frequently slow and progressive, affecting predominantly already vulnerable patient populations. Epidemiological and descriptive studies of patients are many, but gaps in knowledge remain. Foremost among these is a deconstruction of the immune susceptibilities to NTM lung disease. If we can understand potential patient risk profiles, screening tests could be efficiently deployed to identify infection at risk individuals within hours. Such screening tests as well as prognostic tests that can predict outcome  during early treatment would be extremely beneficial for clinicians to make therapy decisions as soon as possible, with potential improvement of patient outcomes. In the current age of immunotherapy, where targeted augmentation of immune responses is now possible, research into adjuvant immune therapies that could be used to “boost” a weakened immune system would beneficial and could be redeployed from the cancer field. Such immune modulating interventions would go a long way in reducing the global burden of NTM disease.The true level of morbidity caused by NTM lung disease is slowly being revealed, in both developed and developing nations and in both immune competent and immune compromised populations. Disease burden is being documented in both childhood and adulthood disease in terms of both direct and indirect morbidity. A cohesive solution to the global challenge of NTM lung infection requires a multipronged approach involving not just epidemiological data, but also clinical and laboratory-based research for new diagnostics, prognostics, and treatments for use in machine learning. These cohesive approaches are urgent as NTM is more common in the warmer climates . Forty pCR drafted the manuscript. VL, AK, DD, DR, MF, SB, RT, and JM provided critical revision.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Candida albicans is a fungal pathobiont present in most healthy individuals that, under certain circumstances, can become pathogenic and cause everything from mild mucosal infections to life-threatening systemic diseases. As an essential part of the innate immunity in mucosae, epithelial cells elaborate complex immune responses that discriminate between commensal and pathogenic microbes, including C. albicans. Recently, several significant advances have been made identifying new pieces in the puzzle of host-microbe interactions. This review will summarize these advances in the context of our current knowledge of anti-Candida mucosal immunity, and their impact on epithelial immune responses to this fungal pathogen.The mucosal surfaces of the human body are challenged by millions of microbes on a daily basis. Co-evolution with these microbes has led to the development of plastic mechanisms in both host and microorganisms that regulate the balance between preserving beneficial microbes and clearing pathogens.  Candida spp., a major component of the mycobiome of ~70% of the healthy population . Whilst not associated with a high mortality, these superficial C. albicans infections can lead to systemic candidiasis in patients subjected to complex medical procedures, such as use of catheters, gut surgery or liver transplantation. In fact, Candida disseminated infections are the fourth most common nosocomial bloodstream infections, and have high associated mortality of 45–75%  protein family, interacting with different host receptors facilitating fungal cell attachment   and other fungal markers resulting in activation of host cell responses. Although host sensing of C. albicans has been studied to a greater or lesser extent for both epithelial and immune cells, it is still not completely understood  present in the oral mucosa, the role of γδ-T cells and Innate Lymphoid Cells type 3 (ILC3) has been controversial and needs to be further confirmed , oral epithelial cells only express IL-17C  are the most well-known  confers protection to C. albicans from the antimicrobial peptides LL-37 and histatin-5  and phospholipases   show increased persistence in comparison to wild type strains, while hypha-locked ones (nrg1Δ/Δ) exhibit decreased colonization capacity , which has previously been shown to be upregulated during growth in the mouse cecum compared to laboratory conditions  and the control of immune responses by cellular metabolism . While tC. albicans. Importantly, IL-1 signaling promotes IL-17-driven responses , and whilst this may be part due to a reduced type 17 response in these animals . However, this classical view of the immune system assigning differential specificity and the ability to develop “memory” states to innate and adaptive cells has been recently challenged.Cells of the innate immune system have now been shown to undergo long-term changes associated with previous encounters with PAMPs, either in isolation  or in complex mixtures , that result in subsequently modulated responses , contrasting with the profile exhibited by LPS/IFNγ-activated macrophages  production using compounds such as mdivi-1, which represses hyphal growth and the yeast-to-hypha transition and promotes metabolic reprogramming in the fungus (Koch et al., C. albicans relies on OxPhos to produce ATP and therefore, mitochondria can be targeted for new antifungal drugs (Duvenage et al., C. albicans surface, thereby enhancing immune recognition and uptake by phagocytes. Conversely, Duvenage et al. also showed that pre-inhibition of respiration promotes the activation of virulence traits, leading to worse outcomes in systemic infection models (Duvenage et al., With the key role that metabolic reprogramming and subsequent pathways have in host and fungal responses during infection, targeting these pathways is an emerging therapeutic option for treating infections. Manipulating immune responses through therapeutic interventions of cellular metabolism has already been proposed not only for treating infections (Rao et al., C. albicans has co-evolved with the human host establishing a complex relationship balanced between commensalism and pathogenicity. Although much work has been done investigating the classical immune responses of microbes, recent studies have begun to uncover the key role played by both epithelial cells and host and fungal metabolism in disease pathogenesis. Completely understanding of these relationships, will allow us to determine the precise roles Candida and other fungi have as commensals, but also to identify those factors that make possible the pathogenic fungal overgrowth. Exploring the role of emerging fields in microbiology and immunology, such as innate immune memory and the control of pathogenesis or immunity by cellular metabolism, will shed light to the still unknown events underlying anti-C. albicans immunity at mucosae.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In recent decades, the study of exosome biology has gained growing interest, representing an active area of cancer research with many potential clinical applications. Exosomes are small lipid bilayer particles released by cells with pleiotropic functions that have been reported to regulate the complex intracellular pathway involved in all steps of breast cancer development—from initiation to progression toward a metastatic dissemination. Particularly, the role of these microvesicles has been explored in metastasis, which represents the leading cause of breast cancer morbidity and mortality worldwide. Reports highlight that the plasticity of breast cancer cells, fundamental for the establishment of distant metastasis, may be in part attributed to exosome-carried signals shared between adjacent cells and long-distance cells in the body. In the present review, we will discuss the functions of exosomes in the metastatic breast cancer process and secondary site outgrowth. The possibility to decode the exosome functions in advanced diseases may offer new opportunities for early detection, molecular targeted therapies and exosome-based therapeutics in breast cancer. Female breast cancer accounts for 11.6% of the total cancer incidence burden and for 6.6% of the cancer-related deaths burden worldwide. It is the most common cancer among women, with more than 2 million 24.2%) newly diagnosed cases in both developed and developing countries, and represents the leading cause of cancer mortality; more than 0.6 million (15.0%) women died in 2018 as reported in the GLOBOCAN database . Indeed,.2% newlyA large body of evidence, in recent decades, has highlighted that cell-to-cell communication represents a key driver of cellular functions and tissue homeostasis in both physiological and pathological conditions, including cancer. As important and well-established mediators of intercellular communication, the membrane-derived vesicles and, particularly, exosomes , have obHere, we will summarize and critically discuss the current advancements in understanding the role of exosomes in the metastatic cascade of breast cancer. Particularly, we will highlight both homotypic- (cancer cell-to-cancer cell) and heterotypic-transfer  of bioactive molecules and signalings able to modulate the key steps of the metastatic process. Because of the difficulty of assigning the correct nomenclature to the lipid bilayer particles released by cells in the different experimental conditions, as claimed by the “International Society of Extracellular Vesicles” , some scExosomes are endocytic membrane vesicles of 30–150 nm in size that are released by various cell types into extracellular spaces, including body fluids such as blood, lymph, cerebrospinal fluid, urine and saliva. These extracellular vesicles are functional vehicles that carry a complex cargo of nucleic acids, proteins and enzymes, depending on the nature and status of original cells. A large cargo of nucleic acids, that can be incorporated into recipient cells, has been identified in exosomes. MicroRNAs (miRNA) and mRNAs are the most important cargos packed into exosomes, but these vesicles also contain a considerable amount of RNAs of other types, such as transfer RNA, ribosomal RNA and small nuclear RNA, small nucleolar RNA, piwi-interacting RNA and long non-coding RNA. MiRNAs and mRNAs packed into exosomes shuttled from donor to recipient cells, actively modulate the activities of recipient cells inducing the post-transcriptional regulation of gene expression and transient or persistent phenotypic change . Different proteins were conserved in exosomes, regardless of their cellular origin . Indeed,Exosomes are enriched in lipids that play a vital role in their biogenesis and are characteristic of the cell origin. Generally, phosphatidylserine (PS), phosphatidic acid, cholesterol, sphingomyelin (SM), arachidonic acid and other fatty acids, prostaglandins and leukotrienes, ensure the stability and structural rigidity of the exosomes. Interestingly, lipids such as lyosbisphosphatidic acid (LBPA) are found in the internal membranes of multivesicular bodies (MVBs) and play an important role in the biogenesis of exosomes . Exosome biogenesis begins within the endosomal system, where early endosomes mature into late endosomes or MVBs, and the inward budding of the endosomal membranes produces an accumulation of intraluminal vesicles (ILVs) in the lumen of the organelles. During this process, transmembrane proteins are integrated into the invaginating membrane, while the cytosolic components are enclosed within the ILVs. The endosomal sorting complex required for transport (ESCRT) is a protein machinery composed of successive complexes  associated with the membrane of MVBs. All components work cooperatively to regulate the formation of vesicle budding and protein cargo sorting in a ubiquitinylation-dependent manner ,15. The 2+/Ca2+-dependent Rab binding protein (Munc13-4) pathway [The mechanisms of exosome biogenesis appear deregulated in cancer, resulting in an increased amount of vesicles released by cancer cell lines as well as recovered in the blood of patients with cancer ,20. Part pathway . More re pathway . The molecular mechanisms involved in exosome internalization into recipient cells are still unclear. Exosome internalization might occur by several biological mechanisms comprising fusion with the plasma membrane, receptor-mediated endocytosis, macropinocytosis and phagocytosis. The first step of exosome uptake involves interaction with the recipient cell near or distant to the donor cell. It is still not completely understood whether this process depends on a specific combination of EV subtype and acceptor cell. The second step of uptake is the internalization into the cell that could occur through a non-specific process such as macropinocytosis or micropinocytosis, or through a specific receptor-dependent pathway . ExosomeMoreover, it has been reported that exosomes can transfer information to recipient cells without delivery of their content, acting directly at the cell surface. For example, cellular responses induced by soluble and juxtacrine signalings do not require internalization but depend on the proteolytic cleavage of exosomal ligands or on the position of ligands and receptors on the exosome surface and in target cells, respectively . AlternaGrowing evidence has highlighted the contribution of exosome-mediated signaling in all the aspects of breast cancer metastatic dissemination. Metastasis is an extremely intricate biological process during which primary cancer cells must: (i) invade adjacent tissues; (ii) enter the blood or lymphatic vessels; (iii) colonize distant target organs where they can proliferate and form clinically detectable neoplastic growths. The findings outlined by the current literature in the field are summarized in The initial event of the metastatic process involves the local invasion of primary tumor cells into the surrounding tissues through the remodeling of the extracellular matrix (ECM) and the acquisition of migratory capacity . During Several proteins, signaling molecules and miRNAs, regulating cytoskeleton remodeling, cell motility and invasion capability, have been identified in the cargos of exosome-like vesicles released from breast cancer cell lines ,66. An iAnother interesting issue explored by authors was the impact of circulating exosomes derived from healthy subjects on tumor epithelial cell properties. Studies carried out using exosomes derived from the plasma of healthy female donors demonstrated that these EVs stimulate the adhesive, motile and invasive properties of breast cancer cells in vitro, as well as their metastatic dissemination in the Zebrafish model, via the focal adhesion kinase (FAK) signaling pathway activation . In miceTo allow the metastatic process tumor cells, after primary growth, they should be able to invade the basement membrane and enter the circulation avoiding apoptotic signals and host immune responses. Primarily, tumor neoangiogenesis occurs to provide breast cancer cells with more nutrients and oxygen, and to gain access to the route for the metastatic dissemination. Next, cancer cells invade the basement membrane and cross the endothelial barrier passing through endothelial cell junctions resulting in the intravasation into blood or lymphatic vessels. Finally, the limiting step of the successful metastatic process is represented by the survival in the bloodstream where circulating tumor cells (CTCs) are exposed to hemodynamic shear forces, innate immunity response and oxidative stress.2+-dependent phospholipid-binding protein associated with the plasma membrane, promotes angiogenesis in a tPA-dependent manner in breast cancer cells [It is well established that the crosstalk between breast cancer cells and endothelial cells, mediated by secretion of growth factors, cytokines and induction of hypoxia may facilitate angiogenesis process. Many findings also support the idea that exosomes secreted by cancer cells could transport angiogenic cargo promoting new vascular network formation through the activation of endothelial cells. In vitro and in vivo experimental approaches revealed that exosomal Annexin II, a Caer cells . The exper cells . Moreoveer cells . It is wer cells , and nower cells . Exosomeer cells  that caner cells . On the er cells . In lineer cells . These lThe intravasation process requires the destruction of basement membrane integrity, by perturbing the endothelial cell barrier. The stability of endothelial junctions is maintained by the expression of the membrane-associated adhesion molecules such as claudin-5, occludin, vascular endothelial cadherin (VE-cadherin) and zonula occludens 1 (ZO-1) . Recentl+Gr-1+ cells to differentiate in myeloid-derived suppressor cells (MDSCs), known to promote tumor progression, via prostaglandin E2 (PGE2) and TGF-β pathways [Evasion of immune surveillance is a crucial step to gain metastatic outgrowth. Many findings revealed that exosomes, using multiple mechanisms, can help breast cancer cells to exert immunomodulatory activities. Exosomes released by murine mammary carcinoma cells TS/A or 4T1 induced cancer growth in a mouse model, inhibiting natural killer (NK) cell cytotoxic activity ex vivo and in vivo . Additiopathways . Moreovepathways .As final step of the metastatic process, the CTCs, that have survived blood stresses, anoikis, and host immune response in the circulation, should reach the distant target organs where they must reacquire the epithelial phenotype and thus epithelial cell-to-cell junctions going through a reversal process named mesenchymal–epithelial transition (MET). The EMT/MET transition implies multiple changes in gene expression, mainly regulated by the EMT-associated transcription factors, and is accompanied by a dynamic transdifferentiation process that occurs in different metastatic microenvironments. Several reports suggest that exosomes actively drive organotropic metastasis of cancer cells by altering the metabolism of non-transformed cells and/or educating the cells of the hosting tumor microenvironment , thus establishing the permissive premetastatic niche ,63,77.To exit from the circulatory system, a mechanism known as extravasation, cancer cells adhere to vascular endothelium in a distant metastatic secondary site and leave the circulation. The preferred sites of colonization of circulating breast cancer cells are in order bone (65%), lung (31%), liver (26%) and brain (8.8%) . Metasta4 in exosomes isolated from breast cancer patients that develop lung metastasis [Lastly, in the metastatic cascade, CTCs that reached the target organ might proliferate and become clinically relevant tumor mass. To accomplish the development of metastatic tumors, CTCs (“seed”) can find a receptive microenvironment in distant target organs (“soil”). Indeed, it is now clear that the specificity of the pre-metastatic niche microenvironment is critical in the fate of CTC outgrowth at the distant site, and several reports indicate a role for tumor-derived exosomes in preparing the “soil” for future metastatic seeding. Exosome labelling experiments using CD63-GFP expressing breast cancer cells in orthotopic nude mice showed that tumor-derived exosomes can be found circulating in the blood of mice as well in lung metastases, where they target stromal cells such as fibroblasts . Opticaltastasis . Moreovetastasis . In additastasis . Recentltastasis . While itastasis . The maiMetastatic breast cancer is still considered an incurable disease that needs new early diagnostic tools and more therapeutic options to become a less deadly malignancy. Thus, tremendous efforts have been focused on the better understanding of the mechanisms by which breast cancer cells escape the primary tumor, survive in the circulation, overcome immune surveillance and initiate outgrowth at secondary organs. A large amount of literature has reported that the dynamic interaction among the different cell types in the local as well as in the distant tumor microenvironment regulates various stages of breast cancer metastasis, and exosomes have been largely demonstrated to mediate many of the involved processes. Indeed, breast cancer-derived exosomes directly participate in cancer cell plasticity by increasing tumor cell motility and ECM degradation. Moreover, the discussed findings support the idea that tumor-derived exosomes may contribute to metastatic organotropism, creating a permissive niche in specific metastatic secondary sites. Although, based on the current knowledge, mainly obtained from in vitro studies, exosome activity is relevant in breast cancer metastasis, several questions arise: How and when do exosomes reach the premetastatic niche during the disease progression? How do cancer cells acquire the ability to release specific exosomal cargo that in turn sustains breast cancer plasticity and tumor metastatic spread? Can the detection of cancer-derived exosomes be used as a marker for the early diagnosis of metastasis? May exosomes from other tissues affect the metastatic process ? To answer these and other questions, further studies should be carried out using genetically engineered animal models that allow the following of circulating exosome routes without external administration of vesicles that could represent an artefact. In addition, the evaluation and characterization of circulating exosomes in breast cancer patients at different stages of disease should be addressed. Overall, the biology of exosomes is still an open discussion to be covered and represents an attractive research area to be explored for novel opportunities in prevention, diagnosis and therapeutic approaches in breast cancer.A search for original articles published in the last two decades was performed in PubMed. We used the following search terms: “exosome biogenesis”, “exosome uptake”, “exosomes and breast cancer”, “exosomes and breast cancer and metastasis”, “exosomes and breast cancer and EMT”, “exosomes and breast cancer and angiogenesis”, “exosomes and breast cancer and immunomodulation”, “exosomes and breast cancer and intravasation”, “exosomes and breast cancer and extravasation”, “exosomes and breast cancer pre-metastatic niche”, “exosomes and breast cancer and organotropism”. Furthermore, we selected additional relevant original articles from the reference lists of the used papers. All the articles selected were English-language full-text papers.


The recent global events related to the coronavirus disease of 2019 pandemic have significantly changed the medical landscape and led to a shift in oncologic treatment perspectives. There is a renewed focus on preserving treatment outcomes while maintaining medical accessibility and decreasing medical resource utilization. Brachytherapy, which is a vital part of the treatment course of many cancers (particularly prostate and gynecologic cancers), has the ability to deliver hypofractionated radiation and thus shorten treatment time. Studies in the early 2000s demonstrated a decline in brachytherapy usage despite data showing equivalent or even superior treatment outcomes for brachytherapy in disease sites, such as the prostate and cervix. However, newer data suggest that this trend may be reversing. The renewed call for shorter radiation courses based on data showing equivalent outcomes will likely establish hypofractionated radiation as the standard of care across multiple disease sites. With shifting reimbursement, brachytherapy represents the pinnacle in hypofractionated, conformal radiation therapy, and with extensive long-term data in support of the treatment modality brachytherapy is primed for a renaissance. Oncologic physicians are increasingly focused on maintaining equipoise of treatment outcome and medical accessibility with decreasing medical resource utilization. In support of these measures, radiation oncologists have used a variety of temporizing measures, including hormone therapy measures , treatment delays (where appropriate), and hypofractionation across all disease sites.,Gynecologic brachytherapy is a vital and irreplaceable component of definitive and adjuvant treatment for gynecologic malignancies. Multiple studies have demonstrated the efficacy of brachytherapy to treatment outcomes in cervical and uterine oncologic malignancies.,Modern HDR brachytherapy is a form of hypofractionated, conformal therapy commonly delivered in 4 to 5 treatments for cervical cancer.Advances in imaging technology, such as magnetic resonance imaging, allow for adaptive image guided brachytherapy (IGBT) with simultaneous dose escalation to tumor targets and sparing of organs at risk. Compared with point-based brachytherapy planning, volumetric-based planning using IGBT has demonstrated improved tumor control and significantly reduced toxicity.,Partial breast irradiation (PBI) has demonstrated comparable treatment outcomes to whole breast irradiation with regard to local tumor control, toxicity, and cosmetic outcomes.,,,Early data for breast brachytherapy delivered in 1 to 4 fractions have demonstrated excellent local tumor control and cosmetic outcomes.Therefore, even with the likely adoption of shorter external beam radiation treatment regimens, breast brachytherapy remains an excellent option for women and provides good local control and cosmetic outcomes.,Prostate brachytherapy results in excellent treatment and toxicity outcomes has a short overall treatment time (OTT), and is more cost effective than other radiation treatment options. Prostate brachytherapy (HDR or LDR) is considered equivalent to radical prostatectomy and external beam radiation for the treatment of prostate cancer and can be completed in 1 (LDR) or several (HDR) implantations.,Brachytherapy as monotherapy is appropriate for patients with low-risk or favorable intermediate-risk disease or as a boost in patients with unfavorable intermediate- and high-risk disease. When used as a boost for patients with unfavorable to high-risk disease, recent data from 2 prospective randomized trials have shown that brachytherapy significantly prolongs biochemical progression-free survival by >50% compared with dose-escalated external beam radiation.Prostate brachytherapy is also useful in the setting of isolated intraprostatic recurrence after definitive treatment with radiation. A recent phase 2 trial, as well as several retrospective studies, demonstrated excellent rates of cancer-free and biochemical recurrence-free survival with brachytherapy and had acceptable, predominantly grades 1 and 2 gastrointestinal and genitourinary toxicity.,The use of hypofractionation in the United States has been increasing, leading to a decline in radiation oncology departmental revenue through reduced episodic fee-for-service reimbursement.,COVID-19 has since accelerated the transition to extreme hypofractionation, including stereotactic radiation therapy and brachytherapy. After COVID-19, we anticipate the continued use of shorter treatment schedules and modalities that minimize patient exposure to high-cost hospital resources, postoperative care, or hospitalization. Brachytherapy is well-positioned to capitalize on these changes given its high value proposition. Most brachytherapy treatments can be delivered with minimal resources,The adoption of the RO-APM may improve financial stability by providing episodic payments for disease site-specific radiation oncology care. These payments would be tied to average episode reimbursements rather than the volume or modality of service. This APM redesign appropriately attempts to incentivize shorter courses of low-cost, high-quality treatment . This change would also protect physicians from uncontrollable downside risks, such as from COVID-19, and provide financially stable payments to practices.However, despite these theoretical benefits, several key changes are necessary to the RO-APM to ensure sustainability of and access to radiation oncology care in the United States. A practice’s bundled reimbursement in the RO-APM will be closely tied to its historical reimbursements per episode of care. Practices that were early adopters of hypofractionation and high users of cost-effective treatments, such as brachytherapy , will receive lower reimbursements than practices that have been slow adopters of hypofractionation or who have not used cost-effective modalities .,Brachytherapy is vital and irreplaceable for gynecologic malignancies, and results in excellent treatment and toxicity outcomes for breast and prostate malignancies. Brachytherapy is value-based and cost effective. The utilization of brachytherapy declined in the early 2000s, and has been associated with a decrease in resident brachytherapy caseload. The decline in residency brachytherapy training has been identified as a barrier to achieving brachytherapy competence and clinical independence.Given preexisting inclinations for shorter radiation courses, a new radiation oncology normalcy will likely establish hypofractionated radiation as the standard of care across multiple disease sites. With shifting reimbursement, brachytherapy represents the pinnacle in hypofractionated, conformal radiation therapy, and with extensive long-term data in support of the treatment modality brachytherapy is primed for a renaissance.


To examine the association between hospital deaths , readmission, length of stay (LOS) and eight hospital characteristics.Longitudinal observational study.A total of 119 teaching and large-sized hospitals in Canada between fiscal years 2013–2014 and 2017–2018.Analysis focused on indicator results and characteristics of individual Canadian hospitals.Hospital deaths (HSMR); all patients readmitted to hospital; average LOS and a series of eight hospital characteristic summary measures: number of acute care hospital stays; number of acute care beds; number of emergency department visits; average acute care resource intensity weight; total acute care resource intensity weight; hospital occupancy rate; patients admitted through the emergency department (%); patient days in alternate level of care (%).Comparing 2013–2014 to 2017–2018, hospital deaths (HSMR) largely declined, while readmissions increased; 69% of hospitals decreased their hospital deaths (HSMR), while 65% of hospitals increased their readmissions rates. A greater proportion of community-large hospitals  improved on both hospital deaths (HSMR) and readmission compared to Teaching hospitals . Hospital deaths (HSMR), readmission and LOS largely showed very weak and non-significant correlations. LOS was largely positively and statistically significantly correlated with the suite of eight hospital characteristics. Hospital deaths (HSMR) was largely negatively  correlated with the hospital characteristics. Readmission was largely not statistically significantly correlated and showed no clear pattern of correlation (direction) with hospital characteristics.Examining publicly reported hospital performance results can reveal meaningful insights into the association among outcome indicators and hospital characteristics. Good or bad hospital performance in one care domain does not necessarily reflect similar performance in other care domains. Thus, caution is warranted in a narrow use of outcome indicators in the design and operationalisation of hospital performance measurement and governance models (namely pay-for-performance schemes). Analysis such as this can also inform quality improvement strategies and targeted efforts to address domains of care experiencing declining performance over time; further granular subdivision of the analyses, for example, by hospital peer-groups, can reveal notable differences in performance. Assessed correlations across eight hospital characteristics and three hospital performance indicators.Assessed 5 years of performance data.Examined the majority of teaching and community-large hospitals in Canada.Inability to apply more complex statistical modelling techniques due to limitations on the use of aggregate hospital-level data in secondary analyses.Length of stay is an aggregate of all hospitalisations, and could not be restricted to condition-specific cases .Over the last two decades, there has been substantial interest in hospital performance,7However, the goals of achieving quality and efficiency can at times be opposing. For example, it seems warranted to investigate whether a hastened hospital stay (shorter LOS) would lead to an increased chance of readmission to hospital.Yet, despite a sizeable research community investigating the interrelationship between these indicators, the evidence base on the patterns of these interdependencies remains inconclusive due to wide heterogeneity in methods and findings across studies (which speaks to the complexity of the topic). For example, a switch between the unit of analysis , on the same underlying admissions data, will yield inconsistent, and even inverse, results.Much of the afore cited literature originates from the USA and Europe. With a scarcity of local examples, this study used a large, nationally representative dataset of hospital performance measures ) to expand interest and add evidence for the Canadian context. Specifically, we investigate the relationship between hospital deaths, readmission and LOS, and explore any associations with hospital characteristics. Our specific research questions are:How have hospitals performed in both the hospital deaths  and readmission indicators over time?What is the correlation between hospital deaths (HSMR), readmissions and LOS?How do a series of eight hospital characteristics correlate with hospital deaths (HSMR), readmissions and LOS?Do the results of the aforementioned research questions show differences between peer groups of teaching hospitals and community-large hospitals?We used the all data export report file from CIHI’s Your Health System In Depth online toolThe following indicators were used for the analysis: hospital deaths (HSMR), readmission (%) and LOS (days); and eight contextual measures of hospital facility characteristics: number of acute care hospital stays; number of acute care beds; number of emergency department visits; average acute care resource intensity weight (RIW); total acute care RIW; hospital occupancy rate; patients admitted through the emergency department; patient days in alternate level of care (%).HSMR and other variations of summary hospital mortality measures are commonly used indicators to assess hospital performance. The hospital deaths (HSMR) indicator is a ratio of observed to expected in-hospital mortality, capturing the 72 leading causes of hospital death . The Readmission indicator captures all urgent patient readmissions within 30 days. The average LOS indicator is a sum of all valid days spent in hospital, divided by the total number of inpatient cases. Detailed technical notes on these indicators,Both hospital deaths (HSMR) and readmission indicators are risk adjusted. Hospital deaths (HSMR) risk-adjustment variables are: age, sex, LOS, admission category, comorbidity (Charlson Index Score) and transfers. As the readmission indicator is an aggregate of four subcategories of readmission , the readmission risk-adjustment variables are not constant across the four subcategories; this range of risk-adjustment variables are: age, sex, acute care hospitalisations in previous 6 months, admission category, comorbidity (Charlson Index Score) and casemix groupings. Detailed information on model specifications and coefficients used in calculations are available elsewhere.16 17CIHI classifies the approximately 600 hospitals in Canada into four distinct peer-group types: teaching hospitals; community-large hospitals; community-medium hospitals and community-small hospitals. This classification facilitates meaningful comparisons across hospitals of similar structural characteristics, patient volume and clinical complexity.A hospital is designated as ‘teaching’ by provincial/territorial ministries of health, or was identified as such in the provincial/territorial ministry’s submission to CIHI’s Management Information System Database. Community-large hospitals meet two of the following three criteria: more than 8000 inpatient cases; more than 10 000 weighted cases; or more than 50 000 inpatient days.In order to qualify for public reporting of results for the hospital deaths (HSMR) indicator, a hospital must meet a minimum of 2500 eligible hospital deaths (HSMR) cases for each of the most recent three consecutive years.Descriptive statistics for the analysis of LOS, hospital deaths (HSMR) and readmission indicators are presented by range of values, peer-group means and 95% CIs and coefficient of variation (CoV) see . Trend oTo compare indicator rates per hospital across 2013–2014 to 2017–2018, three possible outcomes are inferred: a decrease in rate (2013–2014>2017–2018); an increase in rate (2013–2014<2017–2018); and no change in rate (2013–2014=2017–2018). Multiplying these three outcomes by the two indicators of interest  and readmission), in tandem, yields a total of nine trend outcomes see .Graphical representation of the aforementioned tests are shown via scatterplots depicting: (1) percent change over time for hospital deaths (HSMR) and readmission (delineated by peer-group) see  and (2) s (positive and negative) are defined as: 0.00–0.19 very weak; 0.20–.39 weak; 0.40–0.59 moderate; 0.60–0.79 strong; 0.80–1.0 very strong.20A Spearman’s rank correlation test examines the association between LOS, hospital deaths (HSMR) and readmission on 2017–2018 data year values . Strengths of correlations, the absolute value of RLastly, a Spearman’s rank correlation test was also used to assess the correlation between eight hospital facility characteristics against LOS, hospital deaths (HSMR) and readmission values for 2017–2018. All analyses were performed on R V.3.5.0 .Patients or public were not involved in the design of this longitudinal, observational study. However, all data used are available in the public domain.In comparing 2013–2014 and 2017–2018 indicator rates, hospital deaths (HSMR) largely declined, while readmissions increased see . A paire21In examining hospital deaths (HSMR), readmission and LOS for potential associations, only very weak to weak non-statistically significant results were observed see . The comThe number of acute care hospital stays was only statistically significantly correlated with LOS (negatively weakly) in community-large hospitals . Teaching hospitals had a moderate positive and statistically significant correlation in the number of acute care beds and LOS . The number of emergency department visits and LOS were negatively moderately correlated in community-large hospitals . The average acute care RIW was positively strongly correlated with LOS  when assessing both hospital peer groups. With respect to hospital deaths (HSMR), the average acute care RIW was positively moderately correlated in community-large hospitals . Total acute care RIW was only moderately positively correlated with LOS for teaching hospitals . Hospital occupancy rate was only statistically significantly correlated with LOS for teaching hospitals . With respect to hospital deaths (HSMR), a hospital’s occupancy rate is very weak to weakly negatively correlated . Patients admitted through the emergency department had a positive weak to moderate correlation with LOS  and a positive weak correlation with readmissions . The percentage of patient days in alternate level of care  had a positive weak correlation with LOS in Teaching hospitals , and a weak negative correlation with readmissions for all hospitals combined .10.1136/bmjopen-2020-041648.supp1Supplementary dataIn recent years, there has been growing interest in the association between hospital deaths, readmission and LOS.10This secondary analysis of hospital performance data aimed to provide a high level overview of the association between hospital deaths, readmission and LOS across a majority of teaching and community-large hospitals in Canada between 2013–2014 and 2017–2018. The classification and assignment of hospital peer groups allows for more meaningful and valid comparisons of performance of hospitals across similar structural characteristics, patient volumes and clinical services offered. Therefore, any comparison of individual hospital performance should be restricted to within a respective peer-group. Delineating the results of this study’s analyses by teaching and community-large hospitals allows for a more granular interpretation of hospital performance at peer-group level.Of the three outcome indicators, only with the readmissions indicator was there a statistically significant result of community-large hospital peer-group showing a lower peer-group average than that of the teaching peer-group.Detailed data on eight hospital characteristics were also available in the dataset published by the data steward. As this study was exploratory in nature, we additionally included these hospital characteristics in the correlation analyses to explore any meaningful relationships with the aforementioned three main indicators, and delineated by hospital peer-group type.Our earlier researchThe main strengths of this study are the quality and extent of data used; all teaching and community-large hospitals across Canada that had publicly available reported performance results were included in the analysis. The ‘all readmission’ indicator captures, as the title suggests, all readmission to hospital within 30 days; the hospital deaths (HSMR) indicator captures ~80% of all in-hospital mortality; and the LOS indicator quantifies the mean duration across all hospitalisations. Eight diverse hospital characteristics also provided summary measures that capture numerous aspects of a hospital’s performance context. While results for LOS and the eight hospital characteristics were only available for the most-recent year (2017–2018), for hospital deaths (HSMR) and readmission indicators, five fiscal year data points were available to measure trend over time differences.There are limitations in this study with respect to its generalisability beyond Canada; differences in risk-adjustment methodologies, indicator definitions and calculation methods, and hospital type/size definitions, pose challenges to make apples-to-apples comparisons across countries. However, the categorical outcomes of performance simultaneously comparing hospital deaths and readmission, along with the correlation tests of these indicators and hospital characteristics, is available and worthwhile to other settings. Community-medium and community-small hospitals in Canada treat fewer patients, and offer less-complex clinical services. This large group of hospitals  are omitted from this study due to an absence of publicly reported indicator values for hospital deaths. Furthermore, as a result of mergers between disparate hospitals, historic indicator values  are omitted from the reporting platform. Thus, this inhibits a longitudinal comparison . However, current indicator values and hospital characteristics data are available and was included in analyses that only required 2017–2018 data year .An important limitation of this study, inherent to the constraints of using aggregate-level hospital data, is the inability to perform more complex analyses. Previous, more granular analyses by researchers have been able to employ more sophisticated statistical techniques, including modelling, controlling for confounding factors, calculation of composite indicators, application of more refined case inclusion/exclusion criteria and stratification of analyses across different disease groups. Another such example of a limitation exists with the LOS measure reflecting the average of all hospitalisations, and the inability to select just those applicable to hospital deaths (HSMR) or readmission patients, respectively. Acknowledging these limitations of performing secondary analyses on aggregate, publicly available hospital performance data, we nonetheless pursued our four research questions, with the data available at hand, to determine what, if any, level of association exists at the hospital indicator level.The two main outcome indicators themselves, hospital deaths (HSMR) and readmission, also have methodological limitations due to the inability of including non-hospital death data. The hospital deaths (HSMR) indicator, unlike the summary hospital-level mortality indicator, can only account for deaths that occur in hospitals. Similarly, the readmission indicator cannot exclude patients from the denominator that have passed away in the community following hospital discharge. While the indicators of hospital deaths (HSMR) and readmission are risk adjusted (as described in the Methods section), not all risk-factors can be adjusted for (due to reasons such as viability).Public reporting of performance results poses challenges to hospital administrators and the broader public. Public reporting has become a staple in health systems and hospital performance management. But the practice of public reporting is not without concerns.24Pay for performance schemes are commonplace in hospital governance. A governance model that assesses hospitals through isolated performance measures, runs the risk of unintended consequences in other factors of care and performance not under immediate scrutiny.Moreover, government officials charged with hospital governance must take into account inequality across hospital facilities and hospital corporations. Beginning in the 1990s, but increasing rapidly in recent years, there has been a trend of mergers between multiple hospitals and between hospitals and rehabilitation institutes into a singular hospital corporation.27Government bodies and professional associations charged with supporting quality improvement initiatives can use the methods and findings of this type of analysis to identify best practices and top-performing hospitals so as to learn from their effective practices. Similarly, hospitals in an unfavourable quadrant  should receive tailored programmes to support their improvement in quality and efficiency of care.The general public, too, requires consideration when publicly reporting performance results. Efforts in describing indicators in plain language and providing a framework for contextualisation can increase the public’s assimilation of performance results .The results of this study do not provide a definitive outcome to the debate on the complementarity between LOS, hospital deaths, readmission and hospital characteristics. The underlying pathways and differences between hospitals in functions, and scope of services provided, makes the hospital a complex unit of analyses. The corpus of past studies illustrates the wide heterogeneity of research methods and degree of association outcomes. The embedding of this type of analysis into hospital governance formulation can only better-inform those charged with policy-making and administrators of hospitals. Subdividing the research methods of this study, into disease and/or procedure-specific analysis, can help facilitate addressing quality improvement concerns on specific clinical areas; but caution is stressed so as to not unintentionally cause clinicians and hospital administrators to experience tunnel vision.This study shows that secondary analyses of publicly reported hospital performance results can reveal meaningful insights into the association among outcome indicators and hospital characteristics. Good or bad hospital performance in one care domain does not necessarily reflect similar performance in other care domains. Thus, caution is warranted in a narrow use of outcome indicators in the design and operationalisation of hospital performance measurement and governance models (namely pay-for-performance schemes). Analysis such as this can also inform quality-improvement strategies and targeted efforts to address domains of care experiencing declining performance over time; further granular subdivision of the analyses, for example by hospital peer-groups, can reveal notable differences in performance.